The truth about high-functioning depression: When you look fine but feel broken

On October 10, which is known as World Mental Health Day, the message is about asking for help: “It’s OK to not be OK. Reach out. You’ll get better.” But for many of us, the real challenge is staying well once we’re already in treatment.

My depression doesn’t look like the stereotypes of a woman with a resting sad face. It hides behind an avatar of someone who has it all together. I’m a mom and a public mental health professional. I keep my appointments, meet deadlines, do school drop-offs, and arrange playdates. I’ve also lived with a major depressive disorder (MDD) for almost 20 years, which means I sometimes feel like I’m made of lead.

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This is what it looks like to live inside a diagnosis that doesn’t go away—and how I’ve learned to keep my dark thoughts and sadness in off mode.

Here’s what high-functioning depression really looks like.

Depression often causes what’s known as functional impairment, meaning it can interfere with work, relationships, and daily responsibilities. But not everyone experiences it that way.

High-functioning depression isn’t a clinical term, but it is often used to describe people who mask their sadness behind productivity, reliability, or even cheerfulness.

“Some people with depression still get up everyday and go to work and ‘seem fine’ on the outside. People mask symptoms for a number of reasons, including fear of what others may think, or experiencing guilt and shame,” says Gregory Scott Brown, MD, a psychiatrist for the American Psychiatric Association.

For me, depression brings physical pain, like a heavy kettlebell is pressing against my chest. Standing up takes real effort. I feel hollow and depleted. The physical symptoms, while still invisible, are somewhat welcome because they signal to my brain that, yes, we are all in alignment: I suck.

My thoughts grow darker, more self-critical. At my worst, I can’t always tell whether my thinking is rational or distorted. The part of my brain that I’ve spent decades trying to quiet will whisper: “You’re a burden. You should have disappeared before anyone depended on you.”

Depression can hide in plain sight.

One of the dangers of high-functioning depression is that it often slips under the radar. When someone is working, taking care of their family, and keeping up appearances IRL and on social media, their symptoms can be dismissed or overlooked. That, according to the Anxiety and Depression Association of America, can lead to delayed diagnoses, years without proper treatment, and less support from people who can’t see the struggle.

My first major episode came after my father died when I was in college. At first, the sadness made sense; it was grief, after all. On the outside, I’d had a successful stint in college journalism that led to moving to New York City to become a magazine editor. But as the months passed, the sadness stayed and gave me access to a darker space within my mind.

“When we experience emotional or environmental stress like the death of a loved one or the loss of a job, the body releases chemicals called pro-inflammatory cytokines that can affect physical and mental health,” said Dr. Brown.

During my 20s, I was grieving my father’s death and coping with my younger brother’s serious mental illness. The perpetual sadness and hopelessness hardened into full-blown depression. I was permanently in a bad mood, exhausted after more than enough sleep, and seriously wondering why I was even alive. I was adamant that I didn’t need medication—that my mood was a mostly rational response to the world around me.

When my boss noticed that my mood was also impacting my work, I decided to see a psychiatrist who diagnosed me with MDD. I started taking an antidepressant, Lexapro. And while it wasn’t exactly a magic elixir, the fog did lift. The world had color again. Therapy helped too, as did running and cutting back on alcohol. For a while, I believed I’d “beaten” depression.

@drjulie
⏳ You need to know this about high functioning depression: • The term itself is not a clinical diagnosis, but a term that has been used online to describe the experience of those who live with depressive symptoms and struggle to function but don’t cease to function. • This term is pretty useful as many people have a pre-conceived idea that good mental health is all about whether you can still get to work or not. They often feel undeserving of any support because they are not outwardly at rock bottom. • If you take one thing away from this video, let it be that the best time to start doing the right things for your mental health is the moment you think you could benefit from it. • Don’t wait until your mental health prevents you from functioning. That is a much longer and harder journey back. If you are working on your mental health independently and would like some insights from therapy to help you along the way, then click the link in my bio for your copy of my book, Why Has Nobody Told Me This Before?

♬ original sound - Dr Julie | Psychologist

Motherhood raised the stakes.

What I didn’t understand then was that MDD is often a chronic condition. Symptoms can recur months or even years later—especially under stress, during hormonal changes, or for no clear reason at all.

According to the National Institutes of Health, after a first depressive episode, the risk of recurrence is 50%. That jumps to 70% after a second episode, and 90% after a third.

Before getting pregnant, I met with a reproductive psychiatrist to discuss whether I should stay on my SSRI (a class of antidepressant medication). Like many people, I had heard that the side effects of SSRIs could harm my baby.

But experts agree that “the benefits of treating depression almost always outweigh the risks,” says Veronica Gillispie-Bell, MD, MAS, FACOG, an OB-GYN and system medical director of health outcomes at Ochsner Health. While certain antidepressants carry risks—like a small chance of persistent pulmonary hypertension in newborns, or increased risk of preeclampsia or miscarriage—these outcomes are rare, and doctors weigh them carefully against the serious risks of leaving maternal depression untreated.

“Untreated depression, on the other hand, can lead to poor nutrition, substance use, reduced responsiveness to the baby, and in severe cases, suicide. For these reasons, ACOG recommends the use of medications for depression or anxiety disorders during the perinatal period (from pregnancy up to a year after childbirth) when appropriate.

I wasn’t confident enough that my depression was behind me. The risks of relapse seemed much more likely, so I stayed on my SSRI and made it through pregnancy and the first year without a depressive episode.

Sometimes the meds may stop working.

I thought maybe I was in the clear. Then, COVID hit. I was a new mom in Brooklyn and ran communications for a crisis hotline. My husband and I juggled remote work and childcare in a one-bedroom apartment, where sirens wailed past our window. The intensity of that time led us to move—temporarily at first, then permanently—to Pennsylvania.

I held it together through the crisis. But in 2021, when the world started to stabilize, my depression returned. I couldn’t sleep, so I started working around 2 a.m. until my family woke up. My fuse was short and there was not a person I couldn’t find a reason to be mad at. The color drained out of everything. My antidepressant had was no longer effective—a phenomenon that psychiatrists sometimes refer to as “antidepressant tachyphylaxis”—when a medication that once worked well gradually loses its impact.

I needed to adjust my antidepressants, which has been a process of trial and error for me. Sometimes it's led to gaining extra weight, worsening symptoms, or side effects that make daily life harder. Other times I’ve slurred my words in meetings or had visibly shaky hands, but for the most part, no one knows how the medications are (or aren’t) working to quiet symptoms, because I try so hard to hide them myself.

@shessoluckypod This week’s episode is all about understanding high-functioning depression and reclaiming your joy with board-certified psychiatrist, @drjudithjoseph ♬ original sound - She’s So Lucky Pod

This isn’t something I’ll “get over.” It’s something I’ve learned to manage—sometimes well, sometimes barely.

Here’s how I cope with chronic, high-functioning depression.

I don’t want my depression to be more visible—I’m not looking to fall apart in public—but I do wish we talked more about how to manage it beyond that first ask for help.

Here’s what helps me keep moving when depression feels heavier:

Exercise. I know you’ve heard this one before, but moving my body is the fastest way to calm my brain. A sweaty cardio session is often the only thing that cuts through the mental noise. We treat mental illness like a sprint. But for many of us, it’s a marathon with no finish line—and very few water stations along the way.
I watch for warning signs. When I start waking up angry or having intrusive thoughts, I don’t wait for my next appointment. I reach out to my psychiatrist and we make a plan to “step up care” by changing medication or increasing my therapy sessions.
I use PTO strategically. Depression is a serious medical condition, and although it still feels awkward to take sick leave for sad days, I take time off when I feel the darkness creeping back in and need to rest.

After three episodes of depression, I’ve stopped hoping it will go away forever. Instead, I focus on what I can control—my support system, my treatment plan, my determination to keep showing up. I’m not alone in this. People with depression deserve to feel seen, not just when we’re in crisis, but in the everyday work of staying well.

Original article appeared on Self