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Behind the smile: The silent struggle of high-functioning depression in women

25 August 2023

Women are rightfully praised for their strength and resilience, yet their silent struggles often go unnoticed. Did you know that around twice as many women experience depression than men? The problem is many of these women will live their lives as normal without ever letting on that they suffer from high-functioning depression.

According to Dr Ayanda Mbuli, high-functioning depression is a deceptive adversary. Unlike its more overt counterpart (major depressive disorder), it disguises itself beneath achievements, responsibilities, and seemingly 'normal' lives.

In South Africa, the prevalence of mental health issues, including high-functioning depression, has been a concern. A survey conducted by the South African Depression and Anxiety Group (SADAG) indicated that around 30% of respondents reported symptoms of depression, and this figure might be higher when considering high-functioning depression where individuals appear functional on the surface while struggling internally.

Globally, it is estimated that depression affects around 264 million people worldwide, according to the World Health Organisation (WHO). Many of these individuals may be dealing with high-functioning depression, especially in societies that place a strong emphasis on achievement and success.

"Women who experience high-functioning depression may excel in their careers, maintain active social lives, and fulfil familial duties while concealing their emotional turmoil. This phenomenon often leads to their struggles being overlooked or dismissed," Mbuli says.

She says South Africa's history is one of resilience and transformation but is also marred by inequality, discrimination, and social pressures. For women, the burden can be even heavier.

"Traditional gender roles and societal expectations add to the weight they carry, making it harder to express vulnerability. This cultural backdrop can exacerbate high-functioning depression, forcing many women to bear their emotional burdens silently," says Mbuli.

She says the below are some of the tell-tale signs of high-functioning depression:

• Persistent feelings of sadness: While individuals with high-functioning depression may appear cheerful on the outside, they often battle constant feelings of sadness, emptiness, or hopelessness in their inner world. These emotions can be overwhelming and challenging to manage.
• Overwhelming fatigue: Despite managing their responsibilities effectively, those with high-functioning depression may experience extreme fatigue and low energy levels. Simple tasks that were once effortless might become physically and mentally draining.
• Decline in interest and pleasure: A noticeable decrease in interest or pleasure in activities that were once enjoyed can signify high-functioning depression. Hobbies, social gatherings, and even personal relationships may lose their appeal.
• Difficulty concentrating: High-functioning depression can lead to difficulties in focusing, making decisions, or concentrating on tasks. This can impact work performance, further contributing to the internal struggle.
• Disrupted sleep patterns: Insomnia or irregular sleep patterns are common among individuals with high-functioning depression. On the other hand, some individuals might find solace in excessive sleep, using it as an escape from emotional distress.
• Appetite changes: Fluctuations in appetite, resulting in weight loss or gain, can indicate high-functioning depression. Emotional eating or loss of interest in food may also be observed.
• Feelings of guilt or worthlessness: Individuals may experience intense feelings of guilt, worthlessness, or self-criticism, even if there is no objective reason for such emotions. These feelings can contribute to a cycle of negative thoughts and emotions.
• Concealed emotional turmoil: Perhaps the most defining characteristic of high-functioning depression is the ability to hide emotional pain behind a facade of normalcy. Individuals may excel at work, engage in social activities, and fulfil responsibilities while privately battling internal distress.
• Social withdrawal: While some may maintain social engagements, others might gradually withdraw from friends and family, finding it difficult to engage in meaningful interactions.
• Physical ailments: High-functioning depression can manifest in physical symptoms such as headaches, muscle aches, and digestive problems, further blurring the lines between psychological and physical well-being.

Dr Mbuli says breaking through the walls of silence surrounding high-functioning depression is crucial, especially for the mental wellbeing of South African women – who often form the bedrock of their households and communities.

Speaking to what can be done to address this complex issue, she says, education is the first step toward solving the problem of high-functioning depression. We need to promote awareness campaigns that shed light on the nuanced nature of mental health, particularly in the context of high-functioning depression, can help debunk misconceptions and reduce stigma.

"Additionally, we need to create accessible mental health resources that cater to the diverse needs of South African women. This includes offering counselling services that respect cultural sensitivities and linguistic diversity," she adds.

"Breaking the silence around high-functioning depression is a collective responsibility. Families, communities, and the society at large must unite to create an environment where women feel safe to seek help and embrace their vulnerability. Remember, the strength to heal often begins with the courage to share the pain," Dr Mbuli concludes.