“I think the saddest people always try their hardest to make people happy because they know what it’s like to feel absolutely worthless, and they don’t want anyone else to feel like that.”
― Robin Williams.
While high-functioning depression is not a medical diagnosis, it accurately captures the state of a growing number of people. It is particularly visible in high-profile celebrities such as Steven tWitch Boss, Lady Gaga, Avicii, and Robin Williams.
The official diagnosis for depression is major depressive disorder, and it affects people in various ways. There is a particular divide between the way it affects men and women, and the extent to which this difference is biological or socially constructed is unknown. What is becoming clearer, though, is that our approaches to addressing male depression, suicide in particular, need to be examined through our growing understanding of high-functioning depression.
What Is Depression?
Depression is a common and serious mood disorder that affects an estimated 21.0 million adults in the United States each year. In 2021, 8.4% of all U.S. adults had at least one major depressive episode, and this is as high as 17% in Americans aged 12-25.
Adult rates of depression are highest, at 15.9%, in those reporting multiple races (one or more). In adolescents of multiple races, this rises to almost 30%1, which is around seven students in an average middle school class.
Depression can cause a variety of severe symptoms, and it affects one’s ability to feel, think, and handle daily activities. Major depressive disorder or clinical depression is diagnosed using the Diagnostic Statistical Manual-5 (DSM-5), which includes symptoms such as feelings of sadness, low mood, and loss of interest in hobbies and activities. If these symptoms have persisted for at least two weeks and impacted the person’s normal level of functioning, a diagnosis may be made. These feelings must also be accompanied by at least five other common symptoms of depression, including:
- Change in appetite, potentially accompanied by weight loss or weight gain
- Sleeping more than usual or struggling to fall or stay asleep (insomnia)
- Fatigue and low energy most days
- Experiencing intense and lasting feelings of worthlessness, guilt, and hopelessness
- Being unable to focus and concentrate in such a way that interferes with daily tasks at home, work, or school
- Moving in a slow or agitated manner (a change that is often noticeable to others)
- Thinking about death, including suicidal ideation or suicide attempts
What Is High-functioning Depression?
While some individuals contemplating suicide display symptoms that are observable to family and friends, others do not. Some manage to hide their pain and suffering by smiling, laughing, and appearing entirely healthy and happy on the outside. This means that an individual with depression may also manage to complete normal – and sometimes extraordinary – tasks. Notable examples of this apparently juxtaposing condition include; Winston Churchill, Angelina Jolie, Owen Wilson, and Ellen DeGeneres
This can be devastating to families who are unable to recognize the struggles that their loved ones are going through. Although public knowledge and discourse on mental health – particularly regarding depression and suicide – have increased in recent years, many still have an image of what depression looks like. While in many cases of major depression this will most likely be accurate and observable in family, friends, or TV personalities with persistent depressive disorder (PDD), the signs are different.
Persistent depressive disorder, recorded in the DSM-5 as dysthymic disorder, causes consistent feelings of hopelessness, emptiness, and low self-esteem. It is seen as a milder but more enduring disorder than major depression. PDD is generally diagnosed when depression symptoms have been present for over two years, with no accompanying mania or hypomania. Although PDD is widely described as milder than major depression, research suggests that long-term depression may be associated with a higher suicide risk than major depression.
Unlike major depression, the symptoms of PDD don’t necessarily have to cause significant distress or impairment to your daily life, although they might. The combination of symptoms being long-term but not debilitating makes it particularly difficult for individuals, loved ones, and doctors to identify it. Some people may gradually accept the symptoms as normal, thinking that they simply have a pessimistic or depressive personality. In the case of the colloquial “high-functioning” depression, there is a sense that people struggling with the disorder work so hard to mask their symptoms by creating their ideal outer appearance that they often appear the happiest, funniest, and most energetic person in the room.
This not only makes them less likely to be the focus of concern or emotional support, but it also may create a reality that feels impossible to maintain but essential to uphold.
How Does This Link to Male Suicide in the US?
Males die by suicide four times more often than females. While making up 49% of the population, males account for almost 80% of suicides. Although the only data available is recorded before the COVID-19 pandemic, suicide was listed as the 2nd highest cause of death for males under 45.
Life pressures are inevitable and take their toll on everyone in society in a variety of ways. The ways that we deal with these pressures and the resources that we can access vary widely. Accessing support for mental health can never be described as easy, but some people face more barriers than others. Those barriers can be both structural, such as the lack of mental health practitioners in the US, or societal, such as social stigma and affordability of mental health care.
In the year before their suicides, only 35% of men on average sought care from a mental health practitioner, compared to 58% of women. The exact reasons that men take their lives more often than women, yet access support far less, are still unknown. However, there is a wealth of research aiming to shed light on what causes this gender divide.
Some suggest that social stigma around mental health plays a significant role in preventing males from accessing treatment or even getting support from friends or family. Out-of-date ideas, that are not yet out of memory for many, about male strength and masculinity often act as barriers to vulnerability for many men. This denial of their entitlement to act with true authenticity can cause a disturbance in their sense of self and create a mismatch between the wholeness of the person they are and society’s expectation of who they should be.
The gender disparity in suicide deaths is not as clear as it may seem, however, as women experience a higher rate of major depression, suicidal intention, and suicide attempts. It has been suggested that male suicide deaths are higher because they generally choose more lethal means than women. However, it could be argued that men choose these methods because they’re more intent on completing the act. A vast study of more than 4,000 hospital patients who had engaged in self-harm discovered that males had higher levels of suicidal intent than women.
Addressing Male Suicide
Effective suicide prevention hinges on recognizing that the risk factors for suicide may be different for men and women. Some factors associated with suicide risk, such as self-injury, mood disorders such as depression and bipolar disorder, and domestic violence, are significantly more common among women.
In male suicide prevention, the factors that appear to significantly increase suicide risk in men include relationship breakdown, socio-economic factors, challenges of mid-life, and partner bereavement.
The gendered stigma around help-seeking, differing approaches to self-harm, and differences in the choice of suicide methods contribute to the gendered differences in suicide rates.7 Recognizing these factors is essential to addressing male suicide at both community and government levels. Checking in on vulnerable or higher-risk friends and family, encouraging those you are worried about to access the relevant care, and actively addressing the stigma associated with male suicide and toxic masculinity are all ways of supporting the people we love and care about.
If you are in suicidal crisis or emotional distress, the 988 Suicide & Crisis Lifeline provides 24/7 free service, with a network of over 200+ crisis centers across the country.
 U.S. Department of Health and Human Services. (n.d.). Major depression. National Institute of Mental Health. Retrieved February 27, 2023, from https://www.nimh.nih.gov/health/statistics/major-depression
 U.S. Department of Health and Human Services. (n.d.). Men and depression. National Institute of Mental Health. Retrieved February 27, 2023, from https://www.nimh.nih.gov/health/publications/men-and-depression
 Angst, J., Gamma, A., Rössler, W., Ajdacic, V., & Klein, D. N. (2009). Long-term depression versus episodic major depression: results from the prospective Zurich study of a community sample. Journal of affective disorders, 115(1-2), 112–121.
 Centers for Disease Control and Prevention. (2022, March 2). Leading causes of death – males – all races and origins – United States, 2018. Centers for Disease Control and Prevention. Retrieved February 27, 2023, from https://www.cdc.gov/minorityhealth/lcod/men/2018/all-races-origins/index.htm
 Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and Primary Care Providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909–916. https://doi.org/10.1176/appi.ajp.159.6.909
 Harriss, L., Hawton, K., & Zahl, D. (2005). Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. The British journal of psychiatry : the journal of mental science, 186, 60–66.
 Research briefing: Gender and suicide – samaritans. (n.d.). Retrieved February 27, 2023, from https://media.samaritans.org/documents/ResearchBriefingGenderSuicide_2021_v7.pdf