People with depression don't always feel swamped or struggle to complete tasks — some are remarkably efficient and productive, despite their low moods. So it can't be that serious, can it? Wrong!
This article addresses the subject of depression and suicide. Reader discretion is advised.
If you are dealing with severe emotional distress or suicidal thoughts, do not hesitate to reach out for professional assistance. You can locate details on where to find such help, regardless of where you live in the world, at this website: https://befrienders.org/
It's Sunday morning, somewhere between 5 and 6, when I suddenly wake up with a start. Immediately, countless unfinished tasks flood my mind. I leap out of bed and begin moving. This has been my routine for years.
I handle the laundry, the dog, and make breakfast. I work out while contemplating the upcoming week and how draining it will be. I'm exhausted. I'm perpetually exhausted.
Soon after, my son tells me he has misplaced his bank card. It's not a big deal, really, but something inside me breaks and suddenly I'm sobbing, telling my husband that I'm finished with this life. "Can you look after my child when I'm gone?"
My sudden collapse was set off by something so minor and trivial that it frightens me.
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Depression and motivation
Two years ago, I was diagnosed with depression. I attend therapy once a week. For a long time, I believed that was sufficient. After all, I could always go to work, care for my family and our home, and even socialize.
Now I'm in a day clinic, surrounded by people with depression for whom simple tasks like washing dishes demand an enormous effort. Some lack even the energy to get out of bed. For many of them, going to work or exercising is simply out of the question.
It's the opposite for me. The worse I feel, the quicker I move, racing through daily life. I've heard of the non-clinical term "high-functioning depression," which refers to those who experience depressive symptoms but retain their drive. From the outside, those affected seem efficient and productive. This describes how my life feels to me: a highly efficient nightmare.
Not a formal diagnosis
High-functioning depression is not a formal diagnosis in the International Classification of Diseases (ICD-10). Therefore, it is not a mental health condition that psychiatrists or psychologists can officially diagnose.
"I don't think much of the term 'high-functioning depression,'" said Ulrich Hegerl, a psychiatrist who chairs the board of the German Depression Aid and Suicide Prevention Foundation. "It's a trendy term that keeps resurfacing."
Hegerl noted that the fact some individuals remain driven despite having depression could be linked to their personalities. "Even when they are well, people who suffer from depression tend to be those who are there for others — dedicated, responsible, unwilling to let others down, and determined to keep going until their very last bit of energy," he explained.
But at home, Hegerl said, these individuals collapse into bed completely drained, their energy gone.
"A sense of exhaustion, constant inner tension, feelings of guilt, appetite disturbances, sleep problems, a tendency to worry — these are all typical signs of depression found in people with 'high-functioning depression,' just like everyone else," Hegerl said.
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Daniel Huys, a specialist in psychiatry and psychotherapy and head physician at LVR Clinic in Bonn, also doesn't use the term. Instead, he said, his clinic diagnoses the severity of depression, classifying it as mild, moderate, or severe.
"High-functioning depression isn't in the ICD-10," Huys said. "But that doesn't mean it doesn't exist." He noted, however, that the patients he has encountered tend to be people who can no longer handle the demands of daily life and are falling apart.
Depression concealed by success
That's precisely the issue. "I think the biggest misconception is that just because that person appears outwardly successful or productive or whatever it might be, their suffering is typically downplayed because of those things," said Adrianne McCullars, a psychologist at Rogers Behavioral Health, a network of clinics for treating mental illnesses in Tampa, Florida.
She said the term "high-functioning depression" could help make this form of depression easier to identify. Many people think: As long as I can still get up and get things done, it can't be that bad. But that is dangerous — depression is the most common factor in suicides in Germany and many other countries.
McCullars also challenged the idea that high-functioning depression is a milder form of the illness. "A lot of individuals do in fact become more driven or even overproductive when they're feeling those depressive symptoms as a way to cope or avoid," she said.
Performance becomes a coping mechanism
I experienced this myself. I thought: If I just get everything done quickly, the to-do list will shrink and I won't feel so overwhelmed. If I keep moving, the exhaustion won't hit me until evening, when I can finally sleep. If I accomplish enough, I can keep the persistent guilt I constantly feel at bay — toward my family, my colleagues, my friends.
This efficiency and achievement, highly valued by society, can serve as a distraction, said Daniel Wagner, a psychotherapist with his own practice in Cologne.
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When the deep suffering of depression is hidden behind performance and success, it's often to avoid silence and quiet, "in which a state becomes apparent that is difficult to bear," Wagner said.
Mindfulness as a strategy for depression
In therapy, Wagner said, the goal is for patients "to get in touch with their feelings, to enable access to emotions, and to allow for recovery." Mindfulness exercises are well-suited for this — the psychotherapist calls it "organized hanging out."
This can include breathing exercises or guided meditations, where the aim is not to change anything, but simply to be present and observe. Wagner said he integrates such periods of recovery into his patients' daily routines in a structured way.
The psychologists at the clinic proceeded similarly. I received a weekly plan to help me structure each day: work, housework, exercise, and things that I enjoy and that are good for me. For me, the last point remains the biggest challenge and the most painful issue.
In the quiet, my mind grows louder, the feelings more uncomfortable. I desperately want to run away again, to avoid the responsibility of dealing with myself. That means: stopping, enduring, doing nothing.
This article was originally written in German.