Does HFD have a medically accepted definition? If yes, what is it? And is it a relatively new concept?

High Functioning Depression (HFD) is not a new concept in Psychiatry. HFD is also known as Dysthymia or Persistent Depressive Disorder. It is a serious and disabling form of depression that shares many similar symptoms with other types of depressive disorders.

Dysthymia describes the condition inflicting persons who experience persistent low-grade symptoms of depression. As the depressive symptoms of Dysthymia experienced are less severe than Major Depressive Disorder (MDD), for example, sufferers continue to be able to complete the activities necessary to lead a functional life, though barely so at times. Persons with HFD work and often have thriving careers. Outwardly, they take care of their families, their homes and their appearances. But internally, they struggle with feelings of negativity, sadness and despair.

When HFD is complicated by MDD, where the individual experiences severe depressive symptoms of MDD, the condition is known as “double depression”.

As with most depressive disorders, there is no specific clinical test for HFD at the moment. Nevertheless, healthcare professionals, such as primary care doctors and mental health specialists, can use various screening tools of validated scales to evaluate a person’s mood and experiences, to assess the presence of depressive symptoms and their severity.


Based on your experience, how common is HFD in Singapore, assuming there are no official statistics for this?

The Singapore Mental Health Study conducted in 2012 estimates the proportion of the local population that had experienced HFD at some point in their life to be 0.3% This is relatively low compared to MDD, which affects 5.8% of our population.


What might a typical patient with HFD experience or feel?

A typical patient with HFD may feel depressed for most of the day or on most days for a few years. Some examples of such experiences and feelings are as follows:


– Inability to enjoy interests or activities

Things and/or activities, e.g. social gatherings and hobbies, that bring one pleasure before do not excite with the same joy as they used to. Instead of looking forward to participating in them, individuals with HFD find them tiresome and may even seek to avoid them altogether.


– Low self-esteem

When problems are perceived as endless and difficult to overcome, individuals with HFD do not believe they have the resources to cope with them. This is usually a result of low self-esteem and self-criticism. For example, the individual may think that their partner will get angry or will stop loving them if they do not spend enough time with them. Another example is feelings of anxiety and self-doubt if they do not get recognition at work.


– Hopelessness

Those with HFD may engage in multiple activities and often try to keep themselves busy and not waste any time. However, when it comes to feeling happy or building a happy life, they may feel a sense of hopelessness or emptiness. Such feelings may be persistent and can lead to the development of depressive episodes.


– Unable to sleep

While sleep requirements vary from person to person, healthy adults generally need between seven to nine hours of sleep each night to function at their best. However, those with HFD may find it difficult to achieve a regular sleep pattern. Some may sleep less, while others may sleep more.


– Fatigue

Most depressed people may find that they experience fatigue more, regardless of how many hours of sleep they have the night before. Individuals with HFD may continue to work or try to complete their tasks despite feeling extreme fatigue.


– Poor appetite or overeating

Some HFD patients may not feel motivated to take care of their health. They will either lose interest in eating or indulge in too much food.


What are the biggest challenges facing people who have HFD in terms of recognising their problem and taking steps to improve their mental health?

Persons with HFD may have the core belief that, with enough persistence and effort, they can overcome the symptoms they experience. This is due to the relatively lower symptom severity, which allows them to ‘bear with it’ despite the distressing nature. Their ability, while barely so, to maintain a high performance or functional level, may convince them that help is not required.

Some may also choose to maintain a sense of normalcy by distracting themselves with work or compensatory mechanisms e.g. alcohol, cigarettes, drugs, excessive gaming, overindulging in food or binge-watching serials. While these activities may help to alleviate the emotional distress in the short term, they do not help in the longer term and may even complicate circumstances.

Often a person with HFD may not recognise that they are actually depressed or at the brink of their ability to cope until a life event happens, either in their personal or work life. Being aware that they have HFD is therefore crucial. It is a condition that is treatable, very often with the help of the significant other.


How can friends and family of people with HFD identify HFD symptoms?

Depression does not mean that patients are visibly sad. In most HFD cases, sufferers can hide their feelings and still go about their daily activities. Other than noticing glimpses of sadness or suggestions that the person may not be as enthusiastic about their interests/hobbies as they used to, you should be alert if your loved one is also:

– Eating less, or a lot more than usual, or skipping meals

– Experiencing erratic sleep patterns or constantly tired

– Expressing thoughts of hopelessness, meaninglessness or emptiness

– Tearing or crying out of the blue

– Unable to concentrate or focus on the task at hand

– Unwilling to participate or avoiding social activities they used to enjoy


Can you provide four to five coping strategies for people facing or at risk of HFD? For each, please explain how it helps.

In essence, Dysthymia is not a condition that can be willed away or put out of sight. If left untreated, the symptoms can worsen to become severe enough to meet the criteria for MDD. Dysthymia is a medical illness that requires both medication and psychological therapy. At the same time, there are some strategies that one can take on to feel better.

1. Start exercising regularly

Regular exercise has been consistently shown in clinical studies to help improve mood. The improvement in physical fitness also allows one to feel more energetic. With sustained, regular exercise, one can start to take on a more athletic and youthful appearance. While not exclusively so, the improvement in physical appearance often helps one feel better as well.


2. Regulate sleep pattern to ensure adequate rest

Sleep is important as it allows the body to rejuvenate and restore the energy needed for the day ahead. The first step to doing so will be to ensure sleep hygiene, a set of practices and habits that can be developed to allow for a better night’s rest.


3. Maintain a healthy diet

Ensuring a sensible diet with adequate portions of nuts, fruits and vegetables can help ward off depressive symptoms and allow one to feel better. Having said that, the occasional treat of ice cream or something one enjoys can help too. Moderation is key.


4. Avoid alcohol

Alcohol is a deceptive substance. It has short-term mood elevating effects but causes the mood to worsen the morning after. When one drinks excessively, the hangover that results can leave one tired and the worse for wear. Alcohol is a vitality draining substance that should be avoided altogether when one is feeling depressed.

Dr Marcus Tan

Consultant Psychiatrist, Nobel Psychological Wellness Centre

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Dr Marcus Tan is a Consultant Psychiatrist at Nobel Psychological Wellness Clinic, a member of Healthway Medical Group.