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, etc.

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 DSM5 or psychiatric

diagnosis which is actually potentially

even more common than regular

depression. So if we look at sort of a 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 you 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 often times 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? They're 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 four 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 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 is stuff that I I sort of

appreciate that I had this training, but

you have to deal with a lot of really na

nasty smells. If y'all have worked in a

hospital, you know the smell of sea

diff, claustrodium difficil, 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, 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 te 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 you

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 the

part of our brain that allows us to

reflect on ourselves. So when I think

about myself, this kind of metacognition

is when the default mode network

activates. The tricky thing is that when

the default mode network activates or

hyperactivates, 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 metacognitive 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 were

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 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 pale 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 is

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 in 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'mma show that quitter in

me. I'm gonna 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 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 you've been bailing water

for so long that you get exhausted and

eventually things will end up overtaking

you. There's about a 3 to four times

risk uh compared to the regular

population of people with high

functioning depression. winding up

depressed eventually. So there'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 four-fold 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 start

having sex again, you know, then things

can actually get a lot better. So it's

not 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 uh

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 this exercise where like nothing is

off the table. Okay. So in psychotherapy

this becomes really important because

when I offer 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. Well, no. Denial of

problem. No, I'm lucky. I'm blessed. So

many people 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. 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.