I’ve worked in the mental health field for about five years, and in those five years, I’ve worked in different treatment settings, with different populations, and had my fair share of treating and supporting people who suffer from depression and suicidal thoughts. In most cases, these clients have had debilitating symptoms that have resulted in multiple hospitalizations or treatment center stays over their lifespan. They often have other co-occurring diagnoses, and/or struggle with substance abuse or other maladaptive behaviors such as self-harming.
Their symptoms and behaviors are so unmanageable that they struggle to live a productive or seemingly fulfilling life. They stop going to work or school, they stop hanging out with friends, they appear sad or distressed most of the time, and they lack a general sense of motivation or interest in anything. The people closest to them can usually pick up on the fact that something is wrong or off because their behavior isn’t in alignment with the person they’ve known them to be. The person doesn’t have to come out and say “I’m depressed” or “I’m suicidal” because they begin to wear their depression and/or suicidality on their sleeve and this allows for their support system to intervene or try and offer help.
What if the mental illness isn’t easy to spot?
But what happens when a person wears their mental illness well? What happens when the depression and suicidality aren’t as east to spot and you can’t see the downward spiral? How do we support a person when we have no inclination that they are suffering or that they are merely moments or one tough circumstance away from being motivated to check out on life?
After all of my experience with depressed and suicidal clients, this year was the first time I was personally affected. In this past year, I’ve known three highly functioning people that have committed suicide. I wasn’t extremely close with any of the three, but from what I knew and could see, they all appeared to have meaningful and fulfilling lives with support systems that loved and cared about them. The last of the three, a college friend, was in medical school, she was a social butterfly, traveled the world, and was going to change lives. She took her own life two days before Thanksgiving and her death motivated me to write this piece.
It was through experiencing and processing the loss of these people that I realized that there is huge a deficit that exists in addressing what I would consider a silent killer, the combination of high functioning depression and suicidality.
What is high functioning depression?
I firstly want people to understand that depression is different from general sadness, it’s a combination and criteria of symptoms that last a minimum of 2 weeks. Sadness is typically a symptom of depression and other symptoms can include, loss of interest and pleasure in things that once brought joy, hopelessness, worthlessness, or guilt, significant weight loss or weight gain, excessive sleeping or crying, difficulty concentrating and staying committed to tasks, and loss of energy or recurrent thoughts of death. In the mental health field when people refer to depression, they are usually referring to Major Depressive Disorder. The media has convinced us that depression only looks one way, the sad, gloomy, can’t get out of bed narrative.
Over the years people have coined the term “High Functioning Depression” to describe the experience of people who may not meet every criteria of the diagnosis yet still experience intense symptoms of depression. These symptoms can look like going to work or other commitments but isolating, sleeping, or crying immediately after. Spurts of excessive irritability and anger or feelings of inadequacy. Heavily drinking or using substances when not at work or fulfilling other obligations, and/or forcing themselves to participate in social activities. Caretaking for others and putting themselves and their needs last, putting value into others because they don’t see it in themselves. Constantly being in social settings or unhealthy relationships because being alone with themselves is too painful. Feeling tired all of the time even when they get adequate amounts of rest, gaining or losing weight unintentionally, doing regular tasks feels like a huge chore, and feelings of happiness are usually fleeting and don’t last long. They can be so emotionally drained from having to be “normal” and functioning in public that oftentimes other parts of their life are being unkempt or falling apart.
How is depression diagnosed?
When counselors or social workers are taught in their grad school programs how to go about diagnosing, we learn early on that there are levels of severity when it comes to a diagnosis, mild, moderate, and severe. Following a diagnostic criteria strictly by the DSM-V isn’t always a full-proof science, however. A person could meet only a few of the criteria (which is where the high functioning part comes in), be diagnosed as having mild or moderate depression, and still have intense moments or phases of severity associated with emotional dysregulation and suicidal thoughts. When people suffer from depression but are highly functional, they can even minimize what they are experiencing by passing it off as “going through a funk or phase” or just being tired. People may tell them, “Oh you’re just going through a rough patch” or “you’ll be alright”, further emphasizing that what they’re experiencing will just pass. But depression in any form doesn’t just pass, a person has to learn to manage it.
Suicide and depression
What makes the combination of high functioning depression and suicidal ideation so lethal is the fact that being high functioning creates such an illusion to others that everything is ok, that when a person acts on