I’ve worked in the mental health field for about five years, and in those five years, I’ve worked in different treatment settings, with different populations, and had my fair share of treating and supporting people who suffer from depression and suicidal thoughts. In most cases, these clients have had debilitating symptoms that have resulted in multiple hospitalizations or treatment center stays over their lifespan. They often have other co-occurring diagnoses, and/or struggle with substance abuse or other maladaptive behaviors such as self-harming.
Their symptoms and behaviors are so unmanageable that they struggle to live a productive or seemingly fulfilling life. They stop going to work or school, they stop hanging out with friends, they appear sad or distressed most of the time, and they lack a general sense of motivation or interest in anything. The people closest to them can usually pick up on the fact that something is wrong or off because their behavior isn’t in alignment with the person they’ve known them to be. The person doesn’t have to come out and say “I’m depressed” or “I’m suicidal” because they begin to wear their depression and/or suicidality on their sleeve and this allows for their support system to intervene or try and offer help.
What if the mental illness isn’t easy to spot?
But what happens when a person wears their mental illness well? What happens when the depression and suicidality aren’t as east to spot and you can’t see the downward spiral? How do we support a person when we have no inclination that they are suffering or that they are merely moments or one tough circumstance away from being motivated to check out on life?
After all of my experience with depressed and suicidal clients, this year was the first time I was personally affected. In this past year, I’ve known three highly functioning people that have committed suicide. I wasn’t extremely close with any of the three, but from what I knew and could see, they all appeared to have meaningful and fulfilling lives with support systems that loved and cared about them. The last of the three, a college friend, was in medical school, she was a social butterfly, traveled the world, and was going to change lives. She took her own life two days before Thanksgiving and her death motivated me to write this piece.
It was through experiencing and processing the loss of these people that I realized that there is huge a deficit that exists in addressing what I would consider a silent killer, the combination of high functioning depression and suicidality.
What is high functioning depression?
I firstly want people to understand that depression is different from general sadness, it’s a combination and criteria of symptoms that last a minimum of 2 weeks. Sadness is typically a symptom of depression and other symptoms can include, loss of interest and pleasure in things that once brought joy, hopelessness, worthlessness, or guilt, significant weight loss or weight gain, excessive sleeping or crying, difficulty concentrating and staying committed to tasks, and loss of energy or recurrent thoughts of death. In the mental health field when people refer to depression, they are usually referring to Major Depressive Disorder. The media has convinced us that depression only looks one way, the sad, gloomy, can’t get out of bed narrative.
Over the years people have coined the term “High Functioning Depression” to describe the experience of people who may not meet every criteria of the diagnosis yet still experience intense symptoms of depression. These symptoms can look like going to work or other commitments but isolating, sleeping, or crying immediately after. Spurts of excessive irritability and anger or feelings of inadequacy. Heavily drinking or using substances when not at work or fulfilling other obligations, and/or forcing themselves to participate in social activities. Caretaking for others and putting themselves and their needs last, putting value into others because they don’t see it in themselves. Constantly being in social settings or unhealthy relationships because being alone with themselves is too painful. Feeling tired all of the time even when they get adequate amounts of rest, gaining or losing weight unintentionally, doing regular tasks feels like a huge chore, and feelings of happiness are usually fleeting and don’t last long. They can be so emotionally drained from having to be “normal” and functioning in public that oftentimes other parts of their life are being unkempt or falling apart.
How is depression diagnosed?
When counselors or social workers are taught in their grad school programs how to go about diagnosing, we learn early on that there are levels of severity when it comes to a diagnosis, mild, moderate, and severe. Following a diagnostic criteria strictly by the DSM-V isn’t always a full-proof science, however. A person could meet only a few of the criteria (which is where the high functioning part comes in), be diagnosed as having mild or moderate depression, and still have intense moments or phases of severity associated with emotional dysregulation and suicidal thoughts. When people suffer from depression but are highly functional, they can even minimize what they are experiencing by passing it off as “going through a funk or phase” or just being tired. People may tell them, “Oh you’re just going through a rough patch” or “you’ll be alright”, further emphasizing that what they’re experiencing will just pass. But depression in any form doesn’t just pass, a person has to learn to manage it.
Suicide and depression
What makes the combination of high functioning depression and suicidal ideation so lethal is the fact that being high functioning creates such an illusion to others that everything is ok, that when a person acts on taking their own life, there is overwhelming shock and confusion that follows. When a person takes their own life, people often refer to their death as “they died from suicide” and that actually isn’t the case. People don’t die of suicide they die of depression. Suicide is the action urge to solve the problems that come with depression because the symptoms are too painful and discomforting to bear. When a person takes their own life, there are usually a lot of questions that exist for the people closest to them. They often say, “I never would’ve known” or “how could we not see that coming” and the truth is the person more than likely doesn’t want others to know or see it.
People with high functioning depression that commit suicide can be high achievers in many aspects of their life while internally struggling with emotional distress for a long time. They put on a brave and happy face for the sole purpose of convincing others that things are fine, especially when they’ve made up their mind already about what they want to do. Don’t be mistaken however, all suicides aren’t planned, many are impulsive, an act of making a permanent decision driven by overwhelming and debilitating emotions at the time. It’s the impulsive suicides with no preparation (such as giving away belongings), a suicide note, or explanation left behind that can be an indication that the thought had existed in the person for a while and they just finally reached a place of developing true intent.
When people commit suicide, the first thing the people closest to them do is make it about themselves, “how didn’t I know”, “why didn’t you come to me”. Although it is normal for people to harbor guilt associated with losing someone to suicide, I’m here to tell you that suicide has nothing to do with other people. It ultimately doesn’t matter how happy we’ve perceived the person to be. The pain and agony of living becomes stronger than the will to live. Their needs are just no longer being met with external factors and so they make the choice to not have to wake up every day feeling the heaviness of living life. When someone becomes committed to this, unless they are in treatment, there’s nothing you could’ve done to stop them.
You’d be surprised by the number of people who have passive suicidal thoughts like “I wish I could go to sleep and not wake up”, or “maybe the world would be a better place if I wasn’t around”. Many people would tell you that they would never actually kill themselves but the option of being able to check out on life has crossed their minds in times of struggle or being emotionally overwhelmed. Most people would never openly discuss having these thoughts with others due to potential judgment and stigma or being deemed “crazy”, but the reality is by not having a safe space to discuss these thoughts; we don’t give ourselves the opportunity to receive support or intervention. We’ve just begun to make the conversation around mental health speakable and normalized but there is still a lot of stigmatization that exists within the African American community around this topic.
Mental health issues in the Black community
Many Black people have been met with the “What you got to be depressed about?” approach to their expression of their problems. Narratives such as the “strong Black woman” have kept us from seeking help for decades, convinced that we are supposed to carry life’s problems all by ourselves. In our community, celebrities come forth and speak on having mental health issues and people are all “Mental health matters” until the person behaves in a way they don’t understand or don’t like and then they’re being dragged or made fun of on the internet.
If many of us don’t have a safe space to discuss struggles with mental health, God forbid we ever talk about wanting to rid ourselves of it all. We’d be met with clichés like “Just go to church and pray on it”, or “stay strong” and even though the people telling us these things are doing so with good intentions, these phrases are just not enough to instill hope that there is light at the end of the tunnel. In my experience, a lot of people spit out a cliché when someone is venting to them about struggling mentally or emotionally because they really don’t know what else to say. They don’t know how to support someone who is in pain or struggling to see the value in life. They can’t relate to being in a place of extreme hopelessness or running out of resiliency. They don’t realize that just sitting and listening to what the person is saying and validating their feelings is enough.
How to support loved ones
There are steps we can all take to be of better support to those around us. The first thing we can do is listen. We all need to do a better job of genuinely checking in with our loved ones, actively listening to them, and creating a safe space for them so they know they can be vulnerable with us. Check on everyone, not just people you perceive to be strong. Get out of the habit of using social media as a means to check on people. People only show you what they want you to see and they’re not going to post “I’m dying inside”. And honestly, we’re so conditioned to skim past posts, if someone was posting cries for help, it’s likely that we wouldn’t notice them until it is too late. If you suspect someone is struggling mentally or emotionally, support them in finding treatment or a therapist. Depression can cause people to be so unmotivated that the person can’t find the resources on their own, so ask them if they need help finding a professional and follow up with them about it.
Understand that a person being on medication is never enough. Anybody’s primary care physician can prescribe an antidepressant. Medication only helps with the chemical imbalances in the brain, it will not teach someone the proper skills to help manage their depression or suicidality. Lastly, health professionals and providers, have to step up and advocate for systemic changes. There are so many people who need help and who seek help but do not have access to resources due to not having the best of the best insurance. Medicaid, Medicare and government-assisted insurance holders are falling through the cracks especially when it comes to quality and accessible mental health services. Don’t just write a script when told that someone is struggling with depression, research and educate them on the treatment options available to them.
People with high functioning depression wear a mask that is extremely hard to see behind. If you’ve lost someone due to them taking their own life, do not allow guilt to consume you because that weight is not yours to carry. People have different ways of achieving peace and we have to learn to accept that even when we don’t understand it. We just have to remember that just because a person carries their mental illness well, doesn’t mean it isn’t heavy. If you struggle with any sort of mental health issue just know that help exists. Your doctor, your job, your insurance provider, the internet are all resources available to get you connected with a mental health professional. Therapyforblackgirls.com and melaninandmentalhealth.com are also great websites that connect people with clinicians of color all across the country. Therapy and treatment can be life-changing and they can also save a life.