12-05-2025
I was a high-functioning depressive – take this quiz to find out if you are too
On paper, Dr Judith Joseph's life had never been going so well.
During the Covid pandemic her psychiatric research lab was the only one in the building which had been allowed to remain open, so important was her work on helping people cope with the effects of the pandemic. She'd just received an offer to join an elite female medical board at Columbia University, her Ivy league alma mater, from which she had graduated with honours. The psychiatry practice she had built was so well-respected she was invited to give talks about coping with the lockdowns. She was a regular expert speaker on high-profile television programmes, The Today Show and Oprah Daily. At home, she was happily married and had just welcomed a daughter.
Yet one night, sitting alone in her glossy office in Manhattan, Dr Joseph, now 44, had her head in her hands and the admission came bubbling out of her: ' I'm depressed.'
'For me to admit I was depressed was initially a feeling of shame,' Dr Joseph says. 'I thought 'How did this happen? How did this sneak up on me? I'm a psychiatrist and should have known better than to let myself get here. I come from a history of scarcity, from the Caribbean to the US, where we didn't have very much and I felt like I was letting everyone down; like admitting I was depressed was somehow saying that I couldn't handle it.'
Yet what Dr Joseph was going through didn't fit the typical definition of depression.
'Clinical depression is characterised by low mood, anhedonia (the lack of ability to feel joy), low concentration, changes in sleep, changes in appetite, low energy, physical agitation or sluggishness, and sometimes suicidal thoughts,' she explains. 'But the key thing is that those symptoms have impaired your functioning.
'I was experiencing all the symptoms, but I wasn't losing function,' she says. 'In fact, I was coping with those symptoms by becoming overly-productive. I felt empty when I wasn't busy. I took on other projects to avoid having to sit still with my thoughts.' Post-lockdown, she separated from her husband.
As she began to research her condition, Dr Joseph discovered people online were using the term 'high-functioning depression' to describe similar feelings and soon stumbled upon a hidden world of people suffering in silence.
'I began to wonder, how many people were like me – appearing fine on the outside but wearing a mask of pathological productivity and busying themselves, being the rock, being the entrepreneur, being the parent, in spite of what's happening on the inside?' she wondered.
Dr Joseph began to create social media videos about the concept, hoping a handful of fellow psychiatrists might be interested, but soon 'millions of people were responding, telling me they were going through the same thing. That was when I knew I was onto something'.
Though high-functioning depression has similarities with workplace burnout, the conditions are distinct. ' Burnout is where work causes people to feel unmotivated, irritable, with low-energy, mentally exhausted,' she explains. 'High functioning depression is the opposite: people feel internal stress and work extra hard to distract themselves from it. Even if you remove the person from the workplace, they're doing something on the weekend, they're taking on other people's problems, they have a packed social schedule, they're cleaning obsessively, they're keeping their brains busy by doom-scrolling. Being busy is how they avoid the problem.'
In her research Dr Joseph sees three outcomes for untreated high-functioning depression: clinical depression, physical stress, or people's lives coming apart because of their inability to cope.
'There is the case where someone looks put together and happy, but they fall into a period of hopelessness or even die by suicide,' she says. 'In those who don't dip into clinical depression, their bodies give out. They get diagnosed with odd autoimmune conditions or out of control blood pressure, because the mind-body connection is overwhelmed. The third outcome is people trying to find other ways to run from their pain: I see substance abuse, excessive gambling, obsession with technology; anything to stay busy.' All of this in high-achieving, professional clients or students.
In her new book on the subject, High Functioning: Overcome Your Hidden Depression and Reclaim Your Joy, Dr Joseph says: 'Most people with high-functioning depression don't realise they have it. They're not aware that the joy has been removed from their life.'
There are many reasons why we may resist the label of high-functioning depression.
One is our cultural norms. In the UK, manners encourage us to prioritise the happiness of others over our own, leading to us create even more stress for ourselves in our bid to help others.
'With the good manners which are so highly prized in the UK, people-pleasing is normalised and celebrated. If you're bending over backwards and constantly being told your joy doesn't matter as much as someone else's, you end up feeling a lack of joy in life and become overwhelmed.'
High-functioning individuals facing this depression find it difficult to step away from the things that are causing it. 'Those who have trauma put themselves back into traumatising situations,' says Dr Joseph. 'It's our brain's way of trying to control the situation and prevent the same outcome: combat veterans who sign up for additional tours of duty, people who have sexual traumas who throw themselves into chaotic relationships, people who are overloaded at work take on additional work to prove they can handle it.'
But if we're so used to high-functioning depression that we can't even realise it, is this just another example of medicalising, or putting yet another mental health label on something that many of us go through?
'I hear that a lot, but feeling joyless all the time is not normal,' asserts Dr Joseph. 'People think happiness is an ideal and it's not, it is vital to our ability to live. We were built with the DNA for joy: there's a reason we have dopamine [a chemical which incites feelings of happiness] in our brains, you are supposed to get pleasure from life.
'So much research shows that being joyful leads to better health outcomes, better salaries, better relationships. It's up to you: you can say that joy isn't important but science begs to differ.'
Five years since Dr Joseph admitted to struggling with high-functioning depression, she says her life has changed beyond all recognition. Instead of overloading herself with more projects to cancel out her fear of failure, she has focused her energy back to helping others and feels a joy she hasn't experienced in decades. In 2023, she received a Congressional Proclamation from the US house of representatives for her social media advocacy and research in mental health and has given talks on high-functioning depression at the White House, Ivy League universities and Fortune 500 companies across the US and Europe.
'I want people to know that they have the capacity to increase the amount of joy in their lives,' she says. 'If you deal with your high-functioning depression, everyone will feel it.'
High functioning depression: How to break the cycle
High-functioning depression is a behavioural pattern, asserts Dr Joseph, and like all behavioural patterns it can be broken. To do that, she recommends following 'the five Vs'.
1. Validation
Acknowledging and accepting how you feel. For me, that was when I admitted to myself I was depressed. I'd pushed out those feelings for a long time and when I did that I pushed out my ability to feel joy.
2. Venting
Expressing how you feel. Talk to someone, write things in a journal, make art, or even cry.
3. Values
I wanted to become a doctor due to my love for patients. Over time I lost sight of those values and my motivation became 'not failing'. Think about your values and remind yourself of why you're functioning so highly.
4. Vitals
Sleep, nutrition, movement, but also your relationship to technology (are you doom-scrolling all the time and sapping your energy?); relationships to other people (are you prioritising others over yourself?), and work-life balance – people with high-functioning depression have a hard time separating their work role from who they are personally.
5. Vision
How do you plan things that make you happy? Make the time to celebrate your wins, instead of always being onto the next thing. It's important to acknowledge when you do things that you're proud of: that gives you a natural dopamine hit. Celebrate these wins and plan joy in the future otherwise it won't happen.
