By Martha Fernandez, LCSW

High-functioning depression is common in women over 50, and it often goes unnoticed, even in therapy. It doesn’t always present in expected ways, and many women who seek help give up within the first few sessions.

The invisible depression of high-functioning women

Depression doesn’t always look like depression, and it can be challenging to recognize symptoms when you’re used to functioning well. This is true for anyone, but especially so for high-functioning women who have a long history of success and productivity. Symptoms of depression in high-functioning women over 50 can be subtle, and are easily confused with symptoms of stress, hormonal changes and other health conditions.

A composite of my clients

Consider “Jane.” (Jane is a composite of my actual clients, all of whom have shared each of these symptoms or life circumstances with me at some point.) Jane is 58, and is successful in her career and her personal life. She’s the head of a hospital division with 600 people, is divorced with two grown children who have left home, cares for her elderly, ailing father and never misses a board meeting. She’s highly functional, and quietly falling apart.

For eight months, Jane hasn’t slept through the night. Most mornings she cries in the parking lot before work. She can’t think of anyone in her life she’s shared that information with. Two years ago, Jane sought out a therapist for the first time, but quit after three sessions. As one client put it, “The therapist kept asking if I was getting out of bed. I was getting out of bed at 4:45 to answer email. So I guess I passed.”

Depression screening questions: Helpful but insufficient

Jane is highly successful. She’s also depressed. Her story is unfortunately all too common.

Many of the questions clinicians ask focus on whether depression is interfering with daily life. Are you missing work? Have you given up on activities you once enjoyed? These are certainly helpful questions, but insufficient for highly functional women whose lives appear to be intact, because the depression has gone underground. Instead, depression in highly successful women more often presents as:

•       Irritability, or being short with friends and family

•       Unexplained aches and pains

•       Anhedonia: a flatness or inability to feel pleasure in activities she once loved

•       Waking in the night or in the early morning hours and being unable to return to sleep

It’s also important to keep in mind that hormonal and other changes associated with midlife can exacerbate or increase a woman’s vulnerability to depression. In the long-running Study of Women’s Health Across the Nation, which followed thousands of women through the menopausal transition beginning in the 1990s, women were at greater risk of a major depressive episode during and in the years immediately following the menopausal transition than in the years leading up to it.

Unfortunately, many symptoms of depression (e.g., sleep disturbance, fatigue, difficulty concentrating, low mood) overlap with symptoms of menopause, stress and other medical conditions, making it all too easy for women and clinicians alike to write these symptoms off. For Jane, the hormonal shifts of midlife arrived on top of real losses and loads: the end of her marriage, a house that went quiet when her children left, a father who needs more of her care every month, and a job where she is the one everyone leans on.

The importance of seeing the depression beneath success

When highly successful women do seek out treatment for depression, they’re apt to focus on symptoms that fit with their “functioning” persona. They’re stressed. Work is a lot. Coming home to an empty house isn’t so great, either. They’re less likely to mention the depression, the numbness, hopelessness or other less functional emotions. Unless her clinician is trained to recognize depression hiding beneath success, Jane risks once again walking out of a therapy session feeling unheard and invalidated.

Should you give therapy another try?

A 2012 review of 669 studies by researchers Joshua Swift and Roger Greenberg found that about one in five adult psychotherapy patients quits treatment prematurely. From my vantage point as a clinician, here are three reasons I suspect many highly successful women over 50 are among them:

1.     Therapy doesn’t progress beyond small talk. Fifty minutes may not be enough time to get to know your therapist, discuss what brings you in and then dive any deeper, especially if, like Jane, you’re highly successful and used to keeping things together.

2.     Your therapist doesn’t “get it.” Highly successful women have likely spent years serving as “the only one” in leadership positions and decision-making contexts. Whether or not you’re aware of it, you’re scanning your clinician to see if she’s got this, if she understands what it’s like to be responsible for hundreds of people’s lives and livelihoods.

3.     You’re unsure about confidentiality. Highly successful women often hold positions of power and influence in their professional and/or personal lives. Confidentiality matters, and may even be the difference between opening up about depression and leaving after three sessions.

Successful women aren’t immune to depression. But therapy can work for you.

Successful women can struggle with depression. That doesn’t mean therapy isn’t helpful, just that you may need to take a more active role in making sure it’s helpful to you. Here are a few ways to make that happen:

1.     Do some soul-searching. Jot down a few things you’ve never shared with another person. You don’t have to share everything you write down in session, but at least bring that list with you.

2.     Consider a longer session. Some clinicians offer longer sessions, which may give you and your clinician the time you need to get beyond small talk.

3.     Find out how your clinician works with high-functioning clients. If the answer is vague, keep looking.

4.     Ask about confidentiality. Who has access to your clinical record? Will your therapist ever speak with your health plan or your employer? It’s okay to ask, and your therapist should answer forthrightly.

5.     Tell your therapist, “This isn’t working yet.” It’s important to check in with your clinician about whether therapy is helpful for you, as research suggests that many therapy dropouts don’t communicate this to their clinician.

If you’re not ready for therapy

Perhaps you’re not ready to commit to weekly therapy just yet. That’s okay. Here are a few other things you can do right now:

1.     Guard your sleep. Poor sleep exacerbates depression, and depression disrupts sleep. If nothing else, set a consistent wake-up time and turn off the laptop and phone half an hour before bed.

2.     Open up to just one person. Share a burden with one trusted confidant, and pay attention to what happens in your body as you talk.

3.     Take your anger seriously. Irritability can be an early warning sign of depression in otherwise successful women. Anger isn’t a character flaw, so pay attention to what’s stirring beneath the surface.

If you’ve been feeling down for more than two weeks, or you have thoughts of not wanting to be here anymore, please talk to your physician or other mental health professional right away. In the United States, call or text 988 any time, day or night, to reach the 988 Suicide and Crisis Lifeline.

What changed when women like Jane went back

Many of the women Jane represents eventually went back to therapy. This time, they asked for more time, asked how their information would be kept confidential, and told their clinician on day one that they had stopped therapy before because they felt rushed. Within a few months, many were sleeping again. The biggest change, as one client put it, wasn’t some technique. It was being met where she was, not how she presented.

Permission to take up space

Maybe you’re the one who always holds it together. Here’s your permission slip: it’s your turn. And if your symptoms aren’t what you’ve seen in other people? That doesn’t mean you’re wrong or that help won’t work for you. You deserve to be seen and heard.

About the Contributor

Martha Fernandez, LCSW, is a licensed clinical social worker and co-founder of CEREVITY. She treats burnout, anxiety and depression in professionals who look fine from the outside, and she studies the structural reasons they put off getting care. Her reputation rests on getting real results for clients who tried easier forms of therapy and walked away. She is the author of Wired to Burn: A Therapist’s Guide for High Achievers Running on Fumes (2026), and her writing has appeared in Psychreg and Behavioral Health News. She lives in Lakewood, California.