Top Performer, Hidden Pain: When the Woman Who Has It Together Does Not : The American Centinel

Her reviews are glowing. She hits every deadline, mentors younger colleagues and somehow remembers everyone's birthday. At 46, she is the person leadership points to as an example. She is also, quietly, thinking that everyone would be better off without her.

If you or someone you know is thinking about suicide, call or text 988 to reach the 988 Suicide and Crisis Lifeline, available 24 hours a day. If someone is in immediate danger, call 911 or go to the nearest emergency room.

High performers can be very good at hiding depression. The same drive and discipline that make them excel at work can help them keep a calm face in public while they struggle in private. For women in midlife, who often feel pressure to be flawless at work and at home, that mask can become a heavy thing to carry.

How depression hides in high achievers

Depression does not always look like someone who cannot get out of bed. In high achievers, it can look like working longer and longer hours, because work is the only place she still feels competent. It can look like perfectionism that turns every small mistake into proof that she is failing. It can look like a person who is always fine, always helpful, and never talks about herself.

Midlife pressures can deepen it. Perimenopause can disrupt sleep and mood. Caregiving for teenagers and parents leaves little time to rest. Divorce, health scares or the loss of a parent may be happening offstage while she keeps performing at work.

Subtle signs to watch for

Because high performers hide well, the signs may be small. Coworkers, partners and friends might notice:

Dark humor about not being around, or about how nobody would miss her
A sudden drop in the care she takes with her appearance or her health
Never taking time off, eating at her desk and answering messages late into the night
Sharp self-criticism over minor mistakes
Withdrawing from personal conversations even as work output stays high
Talking about being a burden, feeling trapped or seeing no future

When a capable person starts talking about not being here, believe it is serious, even if she quickly laughs it off.

How to ask someone who seems fine

It can feel awkward to ask a strong, successful woman whether she is okay. Do it anyway, privately and kindly. You might say: You always seem to have it together, but I have noticed some things that worry me. Are you thinking about suicide?

Asking directly does not plant the idea. For many people who hide their pain, it is the first time anyone has seen through the mask. If she says yes, stay with her, listen and help her connect with 988 or a clinician. If she is in immediate danger, call 911. During a hard stretch, it is also wise in general terms to make medications and firearms in her home harder to reach.

If you are the one hiding it

If you recognize yourself, know that being good at your job does not mean you have to be good at carrying this alone. Telling one person the truth can be the hardest and most important step. A primary care doctor, a mental health clinician or a confidential employee assistance program can help you start. It is worth mentioning sleep and hormone changes, too.

Depression is treatable. People recover, including high achievers who spent years believing they had to handle everything on their own. Help works, and getting it is a sign of the same strength that has carried you this far.

A newer treatment worth asking about

For a woman whose hidden depression has come with suicidal thoughts, a clinician may describe this newer option. Spravato (esketamine) is a nasal spray the FDA has approved, taken along with an oral antidepressant, to treat depressive symptoms in adults with major depressive disorder who have acute suicidal thoughts or behavior. It is also approved for treatment-resistant depression. It is not a crisis treatment: it does not replace emergency care or a hospital stay when one is needed, and it has not been shown to prevent suicide or to reduce suicidal thoughts or behavior. It is given only in a certified clinic under a safety program called the Spravato REMS. The patient takes it there under supervision, stays at least two hours to be monitored, and does not drive until the next day after a full night of sleep. It is never dispensed for home use. Whether it fits is a clinician's decision after an evaluation.

Many clinics that offer this treatment begin with a free first consultation, a private conversation where she can ask questions and find out whether an evaluation makes sense. She is welcome to bring a partner or close friend, someone who knows the person behind the polish.