The problem with saying high-functioning depression

Content warning: mentions of self-harm and suicide

The issues I want to address in this post are complicated with many layers. As such the real-life possible solutions are also complicated. This is also my story. A real-life story. A complex and difficult one. Hopefully by the end of this post you will appreciate two things. 1. Why the term high functioning, in the context of depression, is harmful. 2. The bias that someone who is well spoken about their mental health struggles faces.

Let’s start with some background. I was completing my PhD when I was diagnosed with depression back in 2011. I was given medication and the medication worked. I started feeling like myself again and enjoying my normal activities. Fast-forward a few years to 2019. I was hospitalized twice for suicidal thoughts. I was released pretty quickly because “I must want to get back to work.” Looking back, I am not sure if I would have gotten more serious help sooner had there not been this bias against me. Doctors look at me and see someone who is educated and assume I must be fine. There is no way I can be that depressed.

It was 2020. My symptoms are horrible. I was having suicidal thoughts and self-harming on a regular basis. My therapist and psychiatrist were trying their best to help me. They were altering meds and giving me skills to use, but I needed help. Then November 22nd came. I had a suicide attempt and had the worst hospital experience of my life. The doctors never hospitalized me for the attempt. They just kept me for the overdose. Again I was met with the line “you must want to get back to lab.” I never made such a statement or implied I wanted to get back to work. I wonder why such an assumption was made and why it was prioritized over my own safety. I was released on my own. I came home to an apartment with pills on the floor. To this day I am not sure what stopped me from attempting again, but it was a miracle.

I was not responding to my medication so I fought to get a treatment called esketamine. It is typically for people who have treatment resistant depression or depression that has not responded to your typical medication. It worked well at first, but again like other medications stopped working. I switched to another treatment, ketamine. It, like many treatments before it, worked for a small amount of time and then stopped working. I asked my doctors to try something new. This whole time I was being told I am “high functioning” and I felt like my concerns were being dismissed. I finally had a consultation with one of the doctors. I told them I was going through a severe depressive episode. I outlined how I wasn’t going to work, I wasn’t cooking, I had no motivation to shower, etc. Still at the end of the conversation I was told, again, I was high functioning. According to criteria run by doctors I was under the category of severe depression.

Let’s break this down.

Being high functioning does not mean life is easy. You are still living with depression. You are still fighting depression every single day to go to work and do “normal” tasks. For me it was staring ar the razor blades at work and trying to ignore them. Or nearly having a panic attack when things do go well. Being high-functioning does not mean your problems are not real and should not be treated. You should not have to live with that kind of burden or pain on a regular basis. Yes, it is true that our healthcare system is overwhelmed. This does not mean you have to live with this kind of pain. Your pain is real. You deserve to be treated. I view it as if you are walking on a broken leg with no cast. It is immensely painful and you might be doing it, but it doesn’t mean you have to be.

There needs to be a change. The first is acknowledging that the term in itself is harmful. It sends a message to the person struggling that the level they are at is a good one and does not need to be improved. I appreciate the need to categorize different levels of depression, but this can be done in a way that doesn’t harm the patient and in a way that doesn’t lag treatment. Bringing me to the second point, high functioning does not mean there isn’t room for improvement. Remember the analogy, the person still has a broken leg. Until we fix that broken leg, they are in pain.

The other part of my story? I wasn’t taken seriously. During this depressive episode, I was clearly not high functioning. I was not functioning at all, but there was this bias against me. If you are able to communicate clearly, you are often dismissed as being okay. Again, right after my suicide attempt, I should have been hospitalized, but instead I was encouraged to go back to work. Having the ability to communicate your needs does not mean you are okay. There is no reason for someone to be treated this way. Being able to communicate your needs is not a reason to be dismissed. The opposite is true as well. Sometimes a person might not be great at communicating their situation and because of that doctors assume their situation is worse than it is. I truly don’t believe my doctors meant any harm but the bias is so strong. They see someone who is “educated” and they automatically assume the person cannot be that sick. You absolutely can be that sick. This type of mentality is what stops many people from seeking help.

There needs to be active training on dismissing this bias. On both ends of the spectrum. There needs to be reframing around the use of the word high functioning in the context of depression. This piece is not a critique of my doctors or doctors in general. It’s my story which I know is shared by many others. I hope it causes some to pause and reflect.

As a side note: I always worry about posting my thoughts on such issues. I wonder how it will affect my job prospects, but if this can help one person? It is worth it. These difficulties I have faced have made me a better teacher and mentor. I have used them to inform how I can better help my future students.