High functioning depression: Are you or a loved one suffering in silence?

‘Holding it together’ doesn’t mean everything’s okay

Thursday, September 1 2022

The almost unnoticeable signs of high functioning depression (HFD) can hide a serious and potentially life threatening deterioration in mental health. While a person living with the condition may continue working and ‘holding it together’ for years, family members should be aware of the symptoms and encourage their loved one to seek professional help.

“Generally, people associate depression with characteristic symptoms such as an overwhelming sense of hopelessness and inability to continue coping at work and in other areas of their lives,” says Phumzile Mthembu, a clinical psychologist practising at Netcare Akeso Richards Bay.

“People who are always busy hardly find time for their emotional and psychological wellbeing. Even while experiencing symptoms of HFD, they shoulder this mental health burden yet manage to carry on with their lives by learning to manage and cope for as long as they are still functional,” she says.


Individuals with high functioning depression may therefore not receive the support they need even when the disorder continues to affect their lives over many years. HFD is also known as persistent depressive disorder [PDD], as the symptoms must be present for at least two years before a person can be diagnosed with HFD.  

“Eventually, HFD may lead to feelings of despair and hopelessness, and in the most severe cases the person may have suicidal thoughts – often before anyone else recognises their suffering,” Mthembu explains.

12 possible symptoms of an ‘almost invisible’ disorder
“A person with HFD and those closest to them may not necessarily realise that the individual affected is depressed because the disorder is almost invisible, in that it does not prevent the person from continuing their daily functions,” Mthembu says.

HFD is only diagnosed where a person experienced mild, yet persistent depressive symptoms for at least two years, and people often learn to live with this mental health burden. “People living with HFD often think that they have everything under control because they have developed a higher ability to cope. Their outward appearance suggests that all is well, and others around them may not even notice that the individual is suffering,” Mthembu says.


“This mental health burden is therefore very hard to identify, as people with HFD can still get out of bed and go to work or engage in social or family obligations without anyone noticing the emotional turmoil they endure privately.”

The symptoms of high functioning depression vary from person to person, and the following are some of the possible signs and symptoms associated with the condition:

  1. Feeling concerned with time: You feel like you are ‘wasting your time’ when doing your work, or engaging in personal activities such as hobbies, going to gym, etc
  2. Feeling misunderstood
  3. Indulging in unhealthy coping strategies such as substance use, overeating, etc
  4. Engaging in excessive pastimes to escape reality, which may include excessive gaming, TV watching, use of social media, etc
  5. Being overly critical of yourself and others
  6. You always convince yourself that you are “okay”, even when you feel overwhelmed.
  7. You hardly engage in social activities such as going out with friends, taking part in hobbies or outings, but only focus on tasks you feel obligated to
  8. Experiencing feelings associated with psychological distress when thinking about work, which might appear as burnout
  9. Excessive guilt and worry about the past and present life that takes over your thought patterns
  10. Chronic fatigue, excessive tiredness
  11. Feeling like you can’t face the world or cannot get of out bed
  12. Depressed mood for most of the day over a period of at least two years, as described either by the person or as observed by others

Signs of concern
In addition to being depressed, the person would also experience at least two of the following: poor appetite or overeating; difficulty sleeping or oversleeping; low energy or fatigue; poor self-esteem; poor concentration or difficulty making decisions; and feelings of hopelessness, to be diagnosed with HFD.

“Family members, colleagues and friends may also describe a person with HFD as a ‘workaholic’ and would perhaps notice signs of social withdrawal, mood swings, excessive use of alcohol, drugs or cigarettes, and that the person often experiences a sense of ‘guilt’ over their perceived shortcomings.

“It is also important to be aware that a person with HFD may begin to show subtle signs of suicidal ideation, such as talking of their own death or suicide, or getting their affairs in order. Signs such as these should never be ignored, and they should be encouraged to seek professional help as soon as possible,” Mthembu advises.

Assistance and advice available
In the event of a psychological crisis, the Netcare Akeso crisis helpline is available 24 hours a day. Simply call 0861 435 787 to talk to an experienced counsellor, or for more information about mental health services and accessing care for yourself or a loved one. The South African Anxiety and Depression Group (SADAG) also provides mental health support and can be reached on 0800 567 567.

“An assessment with a trained psychologist and specialist psychiatrist is required for a mental health diagnosis and for any disorders, including HFD, to be treated properly according to a biopsychosocial model,” Mthembu says.

“Learning more about the condition can also assist a person with high functioning depression and their families in developing insight and healthy coping strategies. Be vigilant about burnout, as HFD can make one more susceptible. Joining support groups can also be helpful for strengthening one’s resilience.

“Families and loved ones can support the person by strengthening communication with them and validating the person with an understanding of what they are experiencing. Focus on what you can do to help the person feel they are not alone, but also allow yourself time and space for your own emotional wellbeing.”


About Netcare Akeso
Netcare Akeso operates a network of private inpatient mental health facilities and is part of the Netcare Group. Netcare Akeso provides individual, integrated and family oriented treatment in specialised inpatient treatment facilities, as well as certain outpatient services, for a range of psychiatric, psychological and substance use conditions. Please visit or contact [email protected] for further information. The COPE Therapy website also contains many useful blog posts on various issues and tips relating to mental health.
In the event of a psychological crisis, call 0861 435 787, 24 hours a day for emergency support. Psychiatrist consultations can be made through Netcare appointmed™, online at or by calling 0861 555 565. Outpatient psychologist and occupational therapist consultations can be booked via

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