The Hidden Cost Of 'Keeping It Together' (High Functioning Depression)

In psychiatry, we define a depressive

episode by impairment of function. Is

your energy level so low that you can't

go to work, you can't fulfill your

family responsibilities or take care of

yourself physically, feed yourself, et

cetera. So, when we think about

depression, we think about being unable

to function. I don't know if you guys

have seen these posts about, you know,

the messes that depressed people will

have in their homes that take hours or

days to clean up. It turns out that

there is a condition called

high-functioning depression, which is

not technically recognized in the DSM-5

or a psychiatric diagnosis, which is

actually potentially even more common

than regular depression. So, if we look

at sort of a depressive episode, the

incidence or prevalence is somewhere

between 5 and 7.8%.

So, in a given year, about 5 to 8% of

people will have a depressive episode.

If we look at high-functioning

depression, the ranges are a lot wider.

It's somewhere between 5 and 41%

with about an average rate, if you pull

together these 113 studies, the rate is

around 11%. So, what separates people

who have a mood disorder from

high-functioning depression is kind of

shocking. It is an over-reliance on

coping strategies. So, I want y'all to

think about this, okay?

So, let's say I'm in a in my life, I'm

struggling in some way. Let's say I'm a

new parent, really common for

high-functioning depression.

And as I'm not sleeping well, as my my

spouse is struggling as well, we have a

newborn at home who's crying all the

time, my spouse is taking maternity

leave, but I still have to go into work,

you know, it's really important that I

go into work because now I'm providing

for a family of two, so I'm under a ton

of stress. And so, the key thing here is

that people who don't crack under the

stress

and get into a full-blown depressive

episode will oftentimes end up with

high-functioning depression. And that's

what's so confusing about it. The way

that people are able to continue

plowing forward is because they're

actually using coping mechanisms to keep

it together. The problem is that while

these coping mechanisms may allow you to

keep it together,

they don't address the underlying

problems. So, when I'm trying to figure

out, does this person have

high-functioning depression? I'll kind

of ask myself a question. When I sit

with this person and I listen to them

talking about their lives, does this

sound like someone

who is has a boat that is taking on

water? There There's damage to the hull

and it's taking on water. And they've

got a pail and they're scooping water

out. If when I sit with someone, this is

sort of the feel that I get from them,

if it kind of feels like they're working

really hard to barely not drown.

That's when I think about

high-functioning depression. So, really

great example of this is the medical

students that I used to work with. So,

you know, these are kids that work

really hard to get into medical school.

They start studying arguably in high

school and spend 4 years in college here

in the United States. They study really

hard for the MCAT, and many of their

friends end up in med school. Many of

their friends don't end up in med

school. It's incredibly competitive. And

so, they're thrilled to finally be in

med school and now I'm going to be a

doctor. And then they wake up maybe

somewhere in first year, second year,

third year, fourth year, and they wake

up one day and they really realize, "Oh

my god,

I actually don't like medicine.

I don't like patients. Like, I had this

idea of what being a doctor is, but I

hate like spending time in the clinic or

spending time in the hospital and

dealing with patients." This sort of

happened for me. This is like how I

wound up in psychiatry. So, when I was

in med school, I was planning on

becoming an oncologist like my dad and

doing holistic cancer treatment and

saving lives and all that good stuff.

And then one day I was in the clinic and

and I was working as a with a primary

care physician, a a GP, and I realized

that like I had to look at a lot of

feet, like a lot of like diabetic

ulcerous, smelly feet. You know, this

This stuff that I I sort of appreciate

that I had this training, but you have

to deal with a lot of really nasty

smells. If y'all have worked in a

hospital, you know the smell of C. diff,

Clostridium difficile. Right? So,

there's like just a lot of nasty smells

that come with being like a real

life-saving doctor. And I just wasn't

super interested in that. And what I

loved about psychiatry, there's a lot of

bad smells in psychiatry, too, if you're

working with homeless population and in

the emergency room,

>> [snorts]

>> but it's not like you're, you know,

dealing with it day in and day out. And

then I have this outpatient practice

where I'm working with high-functioning

depression, highly successful people,

which is just so different. And most of

them smell pretty good and have good

hygiene. So, this is sort of what

happens is we have this kind of idea of,

okay, like I I worked so hard to get

into med school and I don't want to

quit. I don't want to be a quitter. I

want to be a gunner. I want to be a

doctor. I want to be successful. And

what we find in high-functioning

depression is that there is an

overemphasis

on the idea of role or identity. So, I

would say to a T, every single patient

that I've worked with who has HFD is

obsessed with the idea of living up to a

role or embodying an identity. If y'all

want more information about what the

root of those problems looks like, I

definitely recommend y'all check out Dr.

K's guide where I have five videos about

the most common problems, like the the

most common psychological complexes that

I see in my patients. Turns out these

are also the most watched videos in the

depression guide. Also really common for

new new parents, right? So, like, I want

to be a good dad. I want to be a good

dad. And good dads don't cry. Good dads

don't take days off. Good dads are there

for their wives, there for their kids.

I'm going to be a present dad. I'm not

going to be a deadbeat dad. I'm going to

spend time with my kids. I'm going to

teach him how to cook. I'm going to

teach him how to ride the bike. And I'm

going to be a good husband. I'm going to

be an involved husband. And I'm going to

be a provider and I'm going to go to

work and I'm going to work really hard,

I'm going to get promoted, and I'm going

to take my kids on vacation. This is

what it's like. They sort of have this

idea of living up to a role, and

whenever they face hardship, they will

double down on this idea of role. Now,

here's what's really scary. So, when we

get overly involved with a sense of

identity or role that we want to live up

to, this probably activates the part of

our brain called the default mode

network. The default mode network is a

part of our brain that allows us to

reflect on ourselves. So, when I think

about myself, this kind of

meta-cognition

is when the default mode network

activates. The tricky thing is that when

the default mode network activates or

hyper-activates, this is associated with

feelings of depression. So, when I have

patients who are do have mood disorders

or even HFD, right, what we tend to see

in them is that they think a lot about

themselves. Oh my god, I need to do

better. Like literally, the content of

their mind is about themselves in some

way. Now, this isn't like narcissistic.

It's not like they're thinking they're

great. It is literally, if you like map

out their thoughts, they're like

thinking like, "Oh my god, like I need

to do better. I need to be better."

Right? So, they're thinking about

themselves in a meta-cognitive way. And

we also know from many studies on things

like ketamine. So, ketamine is probably

the fastest-acting treatment for

depression, and the way that it works is

it basically shuts off the default mode

network. And when I sit with these

patients who are have full-blown

depression, you know, they're usually

thinking about how much like they're

losers and how their family would be

better off without them and how other

people are so much better than they are.

So, it's once again thinking about

yourself, thinking about yourself,

thinking about yourself. Now, in HFD,

when the default mode network turns on,

there's sort of a different spin to it,

which is they focus on role or identity,

right? Like, "I want to be a good

person. I'm not going to give up. I'm

not going to be this loser." So, they

sort of take their lived experience of

the moment. This is what I'm feeling.

This is what it's like to be me. It's

tiring. It's exhausting. I'm frustrated

with my wife, I'm angry at my kids, I'm

regretting being a parent, which is such

a scary thought to have. Like, oh my

god, like I'm annoyed with my child.

Incredibly common, right? I sometimes

wish I had never had kids. Incredibly

common. So, they have all of these

negative thoughts and then they run away

from them. They push them away and they

go towards this sort of idealized role.

We also see in high-functioning

depression a high amount of avoidant

coping. So, avoidant coping involves

denial of what you are feeling or even

denial of your circumstances. So, we'll

see some of this weird like toxic

positivity kind of stuff where they'll

like, you know, tell themselves all

kinds of things to deny their

experience. So, if I am frustrated with

my kid cuz I haven't slept in 6 months

and I'm trying to be a good husband and

trying to be a good father, then instead

of like being a about it, I'm

going to like man the up and like,

oh my god, like I have all these

negative feelings. Like, that, man.

Like, I'm not going to be that loser.

I'm not going to be someone who dislikes

their kids. I'm not going to be that.

So, they push or deny those feelings

away or they even deny their

circumstances. I'm so privileged. I'm so

lucky. Which is true, right? So, the

this is the key thing to remember about

high-functioning depression.

These are coping mechanisms. These are

things that are actually adaptive and

healthy when used in a short-term

scenario. So, if my boat is taking on

water, I absolutely want to have pumps

or a pail to like bail that water out

while I engage in more permanent fixes.

The problem with high-functioning

depression is that these people will

rely on these coping mechanisms to power

through while they keep going. The other

really scary thing is that avoidant

coping is actually associated with a

higher level of suicidality, especially

in men. And so, this is sort of what

happens with HFD. Is that we're coping,

we're surviving. I don't want to be a

loser. I don't want to give up. And then

eventually things will start to crack.

There's one other coping mechanism that

we have to talk about. And this one is

really fascinating. So this is

sublimation. So when people have HFD,

they do something really interesting,

which is that when they feel like

quitting, they actually double down and

do an even better job. So like this is

where I don't know if you guys watch

anime. Like my kids are watching Naruto

right now, which is like lots of fun

because I watched Naruto like 20 years

ago and wow, the show was moves so

slowly. Like in one episode there's so

little that goes on. But anyway, so if

you sort of look at like the way that

our society glorifies

powering through, right? So like when

someone feels like quitting and oh my

god, I'm crying and I'm sad and I'm a

loser. And they're like, "No, I'm not

going to do that. I'm going to get

better." So all of this shown in anime

is about like taking that weakness and

turning it into badassness. In

psychiatry, in psychology, we call this

the process of sublimation. So this is

something that happens like it's

literally been studied in medical

students where you feel like quitting.

When you're an undergrad and you're

thinking about going to medical school,

you feel like quitting. And what you do

is you take those feelings, you're like,

"I'm going to show that quitter in me.

I'm going to do even better. I'm going

to work even harder." So some people

discover this really, really interesting

kind of toxic but wonderful coping

mechanism of taking that negative energy

and doubling down into effort. And so

these people will will become usually

pretty successful, right? Because

instead of quitting, I'm now working

twice as hard. I'm going to show them

and I'm going to show myself. They do

this really interesting inner alchemy.

The problem is that as these people

continue to do this,

they wind up in a place that is really

not healthy or happy. Because maybe the

reason that I wanted to quit med school

was because I didn't like being a

doctor. But if I use sublimation and

double down and show the world that I'm

not a quitter. I will end up in a

profession I don't enjoy, right? So,

that's like really scary. And that's

what I see in high-functioning

depression. I see people who come into

my office and have a midlife crisis, or

a quarter-life crisis. And these are

people who, when they felt like

quitting, they didn't want to be a

loser, so they kept going. And then they

end up getting promoted, which is great

on the surface, except now you've got 5

years into this career that you don't

enjoy. And then you've got 10 years into

this career that you don't enjoy,

because you're not a quitter. So, it's

kind of scary, right? Because then then

you're sort of in this situation where

it's like, "Okay, do you want to not be

a quitter, but end up miserable every

day doing something that you don't

enjoy?" And people with HFD will be

like, "Fuck yeah, son. That's exactly

what I want." So, this is when things

get really scary, because what we see

with HFD is that a lot of people end up

cracking, okay? They'll end up sort of

the coping mechanisms, since you're sort

of propagating a system that you're not

happy with, you're denying your negative

feelings, you're always doubling down

and pushing forward, you may wind up in

a situation that you don't enjoy at all.

And at some point, sometimes what

happens is you're you've been bailing

water for so long that you get

exhausted, and eventually things will

end up overtaking you. There's about a

three-to-four times risk, uh

compared to the regular population of

people with high-functioning depression,

winding up depressed eventually. So,

it's about a 300-to-400% risk that at

some point your coping mechanisms

mechanisms will fail. Now, for a lot of

people, this doesn't happen, right? So,

just because there's a three-to-fourfold

risk, doesn't mean it's permanent by any

means, or that it's going to happen to

everybody. I've worked with a lot of

people who are like parents who have a

really tough period, and once they start

sleeping again and processing their

emotions, and they start having sex

again, you know, then things can

actually get a lot better. So, it's It's

that this happens to everybody. But

eventually things do kind of feel

overwhelming. So now the question

becomes, okay, so if you've got high

functioning depression, what do you do

about it? And so this is where we have

to understand a couple of basic things.

The first is that coping mechanisms are

great, but you have to solve your

underlying problems, right? If my

boat is taking on water, I got to patch

that up. So often times what I'll do

with with people who have HFD is the

first thing that we'll do is take a

serious look at your life. And what

we'll sort of do is I'll I'll kind of

give them this exercise where like

nothing is off the table, okay? So in

psychotherapy this becomes really

important because when I offer a

reflective listening, right? When

someone says, "Yeah, I'm kind of tired

from having, you know, kids and stuff

like that. Like I want to be a good dad,

but you know, I'm tired." And then

sometimes I'll be like, "Yeah, man, it

really sucks, dude. Like, you know, is

there any part of you that regrets

having children?" Right? And you got to

ask that question in a very specific

way. You got to create a a space that is

safe because if I ask them, "Do you

regret having children?" they're going

to be like the avoidant coping mechanism

will say, "No." Denial of problem. No,

I'm lucky. I'm blessed. So many people

are struggle to have children and I

should be grateful. It's such a

privilege. But if you pay attention to

their words, what you'll notice is that

there's little cracks around their toxic

positivity. So the first thing that you

have to do is acknowledge that you

actually have problems and let those

negative emotions come to the surface.

The second thing that we have to focus

on with high functioning depression

is this idea of a role. And the problem

with this is that often times what my

patients will do is they've invested so

much in the role that it feels really

hard to quit, right? So I had this idea

of being a doctor when I was like 15

years old and I invested my high school

years, I invested my college years, I

invested so much and now I don't want to

quit. They have this idea of being a

quitter. So what I'll ask my patients is

is maintaining the role worth

sacrificing your life? And ultimately,

overcoming high-functioning depression

is about understanding that you are

using these coping mechanisms to

propagate a life that is fundamentally

flawed. And as we start peeling back

those layers, then we can get to the

root of the problem, which is ultimately

what you have to solve. So, if y'all are

struggling with waking up every day and

feeling like there's no joy in life, if

you have spent your whole life devoting

yourself to a particular role, consider

high-functioning depression and consider

talking to someone to get some help

about it.