Are we a generation that is riddled with high-functioning depression; is depression endemic? I pose this question to start with, as it helps us interrogate what high-functioning depression is and investigate the impact it has on our 21st-century generation.

We live in a fast-paced, capitalist world; everyone is in a rat race, chasing the next best thing, and striving. Resultantly, stress and burnout are rife, yet normalised, it’s a part of everyday life. We seldom pause and check in with ourselves, or our loved ones. There’s a warped notion that if one is getting up each day, keeps a job and earns a salary, they’re fine.

What we do not understand, is that some people are struggling internally and living with high-functioning depression, which is debilitating in many ways. Sadly, it often takes a person having a complete mental breakdown and psychic collapse for them, and the people around them, to have an appreciation of how work-related stress can lead to serious mental health problems – acute or chronic.

In my role as a therapist, I have encountered many people who come to therapy with chronic and debilitating mental health problems; the most common one is high-functioning depression. What is bothersome, is that some of these people are not even cognisant of their suffering from depression.

What is high-functioning depression?

High-functioning depression, also known as dysthymia, is a form of depression where the person experiences all the symptoms of depression, but they are typically milder. The symptoms tend to be chronic, low grade and don’t necessarily impair day-to-day functioning. As a result, people with high-functioning depression can carry on with their life as usual, and present as if all is well externally. At times, the sufferer may not even recognise that they have depression, albeit high-functioning, and so this is also easily missed by family, friends and health professionals.

People with high-functioning depression tend to struggle internally and, in many situations, present quite differently outwardly. For example, if they are aware of the low mood or what is often described as “being constantly in a funk”, they may mask their symptoms or become highly performative to disguise the depression. Therefore, it is easy for symptoms to be excused as one’s personality, or as dismissed as one being “moody”.

What are the symptoms of high-functioning depression?

Like frank depression, people with high-functioning depression experience:

• chronic low mood
• difficulties concentrating
• brain fogginess
• hopelessness and pessimism
• sleep disturbances – lack of sleep, broken sleep, or sleeping too much
• low energy levels and lethargy
• low self-esteem and self-regard
• poor appetite or increased appetite
• mood swings (anger, guilt, frustration, sadness) and tearfulness
• apathy – lack of interest and motivation
• general sense of overwhelm and acopia
• low libido

Risk of comorbidities

People with high-functioning depression are at a much higher risk of using narcotic drugs and alcohol as a form of self-medicating, to numb and/or elevate the low mood. This can create a vicious cycle, detrimental to a person’s mental health since alcohol is a depressant and narcotics are stimulants (exacerbating symptoms).

This is common and problematic in corporate environments, where there is a culture of drinking after work and social events where there is access to alcohol and narcotics. It’s not unusual for people who have depression to end up developing alcohol and substance misuse, which feeds into the depression, creating a vicious cycle.

Toxic work environments and high-functioning depression

Many companies are beginning to develop systems to promote mental well-being in the work environment, and there is a drive towards normalising mental health while reducing the stigma around mental illness. Employee Assistance Programmes (EAPs) are also drawn in to provide short-term therapy and support to employees who may be struggling with their mental health.

However, I believe that the main objective is often to get the employees back into work as quickly as possible and minimise loss. The reality of these high-pressured environments where performance is constantly monitored, is that employees are at a much higher risk of developing and living with high-functioning depression.

The work pressures lead to chronic stress, which easily turns to burnout. This can provoke secondary mental health problems, such as anxiety and depression, which can become chronic and low-grade high-functioning depression. Individuals in these environments are less likely to pay attention to their mental health, as their focus is on their work.

If they are less productive, they risk being engineered out, and being put on Performance Improvement Plans (PIP). Bumper bonuses and commissions also reinforce the culture of pushing one beyond capacity, risking their mental health. These environments tend to be highly competitive, and poor performance is associated with incompetence, which creates additional issues around one’s self-esteem and self-image. There is very little empathy for each other and it can be cutthroat.

The toxic cultures in these environments result in some people being pushed to their limits mentally; they continue working while experiencing depressive symptoms. Not attending to these symptoms is what turns into high-functioning depression, where a person is functioning but struggles internally. The stigma around mental health also acts as a barrier for these individuals to access help. Taking time off for mental health can be seen as a sign of weakness or failure.

Suicide and high-functioning depression

Social media and the digital world have given us access to news from different parts of the world. It’s not unusual to read about people who lost their loved ones to suicide, where the individual’s struggles went unnoticed by those around them. Many stories that continue to shock the world are those of celebrities and entertainers reported to have died by suicide: Robin Williams, John McAfee, Alexander McQueen, Stephen “tWitch” Boss, and Kurt Cobain, to mention but a few.

How is it possible that these people, who seem to be coping well with life in the public eye, entertaining others, end their lives? I believe this indicates that they may be struggling internally, and experiencing high-functioning depression, seemingly coping on the outside. Living with this contradiction between the internal and external world can be a real struggle as one lives in duality. Ending one’s life ends up being the solution, albeit a painful one for those left behind.

Many studies have confirmed a correlation between depression and suicide. The World Health Organization (WHO) estimates that 90% of all suicide victims have some kind of mental health condition, depression being primary. People with depression are more likely to end their lives by suicide than any other illness. This is not to exclude anxiety, which often co-exists with depression.

Self-care tips

Identifying symptoms of high-functioning depression is key. If you suspect that you have high-function depression, there are some ways to manage your mental health:

Could l be experiencing high-functioning depression?

People who are experiencing high-functioning depression are not always cognisant of it. In many cases, it takes one small thing to tip them over the edge, and for them to notice how poor their mental health is. When this happens, suicidal ideation emerges; due to the untreated depression. If you think you may be experiencing high-functioning depression, it’s important to seek help in a timely manner and galvanise additional support around you.

High-functioning depression is normal, but it is not a life sentence. With the right treatment, people with high-functioning depression can recover, and continue living their lives normally, feeling more wholesomely.

If you suspect that your loved one is experiencing high-functioning depression – you notice some of the symptoms identified above – it’s important to try to engage them and encourage them to seek professional help. Therapy is key in the treatment of depression – some people end up taking antidepressants, adjunct to therapy. I always remind others that taking antidepressants or going to therapy is not a sign of weakness, quite the opposite, a strength.

It’s more painful to watch a loved one struggle or die by suicide without doing anything about it than to reach out and have honest conversations. You may very well be the only person who has reached out.

It’s hugely significant that we keep re-evaluating our attitudes towards mental health and be open to our experiences being unique to ourselves and different to others. Instead of being quick to judge other people – changes in behaviour or temperament – let’s be open to it being a result of poor mental health. Compassion for each other will always take us a long way.

Family relationships are supposed to be anchoring, a source of nurturance, care, love, and support, where there is respect and acceptance of each other as unique individuals. Healthy familial relationships are made up of individuals who can communicate openly with each other, respect each other’s opinions, and have boundaries that are mutually respected.

Sadly, some people do not have the blessing of healthy family relationships, and they go through life dealing with toxic relationships with family members. The contradiction is that the relationships which bring them the most pain are the ones that should bring them joy. This is indeed a painful place to be, one that also leads many people into therapy, to address and work through.

There is a need to manage the relationships in a tactful and consistent manner to minimise the distress that is created. Some family dysfunctions run through generations, which is a result of unresolved relational traumas from the previous generations. Therapy is a way of addressing, and healing from that generational trauma.

It is very easy for one to feel isolated and question their reality, due to the constant gaslighting when dealing with family members who are toxic and where there is dysfunction. By ‘toxic’, l mean people who violate other’s personal boundaries whether it’s by disrespectful behaviours, controlling behaviours, gossip, lies, manipulation, blaming, envy, and jealousy.

The conflict, toxicity, discord, dysfunction, and negativity, whether it’s a single event or ongoing, can lead to some family members distancing themselves, and estrangement. Often there is stigma and negative stereotypical attitudes towards the individual who is estranged, and a failure to understand their position and the underlying dynamics at play.

Distancing oneself from negative family relationships and dynamics is indeed a form of self-care and a way of creating boundaries and safety for oneself. Many people hold on to toxic family relationships that cause them pain because of poor self-esteem and an inability to self-validate – the lack of conviction that they can survive in life without these negative relationships.

Group mentality (basic assumptions) and family dynamics

A family is made up of a group of people, albeit a complex one. Familial relationships are shaped by unconscious dynamics, just like any other group where people are brought together for a common purpose.

Sibling rivalry is one of the common features in families where there is underlying dysfunction. There are often two siblings, at times more, who get into conflict and play this out within the family. While the “drama” is acted out by the siblings, the dysfunction often lies in the parents or the family as a whole.

Wilfred Bion’s study of groups during World War Two can shed some light on some of the unconscious processes at play in the family as a group. Bion (1962) defines this pairing of individuals in any group that is gripped by unconscious anxieties as a basic assumption pairing (BAP), where these two individuals are unconsciously acting out the underlying conflicts on behalf of the group. The source of rivalry is not always to do with whatever issue that is consciously fought over, but rather the underlying issues that are avoided and denied by the family and therefore acted out by the pair.

In some families, the dysfunction manifests in one individual who is the “outcast” or the “scapegoat”.  This induvial becomes the one who holds all the badness on behalf of the family. This is all a function of projections of unwanted aspects of a family member, or the family as an entity onto and into the individual.

Under the sway of these powerful projections, it’s very easy for that individual, who is a recipient of these projections, to act out these projections.

Melanie Klein (1946) would call this ‘projective identification’. It’s also easy to internalise these notions leading to limiting/negative core beliefs about oneself – “I am a terrible person”, “No one likes me, even my own family”, etc. Having these family fights leading to an individual family member, or an individual family within a wider family, being ostracised would fit what Bion (1962) considers a basic assumption fight-flight (BAFF) where there is a turning away from the issue at hand, increased hostility, rage and aggression directed at the enemy, and fighting between group members. This perpetuates the issue as alienating and vilifying the individual, leaving the underlying issues unresolved.

In other families, there is an individual, typically an elder, who is seen as a source of wisdom and cannot be challenged, no matter how wrong they are. This person is seen as omnipotent and the person who is meant to resolve all the issues for the family. This can be very harmful as this member is unchallenged, regardless of how unsound their opinion is; they are protected at all costs. This way of functioning is what Bion (1962) considers a basic assumption dependency (BAD), where there is a dependency on an individual; the phantasy is for that individual to save the family.

This powerful basic assumption often leads to despair and, as that individual is unconsciously seen as the problem solver, however, they do not have the ability to save the family. The underlying issues in the family which can be solved by open and honest communication are avoided which perpetuates conflict and toxicity.

Narcissistic parenting 

In most families, the dysfunction and sibling rivalry lies in the parents and their relationship with their children and how they raised them. “Narcissistic” parents are parents who are unable to accept responsibility for their own failures, shortfalls, feelings, or insecurities. To deflect their own feelings – a sense of shame, guilt, or failure – the individuals who are unconsciously picked in any of the BAP, BAP, or BAD, are simply acting out a family drama.

If the underlying issue is not addressed and communicated openly, thoughtfully, and responsibly, the drama only perpetuates. This hurts everyone else but the people who are responsible which is either one or both parents. Narcissistic parents typically don’t take responsibility for their own failures. Instead, they unconsciously project it onto their children, leading to a lot of conflict and rivalry in the family and between siblings or family members. The sad part is that the people who are in conflict are acting on behalf of everyone else and the root cause is often the family and their lack of dealing with acknowledging their own dysfunction.

How do you move on from an unhealthy family dysfunction?

Open, honest, mature, and respectful communication about family issues that are deemed difficult or risky is central to families moving from unhealthy dysfunction into healthy, nurturing relationships, and cohesiveness. It may mean confronting each other; however, if this is done respectfully, it is likely to lead to growth and meaningful relationships. Avoidance and denial of the issues only perpetuate the dysfunction.

If you are estranged from your family, here are some tips to manage this situation:

1. Create healthy and meaningful relationships with friends and loved ones (not parents or siblings) who you can have mutually nurturing relationships with. This helps you replenish and foster a sense of community and security.
2. Create firm boundaries with family members and be consistent – how far one can go with contact and how they communicate and treat you?
3. Limit contact if it causes you distress – consider blocking on apps if necessary. Protect your peace, you owe yourself that.
4. Remind yourself that you are not responsible for other peoples’ feelings, behaviours and what they think of you. People will always judge no matter what. They have never walked in your shoes.
5. Self-validate – remember you are enough without the family. The toxicity will only weigh you down. You are not responsible for the dysfunction. Your family dysfunction doesn’t define you.
6. Create a routine and find new hobbies where you can expand your social circle. This will make you feel less isolated and foster a sense of belonging and community.
7. Find ways to self-soothe – yoga, mindfulness, sport, and other self-care routines. Do things that enable you to regulate yourself emotionally whenever you are overwhelmed, instead of lashing out at the toxic individuals or others around you. You simply perpetuate the dysfunction of if you lash out.
8. Do things that you enjoy, and that mastery, that gives you a sense of purpose. Meaning is derived from how much we feel integrated, take part, and value in life.
9. Be kind to yourself – therapy helps you heal from this trauma. Remember it’s a family trauma and you just happen to be the victim.
10. If you are that elder who is there to solve everyone’s problems, step back and relinquish that role. Other people have minds of their own and their opinions matter.

References

• Bion, W. R. (1962). Learning from experience. London: Heinemann.
• Klein, M. (1946). Notes on Some Schizoid Mechanisms. International Journal of Psychoanalysis, 27, 99-110.