Depression. For most people, images of endless weeping in the corner of a dark room following a major tragedy spring to mind. In reality, depression can look very different across each person experiencing it. Let’s say you have a work friend who confides in you they’re struggling and think they may be depressed while somehow still smashing their KPI’s, organising their kids’ weekend sports and smiling good morning each day. This might make you ask: “Are they really that depressed?”. “How can they be depressed if they’re doing everything just fine?”.

What is Depression?

To begin exploring these questions, we first need to understand what depression is. What are the symptoms? How do you get a diagnosis? In Australia, the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (or DSM-5 for short) is the primary standard for diagnosing any mental disorder. The DSM-5 outlines which criteria need to be met to diagnose someone with a mental disorder. The ‘Depression’ most people refer to is actually called Major Depressive Disorder (MDD) and falls under the category of Mood Disorders. Another little known diagnosis that also falls under this category is Dysthymia or Persistent Depressive Disorder (PDD). This is where it can get confusing. 

MDD and PDD share almost the same symptoms, the main difference being the duration a person experiences these symptoms. To be diagnosed with MDD symptoms need to be present for at least 2 weeks, whereas for PDD this stretches to a 2-year minimum. Another key difference is the severity of symptoms with PDD symptoms considered less severe though more chronic in nature. 

Overall, the main symptoms across both types of depression include: 

• Depressed mood most of the day, most days
• Loss of interest or pleasure in activities
• Significant change in appetite (increased or decreased)
• Low energy or fatigue (for no observable physical or other medical reason)
• Difficulty concentrating
• Feelings of hopelessness, worthlessness or inappropriate guilt

What is high-functioning Depression?

Let’s go back to that work friend again. They told you they often feel sad or hopeless and struggle to get out of bed each morning. You might be thinking “They don’t seem sad at work and they turn up on time every day, this doesn’t make sense! They’re just looking for attention!”. While not considered an official diagnosis, many people may be perceived as, or identify as, having ‘high-functioning’ depression.

Firstly, how can we define high functioning? The answer: it depends on the person. For some people, high functioning is maintaining their B+ average at university while participating in organised exercise classes each week. For others, it means merely getting through the day by feeding themselves and getting to work while their brain fights them every step of the way. What matters here is the concept of ‘functional impairment’.

Basically, to be diagnosed with any mental illness or disorder, you not only have to meet the symptomatic criteria but also have to display a level of functional impairment. That is; the symptoms have impacted your ability to function in daily life as you normally would, causing some distress. Remember; high-functioning depression is not an actual diagnosis; instead, it is a descriptive label someone might identify with or appear to fit under. Quite often, those perceived as having high functioning depression have the functional impairment element of their diagnosis in a less obvious aspect of their life such as self-care routines or libido, facets not often available at face-value. Pair this with a PDD diagnosis entailing less severe symptoms over a longer period and voilá, you have your stereotypical case of high-functioning depression.

How can you spot it?

Okay, we know what high-functioning depression is now, but how can we look out for it next time? Firstly, we need to throw out the idea that depression requires recent catastrophic trauma or loss and a complete inability to experience anything other than permanent sadness. A person with depression is not incapable of experiencing positive emotions as well, though they will likely be less frequent and enthusiastic. A good rule of thumb: if you are worried about a friend, don’t expel the idea of investigating further just because they had a day they were able to laugh.

Though signs of high-functioning depression are more discreet and difficult to spot, there are a few things you can look out for in those around you:

• Overly harsh self-criticism: This one might be more observable in a place of work or sport. Yes, your work friend smashed their KPI’s and everyone is praising them, but what are they saying about it? Maybe they’re beating themselves up saying they should have and could have done better. Maybe they’re attributing the success to someone or something else, making excuses as to why it wasn’t truly them that achieved this. 

• Complaints of chronic physical pain: A less commonly known symptom of depression, particularly in chronic depression like PDD is chronic pain. Individuals with depression are more likely to report some type of chronic pain than individuals without depression. The reported pain severity also seems to increase with depression severity. (Careful with this one not to discredit someone’s pain with “It’s all in your head”.) Checking in on a loved one complaining of ongoing physical pain is likely to be helpful as long as it is coming from a place of genuine care and compassion. Maybe the pain is depression-related and the conversation leads them to seek the help they need. Or maybe, their pain is from a physical injury and the conversation encourages them to seek help in the form of a physio.

• Significant weight change: As noted before, a common symptom of depression is significantly increased or decreased appetite. Lower appetite = reduced food intake. Greater appetite = increased food intake. Consequently, sudden unintentional weight gain or loss can be a good indicator that something may not be quite right. As with chronic pain though, be careful not to assume as this could also be caused by other medical issues.

• Cancelling on activities or events: Though those with high-functioning depression are often capable of tending to all regular daily events, extra activities may prove too much. If you notice a friend has been regularly cancelling or deferring plans to catch up or go to that yoga class you both used to love; it might be time to talk. 

• Major life event: I know. I said depression didn’t always have to be linked to some type of catastrophe; however, it is a very common antecedent. Someone who has recently endured a significantly difficult event or series of events could very well be struggling with it internally.

How can I help someone with high-functioning depression?

Now you have all this new knowledge, you may be tempted to don the psychologist cap and diagnose all your friends and family members. 

Probably, best to leave the psychology to the psychologists. The easiest and best way you can help is simply to check-in with those around you and ask how they’re doing. Now, while bluntly asking “Are you depressed” may work for some, asking how someone is doing on a more general level might be a safer approach. No, I don’t mean that scripted social etiquette “How are you” a retail worker delivers as you walk into the store where a response other than “Good thanks” would be weird. Showing genuine compassion and care is key to encouraging someone struggling to open up. If you need help, the Australian government ‘RUOK’ website has a great breakdown on just how to ask.

If you think you or someone you know might be experiencing depression of any type, seeking help from a professional is always a good strategy. There is no such thing as ‘not depressed enough’ to seek help. If your employer offers an Employee Assistance Program (EAP), use it. If not, booking an appointment with your GP or connecting with an online resource like Lifeline is a great start.