Some people with clinical depression can't get out of bed. But what about those who exhibit other signs of depression who never stop moving, and may double down on their work?
Psychiatrist Dr. Judith Joseph says the second group often goes unnoticed, even by the people living it. She calls it "high-functioning depression": people who keep meeting their obligations at work and at home while quietly losing the ability to feel pleasure.
"When you are joyful, you have better physical health, you have better relationships, you have better productivity at work," Joseph said in an interview for the Your Turn podcast. "So why don't we prioritize it?"
At the center of Joseph's work is anhedonia: a reduced ability to feel joy, pleasure or interest in things that once brought those feelings. Joseph describes it as "the silent sister" of depression.
"One sister is depressed, and crying, and not getting out of bed, and getting all the attention," she says. "The other one is quiet and numb." Anhedonia may not seem like a crisis in the classic sense, Joseph says. "But it is an existential crisis, and it's not something to ignore."
What the research shows
In a peer-reviewed study published in the journal Cureus, Joseph and colleagues interviewed adults using a set of questionnaires designed to assess high-functioning depression, trauma and anhedonia.
The results supported the researchers' hypothesis that people with high-functioning depression have increased levels of anhedonia and trauma. Participants with higher anhedonia scores also had higher high-functioning depression scores.
Parents and caregivers had the highest anhedonia and high-functioning depression scores in the study.
The authors note that high-functioning depression is not an official diagnosis in the DSM-5, the manual clinicians use to diagnose mental health conditions. They say that is part of the problem: people who keep functioning may not recognize their symptoms or seek treatment until they reach burnout.
'Something's gonna give'
Joseph says she often sees the pattern in women who are the steady presence for everyone around them. They are so focused on their responsibilities at work and at home that they don't realize they are burned out, or close to it.
"But eventually something's gonna give," she said. "Either they do break down and they have a clinical depression and they lose their functioning, they go into distress or crisis, or they physically break down."
She said she has seen patients end up in the emergency room without understanding why, only to learn they had been carrying unresolved emotional pain.
Joseph said the pattern is common in professions that discourage vulnerability, including her own. In medicine, she said, crying after a patient died was seen as weakness.
"In medicine, we focus on the crisis," Joseph said. "You're [taught] to look for the mania, for the psychosis." She believes there should be more focus on anhedonia, the loss of sense of joy.
A self-assessment
Joseph developed an anhedonia quiz based on the Snaith-Hamilton Pleasure Scale, a measure of the capacity to feel pleasure that was published in the British Journal of Psychiatry.
The questionnaire asks about everyday experiences, such as whether you have trouble enjoying praise, whether you savor your meals or other small pleasures, and whether you struggle to enjoy your work or accomplishments because they never feel good enough.
The quiz is not a diagnostic tool. It's an invitation to take stock of what might be standing in the way of a fuller, more joyful life. If you'd like to take the quiz, you'll be asked to share your email to see the results.
Five V's
In her book, "High Functioning: Overcome Your Hidden Depression and Reclaim Your Joy," Joseph also outlines a framework she calls the Five V's:
- Validation: naming and accepting what you feel.
- Venting: expressing emotions, through talking, writing, creative expression or maybe a good cry.
- Values: making time for what matters most.
- Vision: having something to look forward to.
- Vitals: caring for your whole self (mind + body) through sleep, nutrition and movement.
Joseph says anhedonia appears across many conditions, in many people in midlife and other times, too. "It's something that we need to learn how to detect," she said, because it can be a silent problem.
If you or someone you know is in crisis, call or text 988, to reach the Suicide & Crisis Lifeline
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