Psychiatrist calls anhedonia the 'silent sister' of high-functioning depression

Psychiatrist Dr. Judith Joseph describes a form of depression that rarely gets attention: people who never stop moving, may double down on their work, and keep meeting their obligations at home and on the job while quietly losing the ability to feel pleasure. She calls it "high-functioning depression," and says it often goes unnoticed, even by the people living it.

At the center of Joseph's work is anhedonia — a reduced ability to feel joy, pleasure or interest in things that once brought those feelings. She calls it "the silent sister" of depression. "One sister is depressed, and crying, and not getting out of bed, and getting all the attention," she told the Your Turn podcast. "The other one is quiet and numb." Anhedonia may not look like a crisis in the classic sense, she said, "but it is an existential crisis, and it's not something to ignore."

What the research found

Joseph and colleagues interviewed adults for a peer-reviewed study published in the journal Cureus, using questionnaires designed to assess high-functioning depression, trauma and anhedonia. The results supported the researchers' hypothesis that people with high-functioning depression have increased levels of anhedonia and trauma, and participants with higher anhedonia scores also had higher high-functioning depression scores. Parents and caregivers recorded the highest scores in the study.

The authors note that high-functioning depression is not an official diagnosis in the DSM-5, the manual clinicians use to diagnose mental health conditions. They say that is part of the problem: people who keep functioning may not recognize their symptoms or seek treatment until they reach burnout.

Who is most at risk

Joseph says she often sees the pattern in women who are the steady presence for everyone around them, so focused on their responsibilities at work and at home that they do not realize they are burned out, or close to it. "But eventually something's gonna give," she said. She has seen patients end up in the emergency room without understanding why, only to learn they had been carrying unresolved emotional pain.

The pattern is common in professions that discourage vulnerability, she said, including her own. In medicine, crying after a patient died was seen as weakness, and clinicians are taught to look for mania and psychosis. She believes there should be more focus on anhedonia, the loss of a sense of joy.

A quiz, not a diagnosis

Joseph developed an anhedonia quiz based on the Snaith-Hamilton Pleasure Scale, a measure of the capacity to feel pleasure published in the British Journal of Psychiatry. It asks about everyday experiences — whether you have trouble enjoying praise, whether you savor your meals or other small pleasures, and whether you struggle to enjoy your work or accomplishments because they never feel good enough. The quiz is not a diagnostic tool, but an invitation to take stock of what might be standing in the way of a fuller, more joyful life.

Her book, "High Functioning: Overcome Your Hidden Depression and Reclaim Your Joy," outlines a framework she calls the Five V's.

If you or someone you know is in crisis, call or text 988 to reach the Suicide & Crisis Lifeline.

Source: NPR News.