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Some people with clinical depression cannot get out of bed. But what about those who show other signs of depression, who never stop moving and may try harder?
Psychiatrist Dr Judith Joseph says that the second group often goes unnoticed, even by those who experience it. She calls it “high-functioning depression”: people who continue to fulfill their obligations at work and 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 not prioritize it?”
At the center of Joseph’s work is anhedonia: a reduced ability to feel joy, pleasure, or interest in things that once caused those feelings. Joseph describes it as the “silent sister” of depression.
“One sister is depressed, she cries, doesn’t get out of bed and doesn’t get all the attention,” she says. “The other is calm and numb.” Anhedonia may not feel like a seizure in the classic sense, Joseph says. “But it’s 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 surveyed adults using a set of questionnaires designed to assess high-functioning depression, trauma, and anhedonia.
The findings support 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-function depression scores.
Parents and caregivers had the highest anhedonia and high-level depression scores in the study.
The authors note that high-functioning depression is not an official diagnosis in the DSM-5, the manual used by clinicians to diagnose mental health problems. They say that’s part of the problem: People who continue to function may not recognize their symptoms or seek treatment until they reach burnout.
“Something is going to give”
Joseph says she often sees this pattern in women who are a constant presence to everyone around them. They are so focused on their responsibilities at work and at home that they don’t realize they are exhausted, or almost exhausted.
“But eventually something will give,” she said. “They either break down and have clinical depression and lose functioning, or they go into distress or crisis, or they physically break down.”
She said she’s seen patients end up in the emergency room without understanding why, only to learn they were carrying unresolved emotional pain.
Joseph said this pattern is common in professions that discourage vulnerability, including his own. In medicine, she said, crying after a patient dies is considered weakness.
“In medicine, we focus on the crisis,” Joseph said. “We (you were taught) to look for mania, psychosis.” She thinks we should focus more on anhedonia, the loss of the feeling of joy.
A self-assessment
Joseph developed a anhedonia quiz based on the Snaith-Hamilton Pleasure Scale, a measure of the capacity to feel pleasure 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 have trouble enjoying your work or accomplishments because they never feel good enough.
The quiz is not a diagnostic tool. It is an invitation to take stock of what could stand in the way of a fuller and more joyful life. If you want to take the quiz, you will be asked to share your email to see the results.
Five Vs
In her book “High Functioning: Overcome Your Hidden Depression and Reclaim Your Joy,” Joseph also describes a framework she calls the Five Vs:
- Validation: name and accept what you feel.
- Ventilation: express emotions, through speech, writing, creative expression or maybe a good cry.
- Values: take time for what matters most.
- Vision: have something to hope for.
- Vitality: take care of yourself as a whole (mind + body) through sleep, nutrition and movement.
Joseph says anhedonia appears in many conditions, in many people in quarantine and at other times as well. “It’s something we have to learn 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.
Want to know more? Follow it Your Turn Newsletter and listen to it Your Turn Podcast on the NPR app or wherever you get your podcasts.
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