Monique Judge, 46, describes herself as "an extroverted introvert." She's always active and on top of things at work, takes part in regular yoga classes, and frequently goes out with her friends—even though she prefers unwinding in front of the TV at home. But seven years ago, after shooting up the consumer finance career ladder, she started feeling tired all the time. When she wasn't working, she couldn't motivate herself to get out of bed. Instead, she just lay in all day, sleeping on and off. A friend recognized her symptoms and eventually recommended Judge see a doctor. The diagnosis, it turned out, was depression.
"I still have extreme low points," Judge says. "I've quit that job and I'm at a brilliant position in my career, but there's always a cloud that I'm trying to avoid, that you might not even recognize from the outside."
This is the ordeal for millions of Americans who have depression: always "on" because of high-pressure jobs, sleep-deprived and feeling like you just have to continue keeping your chin up. Many don't realize that depression can lurk in the background, allowing you to go through the motions but still depriving you of the ability to live life to its fullest.
There are nine different types of depression a person can be diagnosed with, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) that mental health experts use. While "high-functioning depression" isn't an official term for any of them, and has even been debated on social media, it's what many like Judge use to describe their condition. Part of the reason is that they don't fit the stereotypical image of a depressed person, the one put forward in antidepressant ads and TV dramas. They may not be skipping work, withdrawing from social activities, feeling hopeless or crying all the time. In fact, they may be honors students in college, business executives, physicians, journalists, startup employees, or any of a variety of seemingly confident, successful individuals.
"Depression is a very heterogeneous condition," says Michelle Craske, a professor of psychology and psychiatry at UCLA. "It takes a lot of different forms in terms of its severity and in terms of what it looks like in the actual symptoms. We should not dismiss the mild forms because it's still a struggle and there's still a value to getting treatment," she says.
On the surface, high-functioning depression may seem like it's easier to deal with, but it can persist for years, leading to more functional impairment over time than acute episodes of major depression, Craske says. Research has shownthat the low self-esteem, lack of energy, irritability, and decrease in productivity that accompanies persistent depression is associated with significant long-term social dysfunction, psychiatric hospitalizations, and high rates of suicide attempts. And, ironically, persistent depression also puts people at a higher risk for major depressive episodes with more severe symptoms.
But the stigma around mental illness—or any signs of weakness—prevents people from revealing their stress to friends and colleagues. In some cases, racial and ethnic minorities as well as immigrant populations may feel even more pressured to hide their condition with jokes and laughter. "If you admit that you're depressed or you have a mental health issue, people on the outside, who are not dealing with that, automatically label you as being crazy," Judge says.
When Sen was in medical school, one of his childhood friends, who was a training as a resident, jumped off a balcony in an attempt to take his own life. Sen's friend—who now works as a physician in Canada and requested to be referred to as "Dr. K"—didn't reveal that he had depression to his university chairman, dean, or fellow medical residents. "There's a fear of the consequences, of what will happen if you're open about your condition," K says. "You wonder if the college will do anything, if your supervisors will question your abilities, if the medical board will take away your license, restrict your practice and so on."
A lot of the things that make people susceptible to mental illness tend to be the same qualities that make them leaders in their fields. People prone to depression are more likely to be attentive, empathetic, willing to be vulnerable, and open to different experiences, K says. That has led Sen and other psychiatrists to focus their research on understanding the underlying biological pathways that contribute to depression. "As we make progress, we're starting to see that depression is just as biological as diabetes or high blood pressure or cancer," he says.
Recently, scientists have found that depression is highly heritable. In other words, the tendency to become depressed is almost completely genetic in nearly half of all cases. In other cases, it's not really genetic at all. And sometimes, it's a combination of genetic and psychological or physical factors like past trauma, big life changes, chronic illness, and out-of-whack hormones.
Brain scans of people with persistent high-functioning depression also show that regions associated with inward thinking or rumination are hyperactive. These regions, one of which is called the Default Mode Network, could be the basis of negative thoughts about oneself. And studies have shown that certain pharmaceutical drugs, meditation, and psychotherapy all help to tame these overactive networks.
But psychiatrists can't point to a brain scan, a genetic test, or other biomarker and say what depression looks like. "That's the dream," says David Hellerstein, a research psychiatrist at the New York State Psychiatric Institute. "That's something you can do in a lot of other fields of medicine, but not in psychiatry because of how variable depression is and how many different types of conditions fall under the umbrella of depression." It's also why pharmaceutical treatment of depression is so uncertain, Hellerstein says.
When psychiatrists prescribe medication for depression, their first choice is usually antidepressants. These drugs target serotonin, a chemical in the brain that affects mood. They often have unpleasant side-effects and don't even produce any helpful effects in up to two-thirds people with depression. Then patients have to try a different medication, or use combination of medication and psychotherapy, Hellerstein says. Arriving at the right treatment can take time.
Judge, who's now based in Los Angeles, says yoga and psychotherapy have helped her. "Depression is something you can get help for, and there are other people out there who are going through it too," she says. Talking to psychiatrist, a friend, or a family member can be extremely helpful. But the burden of opening up shouldn't just be on individuals who have depression, she says. "You can go to Planned Parenthood and doctors there will ask you questions about women's health and take care of you, but those services and that kind of understanding should also be there for people with mental health issues."