HealthyGamerGG - The Hidden Cost Of 'Keeping It Together' (High Functioning Depression)

Episode Date: April 6, 2026

In this episode, Dr. K explores the "Alchemy of High Functioning Depression" (HFD)—a condition that is not officially recognized in the DSM-5 but may be even more common than regular depression. He explains why people who appear to be "keeping it together" are often just bailing water out of a sinking boat to keep from drowning. What to expect in this episode: The Coping Strategy Trap: Why an over-reliance on survival mechanisms allows you to plow forward without ever addressing the underlying problems in your life. Obsession with Role and Identity: A look at how the pressure to be a "good parent," a "successful doctor," or a "provider" forces people to double down on a life that makes them miserable. The Default Mode Network: The neurology of HFD, where the brain's "self-reflection" circuit hyperactivates, causing constant, exhausting thoughts about improving the self. Toxic Positivity and Denial: How avoidant coping—denying your negative feelings or your circumstances—leads to a higher risk of suicidality and mental burnout. Sublimation (The Inner Alchemy): Why taking the feeling of wanting to quit and turning it into "badass" effort can lead to a successful career in a profession you actually hate. The Risk of Cracking: Why those with high functioning depression have a 300% to 400% higher risk of eventually falling into a full-blown depressive episode. Patching the Hull: Practical advice on how to move forward by letting negative emotions surface and questioning if your idealized role is worth sacrificing your life for.Something sexy is coming to HG! Join the waitlist: https://bit.ly/3PGdmUAHG Coaching : https://bit.ly/46bIkdo Dr. K's Guide to Mental Health: https://bit.ly/44z3SztHG Memberships : https://bit.ly/3TNoMVf Products & Services : https://bit.ly/44kz7x0 HealthyGamer.GG: https://bit.ly/3ZOopgQ Learn more about your ad choices. Visit megaphone.fm/adchoices

After 19 years, they're back. Frankie Munes, Brian Cranston, and the rest of the family reunite in Malcolm in the middle, life's still unfair. After 10 years avoiding them, how and lowest demand Malcolm be at their anniversary party, pulling him straight back into their chaos. Malcolm in the middle, life's still unfair. A special four-part event, streaming April 10th on Hulu on Disney Plus. Hey, chat, welcome to the Healthy Gamer Gigi podcast. I'm Dr. Alokanojo, but you can call me Dr. K.

I'm a psychiatrist gamer and co-founder of Healthy Gamer. On this podcast, we explore mental health and life in the digital age, breaking down big ideas to help you better understand yourself and the world around you. So let's dive right in. In psychiatry, we define a depressive episode by impairment of function. Is your energy level so low that you can't go to work, you can't fulfill your family responsibilities or take care of yourself physically, feed yourself, et cetera.

So when we think about depression, we think about being unable to function. I don't know if you guys have seen these posts about, you know, the messes that depressed people will have in their homes that take hours or days to clean up. It turns out that there is a condition called high functioning depression, which is not technically recognized in the DSM-5 or psychiatric diagnosis, which is actually potentially even more common than regular depression. So if we look at sort of a depressive episode, the incidence or prevalence is somewhere between

5 and 7.8%. So in a given year, about 5 to 8% of people will have a depressive episode. If we look at high functioning depression, the ranges are a lot wider. It's somewhere between 5 and 41%. With about an average rate, if you pull together these 1113 studies, the rate is around 11%. So what separates people who have a mood disorder from high functioning depression is kind of shocking. It is an over-reliance on coping strategies. So I want you all to think about this, okay? So let's say I'm in my life, I'm struggling in some way. Let's say I'm a new parent, really common for high functioning depression. And as I'm not sleeping well, as my spouse is struggling as well, we have a newborn at home who's crying all the time. My spouse has taken maternity leave, but I still have to go into work.

You know, it's really important that I go into work because now I'm providing for a family of two. So I'm under a ton of stress. And so the key thing here is that people, who don't crack under the stress and get into a full-blown depressive episode will oftentimes end up with high functioning depression. And that's what's so confusing about it. The way that people are able to continue plowing forward is because they're actually using coping mechanisms to keep it together. The problem is that while these coping mechanisms may allow you to keep it together, they don't address the underlying problems. So when I'm trying to figure out, does this person have high functioning depression? I'll kind of ask myself a question.

When I sit with this person and I listen to them talking about their lives, does this sound like someone who has a boat that is taking on water? There's damage to the hull and it's taking on water and they've got a pail and they're scooping water out. If when I sit with someone, this is sort of the feel that I get from them, if it kind of feels like they're working really hard to barely not drown, that's when I think about high functioning depression. So really great example of this is the medical students that I used to work with. So, you know, these are kids that work really hard to get into medical school. They start studying arguably in high school and spend four years in college here in the United States. They study really hard for the MCAT and many of their friends end up in med school.

Many of their friends don't end up in med school. It's incredibly competitive. And so they're thrilled to finally be in med school and now I'm going to be a doctor. And then they wake up maybe somewhere in first year, second year, third year, fourth year, and they wake up one day and they really realize, oh my God, I actually don't like medicine. I don't like patients. Like, I had this idea of what being a doctor is, but I hate like spending time in the clinic or spending time in the hospital and dealing with patients. This sort of happened for me. This is like how I wound up in psychiatry. So when I was in med school, I was planning on becoming an oncologist like my dad and doing holistic cancer treatment and saving lives and all that good stuff.

And then one day I was in the clinic and I was working with a primary care physician, a GP. And I realized that like I had to look at a lot of feet, like a lot of like diabetic, ulcerous, smelly feet. You know, this is stuff that I sort of appreciate that I had this training, but you have to deal with a lot of really nasty smells. If you all have worked at a hospital, you know the smell of C. diff, Clostridium difficile. Right? So there's like just a lot of nasty smells that come with being like a real life-saving doctor.

And I just wasn't super interested in that. And what I loved about psychiatry, there's a lot of bad smells in psychiatry too if you're working with the homeless population and in the emergency room. But it's not like you're, you know, dealing with it day in and day out. And then I have this outpatient practice where I'm working with high functioning depression, highly successful people, which is just so different. And most of them smell pretty good and have good hygiene. So this is sort of what happens is we have this kind of idea of, okay, like I worked so hard to get into med school and I don't want to quit. I don't want to be a quitter. I want to be a gunner. I want to be a doctor. I want to be successful. And what we find in high functioning depression is that there is an over emphasis on the idea of role or identity. So I would say to a T, every single patient that I've worked with who has HFD is obsessed with the idea of living up to,

a role are embodying an identity. If y'all want more information about what the root of those problems looks like, I definitely recommend y'all check out Dr. Kay's Guide, where I have five videos about the most common problems, like the most common psychological complexes that I see in my patients. Turns out these are also the most watched videos in the Depression Guide. Also really common for new parents, right? So like, I want to be a good dad.

I want to be a good dad. And good dads don't cry. Good dads don't take days off. Good dads are there for their wives, there for their kids. I'm going to be a present dad. I'm not going to be a deadbeat dad. I'm going to spend time with my kids. I'm going to teach him how to cook. I'm going to teach him how to ride the bike. And I'm going to be a good husband. I'm going to be an involved husband. And I'm going to be a provider. And I'm going to go to work and I'm going to work really hard. I'm going to get promoted. I'm going to take my kids on vacation. This is what it's like. They sort of have this idea of living up to a role. And whenever they face hardship, they will, double down on this idea of role. Now, here's what's really scary. So when we get overly involved with a sense of identity or role that we want to live up to, this probably activates the part of our brain called the default mode network. The default mode network is a part of our brain that allows us to reflect on ourselves. So when I think about myself, this kind of metacognition is when the default mode network activates. The tricky thing is that when the default mode network activates or hyperactivates, this is associated with feelings of depression. So when I have patients who do have

mood disorders or even HFD, right, what we tend to see in them is that they think a lot about themselves. Oh my God, I need to do better. Like literally the content of their mind is about themselves in some way. Now, this isn't like narcissistic. It's not like they're thinking they're great. It is literally if you like map out their thoughts, they're like thinking like, oh my God, like I need to do better. I need to be better. Right. So they're thinking about themselves in a metacognitive way. And we also know from many studies on things like ketamine. So ketamine is probably the fastest acting treatment for depression. And the way that it works is it basically shuts off the default mode network.

And when I sit with these patients who have full-blown depression, you know, they're usually thinking about how much like they're losers and how their family would be better off without them and how other people are so much better than they are. So it's once again thinking about yourself, thinking about yourself, thinking about yourself. Now in HFD, when the default mode network turns on, there's sort of a different spin to it, which is they focus on role or identity, right? Like, I want to be a good person. I'm not going to give up.

I'm not going to be this loser. So they sort of take their lived experience of the moment. This is what I'm feeling. This is what it's like to be me. It's tiring. It's exhausting. I'm frustrated with my wife. I'm angry at my kids.

I'm regretting being a parent, which is such a scary thought to have. Like, oh my God. Like, I'm annoyed with my child. Incredibly common, right? I sometimes wish I had never had kids. incredibly common. So they have all of these negative thoughts and then they run away from them. They push them away and they go towards this sort of idealized role. We also see in high functioning

depression a high amount of avoidant coping. So avoidant coping involves denial of what you were feeling or even denial of your circumstances. So we'll see some of this weird like toxic positivity kind of stuff where they'll like, you know, tell themselves all kinds of things to deny their experience. So if I am frustrated with my kid because I haven't slept in six months and I'm trying to be a good husband and trying to be a good father, then instead of like being a pussy about it, I'm going to like man the fuck up. And like, oh my God, like I have all these negative feelings. Like, fuck that, man. Like I'm not going to be that loser. I'm not going to be someone who dislikes their kids. I'm not going to be that. So they push or deny those feelings away or they even deny

their circumstances. I'm so privileged. I'm so lucky, which is true. Right. So this is, this is the key thing to remember about high functioning depression. These are coping mechanisms. These are things that are actually adaptive and healthy when used in a short-term scenario. So if my boat is taking on water, I absolutely want to have pumps or a pail to like bail that water out while I engage in more permanent fixes. The problem with high functioning depression is that these people will rely on these coping mechanisms to power through while they keep going. The other really scary thing is that avoidant coping is actually associated with a higher level of suicidality, especially in men. And so this is sort of what happens with HFD, is that we're coping, we're surviving. I don't want to

be a loser. I don't want to give up. And then eventually things will start to crack. There's one other coping mechanism that we have to talk about. And this one is really fascinating. So this is sublimation. So when people have HFD, they do something really interesting, which is that when they feel like quitting, they actually double down and do an even better job. So like, this is where, I don't know if you guys watch anime. Like my kids are watching Naruto right now, which is like lots of fun because I watch Naruto like 20 years ago. And wow, the show is moves so slowly. Like in one episode, there's so little that that goes on. But anyway.

So if you sort of look at like the way that our society glorifies powering through, right? So like when someone feels like quitting and oh my God, I'm crying and I'm sad and I'm a loser, and they're like, no, I'm not going to do that. I'm going to get better. So all of this shonen in anime is about like taking that weakness and turning it into badassness. In psychiatry, in psychology, we call this the process of sublimation. So this is something that happens like it's literally been studied in medical students where you feel like quitting. When you're an undergrad and you're thinking about going to medical school, you feel like quitting.

And what you do is you take those feelings. you're like, I'm a show that quitter in me. I'm going to do even better. I'm going to work even harder. So some people discover this really, really interesting, kind of toxic, but wonderful coping mechanism of taking that negative energy and doubling down into effort. And so these people will become usually pretty successful, right? Because instead of quitting, I'm now working twice as hard.

I'm going to show them and I'm going to show myself. They do this really interesting inner alchemy. The problem is that as these people continue to do this, they wind up in a place that is really not healthy or happy. Because maybe the reason that I wanted to quit med school was because I didn't like being a doctor. But if I use sublimation and double down and show the world that I'm not a quitter,

I will end up in a profession I don't enjoy, right? So that's like really scary. And that's what I see in high-functioning depression. I see people who come into my office and have a midlife crisis or a quarter life crisis. And these are people who, when they felt like quitting, they didn't want to be a loser, so they kept going. And then they end up getting promoted, which is great on the surface, except now you've got five years into this career that you don't enjoy. And then you've got 10 years into this career that you don't enjoy because you're not a quitter. So it's kind of scary, right?

Because then you're sort of in this situation where it's like, okay, do you want to know? not be a quitter, but end up miserable every day doing something that you don't enjoy. And people with HFD will be like, fuck yeah, son, that's exactly what I want. So, this is when things get really scary because what we see with HFD is that a lot of people end up cracking. Okay? They'll end up sort of the coping mechanisms since you're sort of propagating a system that you're not happy with. You're denying your negative feelings. You're always doubling down and pushing forward.

you may wind up in a situation that you don't enjoy at all. And at some point, sometimes what happens is you've been bailing water for so long that you get exhausted and eventually things will end up overtaking you. There's about a three to four times risk compared to the regular population of people with high-functioning depression winding up depressed eventually. So there's about a 300 to 400% risk that at some point your coping mechanisms will fail. Now, for a lot of people, this doesn't happen, right? So just because there's a three to fourfold risk doesn't mean it's permanent by any means or that it's going to happen to everybody.

I've worked with a lot of people who are like parents who have a really tough period. And once they start sleeping again and processing their emotions and start having sex again, you know, then things can actually get a lot better. So it's not that this happens to everybody. But eventually things do kind of feel overwhelming. So now the question becomes, okay, so if you've got high functioning repression, what do you do about it? And so this is where we have to understand a couple of basic things. The first is that coping mechanisms are great, but you have to solve your underlying problems, right? If my boat is taking on water, I got to patch that up.

So oftentimes what I'll do with people who have HFD is the first thing that we'll do is take a serious look at your life. And what we'll sort of do is I'll kind of give them this exercise where like, nothing is off the table. Okay. So in psychotherapy, this becomes really important because when I offer reflective listening, right, when someone says, yeah, I'm kind of tired from having. you know, kids and stuff like that. Like, I want to be a good dad, but, you know, I'm tired. And then sometimes I'll be like, yeah, man, it really sucks, dude. Like, you know, is there any part of you that regrets having children, right? And you got to ask that question in a very specific way. You've got to create a space that is safe. Because if I ask them, do you regret having

children? They're going to be like the avoiding coping mechanism. Well, no, denial of problem. No, I'm lucky. I'm blessed. So many people struggle to have children. And I should be grateful. it's such a privilege. But if you pay attention to their words, which you'll notice is that there's little cracks around their toxic positivity. The first thing that you have to do is acknowledge that you actually have problems

and let those negative emotions come to the surface. The second thing that we have to focus on with high functioning depression is this idea of a role. And the problem with this is that oftentimes what my patients will do is they've invested so much in the role that it feels really hard to quit, right?

So I had this idea of being, a doctor when I was like 15 years old and I invested my high school years, I invested my college years, I invested so much and now I don't want to quit. They have this idea of being a quitter. So what I'll ask my patience is, is maintaining the role worth sacrificing your life? And ultimately, overcoming high functioning depression is about understanding that you are using these coping mechanisms to propagate a life that is fundamentally flawed. And as we start peeling back those layers, then we can get to the root of the problem, which is ultimately what you have to solve. So if y'all are struggling with waking up every day and feeling like there's no

joy in life, if you have spent your whole life devoting yourself to a particular role, consider high functioning depression and consider talking to someone to get some help about it. Thanks for joining us today. We're here to help you understand your mind and live a better life. If you enjoy the conversation, be sure to subscribe. Until next time, take care of your and each other.