Signs you may have high-functioning depression and 5 ways to fix it with Dr. Judith Joseph

We often associate depression with withdrawal and low energy - but what if it hides behind a packed schedule and staying busy? Board-certified psychiatrist Dr. Judith Joseph joins Professor Sarah Berry to explore high-functioning depression.

We discuss how a busy, high-achieving lifestyle can actually mask the symptoms of depression - and even perpetuate it.

Dr. Joseph, the first psychiatrist to run a lab focused on high-functioning depression, shares her latest findings on its causes, signs, and long-term impact. ZOE’s Chief Scientist Prof. Sarah Berry explains how food and the gut microbiome may hold the key to reducing these symptoms.

If this sounds familiar, Dr. Joseph introduces a quick self-test to help identify high-functioning depression - and outlines five practical strategies to begin healing, and Sarah gives you the foods that could help.

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Transcript

Jonathan: Judith, thank you for joining us today. 

Dr. Judith Joseph: Thank you for having me. 

Jonathan: I'm really excited, this is a new topic. But we always start in the same way at ZOE, which is that we have a quick-fire round of questions from our listeners. With these very strict rules, you can say yes or no, or if you absolutely have to, you can give us a one-sentence answer, and it's designed to be really difficult for doctors and academics. 

Are you willing to give it a go? 

Dr. Judith Joseph: Of course. 

Jonathan: Alright. If you can't get out of bed in the morning, could you be depressed? 

Dr. Judith Joseph: Absolutely. 

Jonathan: If you're out of bed every morning at 6:00 AM for a busy day, could you be depressed? 

Dr. Judith Joseph: A hundred percent. 

Prof. Sarah Berry: Do men and women typically express depression in the same way? 

Dr. Judith Joseph: No. 

Jonathan: Could you improve your mood with the foods you eat?

Dr. Judith Joseph: Of course. 

Jonathan: Last question, and this one you're allowed a whole sentence for. What is the most surprising thing you've found from your research into depression? 

Dr. Judith Joseph: The most surprising thing that I've found is that you don't have to be sad to be depressed. 

Jonathan: In the description of your new book, you describe people who look fine on the outside, but don't feel fine on the inside. I found that incredibly powerful, Judith.

I'd like to talk about something that I've never mentioned on the podcast before, actually. So frequently over the last few years, I think I felt exactly as you describe in this book.

So that on the outside, I appear fine. I'm CEO of this successful startup, I'm hosting this amazing podcast, but on the inside, actually, I feel really numb and unable to enjoy myself.

I feel pretty overwhelmed by the pressure of making ZOE a success. And it feels very alone, right? Lots of people are relying on you, and I'm sort of doing this on my own. 

In that situation, even when people say how great it is, I can't actually source any joy, while pretending that I do, because your expectation is you’re just supposed to look like you're really happy.

I know you're basically the first doctor to really start researching this as a phenomenon. Can you start by explaining what classical depression is, and what's going on in the brain? And then take us into this new form of depression you're talking about. 

Dr. Judith Joseph: Well, first, thank you for sharing that story. It's vulnerable, and I think people need to hear that. 

Jonathan: Thank you. 

Dr. Judith Joseph: Because you're not the person that a doctor's going to say, let's address this. You're someone who, you'll go into a doctor's office, they'll ask you about symptoms of depression, you may say yes to some of them, but then they'll ask you, Are you functioning? Are you delivering? You'll say, yep. Then they'll say, we'll see you next year. 

In my lab, I was seeing cases like this throughout the pandemic, after the pandemic. People were coming in, and I was checking the box of the DSM-5. 

Jonathan: Could you explain what the DSM-5 is? 

Dr. Judith Joseph: So, in America, in the United States, we use the Diagnostic Statistical Manual for psychiatric conditions, and version five has criteria for depression. So, symptoms of depression. 

In medical school, we learned it as SIGECAPS, that was our acronym. Sleep, lack of interest, guilt, low energy is the E, C is concentration, A is appetite, P is pleasure or psychomotor retardation, and s is suicide. So you have to have five of these nine criteria plus low mood or anhedonia.

But the thing that a lot of people miss is the anhedonia part. So if a doctor asks you how you're feeling, and you don't say that you're sad, and you just say, I'm okay. Which is most of our auto-response, right? We say, I'm okay, and you say no to sadness. Doctors don't dwell on anhedonia. 

Prof. Sarah Berry: And Judith, you've said a word a few times, anhedonia. I have never heard of that word. Could you explain what that means? 

Dr. Judith Joseph: So it's actually a word that if you ask any nurse, any healthcare professional, they know what it is. It's such an antiquated old medical word.

Prof. Sarah Berry: Have you heard of it, Jonathan? 

Jonathan: No, go on. 

Dr. Judith Joseph: Most people haven't, that's okay. It was really coined by a French psychologist. I think he may have been a psychiatrist in the 1800s. And what he was seeing was this lack of pleasure and interest in things in people who had substance abuse and people who had depression, and people who had schizophrenia. And that's where you see a lot of anhedonia.

You even see it in people with dementia. So older people who are going through that dementia phase, they just stop enjoying or being excited about things. Anhedonia is prominent there.

But people who have depression suffer from anhedonia, and people who have trauma suffer from anhedonia. It's a numbing of the things that make life worth living, but it's a sneaky symptom. It's quiet. People don't walk around saying, I have anhedonia. They say, I feel me, or blah. Right? 

And if you're not crying or not getting out of bed, no one's going to address it. It's like, well, don't we all feel like that? I think many of us do feel like that.

I think that many of us don't process pain, but many of us process pain by self-soothing and numbing with things like drinking a lot, excessive buying, excessive use of social media, doom scrolling, and busying themselves with work. Just to get through, just to get things done, just to busy from, and distracting from these unpleasant feelings or this emptiness that they feel.

A lot of my patients would say that when they're not busy, when they're not working, they feel empty or they feel restless, so they have to be busy, and it's a distraction. 

So when you don't process these painful emotions, when you don't process the trauma, then you may start to get numb, and anhedonia feels like a numbing of pleasure, a numbing of interest in things that you once loved.

When was the last time a doctor said, Are you really enjoying life? Do you get out of bed with joy? No. They are in the business of eradicating disease, not cultivating joy, and that was what was missing. 

A lot of patients were not meeting the criteria for depression, but something was off. And I found that after the pandemic, I was seeing more and more of these cases. Then I saw a term floating around on the internet: high-functioning depression. 

You hear about these celebrities who died, who had a mask of happiness, who were performing, who were doing great things, but suddenly they decided to take their lives, right?  They died by suicide, and a lot of their family members were saying that they were having high-functioning depression. Doctors in very, very important newspapers were saying that's not even a thing. 

Well, if people are experiencing symptoms, but they don't meet a criteria that probably doesn't apply to everyone these days, because a lot has happened, a lot has changed in the world. If they don't meet this criteria for something that was classified 30 years ago, then are we just going to leave them alone? 

Sometimes we have to let our patients lead us and to use the language that they identify with. So if your patient is saying that you're having symptoms of depression, that you're not enjoying things, but you're still performing, but you're still delivering, but you're having these symptoms, are we just going to wait for them to stop functioning, for them to be broken, to do something about it?

That's why I thought that term was so powerful because it shakes to the core what we believe, what we think depression looks like. 

We're missing people who don't meet the criteria, but we could be helping them before it gets to a crisis, before they stop functioning. I'm passionate about this work because frankly, I was that person who was running a lab, taking care of employees, taking care of a small child at home, married to a frontline worker, seeing the world fall apart, having to help people.

There was no way that I could stop; I had to keep going. So I pushed through the pain. I suffered from high-functioning depression, and I knew that I had to do something about this, and that's why I started studying it.

Jonathan: And if you went to see your doctor, what would generally happen with this high-functioning depression that you're talking about, what would you expect? 

Dr. Judith Joseph: So there was a scale that I was using in my research studies. It was the SHAPS scale.

I think it's actually developed by someone who's British. It's an old scale, and there are items on there that I was using in my lab, but I found that some of the scales on there were a bit antiquated. In the U.S., many people don't drink tea, but tea shows up on that scale. So I had to change some of the items on there to match modern day.

The things that I would ask my patients were, When you eat a meal, do you enjoy it? Most of my patients who were suffering from high-functioning depression were just eating to live. They weren't savoring their meals.

Or, do you enjoy social interactions? And some of them would be saying, well, kind of, but most of the time, I wish I weren't there, or I wish I would just hurry up and get through it. Do you enjoy intimacy? And a lot of them were saying no.  

So the simple pleasures in life are just not exciting. They're not bringing that same joy that they once did. And those are the things that I ask.

Now. I also ask about those other symptoms that I mentioned, the SIGECAPS of depression, to see if people are experiencing changes in their appetite, their sleep, their energy, guilt, and hopelessness. 

I find that guilt is one of the things that I've noticed a lot with these patients. There's a guilt if they take a break. There's this feeling as if they're not producing enough, even though they're producing so much. Producing a podcast, running a business, it just doesn't feel like enough. 

So there's this guilt to keep pushing through and keep making more, but there's a lack of satisfaction. So this busying and this guilt that drives people to produce in order to feel worthy is really tied to high-functioning depression and overachiever.

Prof. Sarah Berry: Judith, do you think that it's increasing in prevalence, given the demands of the modern way we live our lives? Do you think this is something that existed a hundred, 200 years ago, or do you think it is purely because of the expectations that I think are placed on so many of us now? 

Dr. Judith Joseph: It's an excellent question. In medical school, we learned the biopsychosocial model. So it sounds fancy, but it is very straightforward. So there are three circles, and I love this diagram because it's very easy to explain to patients. 

Biologically, there are risk factors that everyone has, and biologically, you have genetic loading, you have people who have medical conditions, physical conditions that contribute to depression. Psychologically, you have past traumas, you have your inner resilience, your IQ, whether or not you are pessimistic or optimistic, and your attachment  styles. 

Then socially, the things in the environment that contribute to symptoms, or disease states, right? So your relationships, if they're unhealthy or stressful, that's pressure. Your diet, which I know that you're an expert in, your habits such as smoking and drinking and so forth. 

So the biopsychosocial model is really important. But I think in today's day and age, we, in the social aspect of that model, do have to consider capitalism and the wage gap and the fact that the rich are just getting richer and the poor are getting poorer.

The fact that there's social media, that we have this never-ending amount of content being thrown our way. It's a lot. 

So there are pressures from a societal standpoint that were not there 30, 40 years ago, and that's why it's important to revisit the biopsychosocial model. It's an old model, but it's a good one because it changes over time, and you can fashion it to the patient in front of you.

For example, if I have a patient who has an autoimmune disorder, well, looking at the biopsychosocial model, I could focus on the relationships and your boyfriend who's not really treating you well, or what if the autoimmune condition is the thing that's really stressing the system here, right? The biological, let's get that under control first. 

Or if it's someone who's perfectly healthy from a biological standpoint, and then psychologically they're okay, but their current situation, let's say the job is toxic, then that's where I'm going to spend my time and focus my effort. So the biopsychosocial model is really important.

So to answer your question, absolutely capitalism, technology, all of these changes, a post-pandemic world, these political uprisings, all of these things impact us today. 

Jonathan: That's really interesting. So what I'm understanding, Judith, you're saying that you can have someone who's almost hiding a set of underlying symptoms, and I was describing my own story, reading your book. So they look very non-depressed. 

But what you're saying is underneath quite a few of these symptoms of depression are there, and that in a way, being busy is in part a response to this. 

So, in some sense, a mask, but also it's a way to try and deal with it. You feel like, obviously, you have some purpose, there's something you're supposed to do. So you do this, am I sort of playing this back right? 

Dr. Judith Joseph: Somewhat, yeah. More of a prodromal state to a depression or to a physical breakdown or to a substance abuse, right? Because eventually something's going to give. 

You can't continue doing that. Something will break. Either you physically will break down, or you may develop low functioning or clinical depression, or an unhealthy habit, or an unhealthy addiction. So, eventually, this is something that we want to prevent. 

In modern medicine, we are in the business of fixing things, not preventing conditions. 

Prof. Sarah Berry: So Judith, can we dive a little bit into your research? Because I know that you are the one that's really led this area of high functioning depression. What do you think are the main causes of this?

Dr. Judith Joseph: I do look at what's been happening over the past couple of years, like I mentioned. 

I think that in a post-pandemic world, we didn't really process the pandemic. At least there's no memorial, there's no recollection of, well, let's reflect and get through this. It was more like, let's forget that ever happened. Let's just continue moving forward.

Then, like I mentioned with the biopsychosocial model. The rich are just getting richer, the poor, getting poorer. There's just so many factors that make depression today so different than depression 30, 40 years ago. 

So I think that looking even at technology, we didn't have non-stop exposure to technology. Our brains weren't overwhelmed the way they are. Who knows what that's going to do to the adult brain? We know already what happens to the pediatric brain. We're seeing it, I treat children as well. 

So I think that the stressors in the world are just different. You're from a nutritional standpoint, and you know that the foods these days are ultra-processed. We're not getting the things that we used to 50 years ago that fed our brains, that fed our bodies. 

So there are so many factors, and that's why I think this is a new depression. And I think that we have to think about the biopsychosocial model. We have to think about preventing it because we have a mental health epidemic on our hands.

In some parts of America, there's one psychiatrist for 50,000 patients. One of me, for 50,000 people, I can barely handle 50 patients. 

I like to use words like the New Depression because it gets your attention. If I tell you, if I call up my colleagues who work in the ER and I say, I have a patient who's suicidal, they'll be like, well, bring them in.

But if I call them up and I'm like, I have a patient who has anhedonia, they're like, well, when they're suicidal, bring them in. That is not okay. But that is our current system.  

I studied cultural psychiatry in different countries throughout my training, and it's so interesting because in some cultures, I would see doctors who are not psychiatrists approaching mental health in so many creative ways. 

They talk to patients from a spiritual level, like, So how is your family, and what are you doing in terms of making yourself happy? And they would talk about praying and meditation and things like that. 

That is what we should be doing. We need to focus on cultivating joy and purpose versus preventing disease and crisis. And when we shift that, you won't need one of me for 50,000 people because you will be preventing this crisis from happening. 

Prof. Sarah Berry: And with high-functioning depression, do you see the same differences between men and women that we see with, maybe I should call it the old depression?

Dr. Judith Joseph: There are some colleagues at major institutions who are saying that men are particularly at risk because men, at least in our country and in the United States, are not acculturated to express feelings. 

So they are told to suck it up. You see a lot of irritability. So a lot of times, these bad actors, you see them misbehaving, and they're like, oh, that guy's a jerk. Or it's an untreated depression, right? They're irritable and angry, and irritability is one of those other, not well-known symptoms of depression. 

In my laboratory, some of the clinical rating skills that I use look at symptoms not just of sadness, but of irritability. But when people think about irritability, they don't necessarily think of depression.

So someone who's irritable doesn't get the sympathy or the empathy. They're just a bad person. They're just in a bad mood, right? Think about other people, you know.

But irritability is one of the hallmarks of depression, and I see that a lot in men. So I think that men express it that way, and they may cope with the depression by substance abuse.

So, one of my patients over the years, I try to do a family tree with them to see who in the family may have had depression, because I talked about the biological component, right? The biopsychosocial, and that's the family history part. And he was like, Well, you know, no one in my family had depression, but my dad did come home and yell a lot and drank every day.

And I was like, So do you think he was happy? And then he was like, Oh my gosh, never thought about it, just thought he was a jerk. 

Jonathan: So you are saying, I just want to make sure I've understood it, that might be a consequence of being really unhappy. Which you're saying is also close to being depressed, and then you potentially start abusing substances or alcohol, you're talking about here.

Then obviously, someone might become an alcoholic, and we know all the bad things that come from that. But you're saying that's not necessarily the starting point, not necessarily sort of innocently drinking too much and falling into this. 

Actually, this might be a crutch, it's a way of coping, which makes sense to me, and I can definitely think of friends of mine for whom that's clearly been the case. 

Dr. Judith Joseph: Yeah. I mean, so what you're saying is basically the person expresses their depression instead of sadness with irritability. The coping with the sadness, the coping with the emptiness. 

That they don't necessarily identify as being sad, because a lot of people who are angry will not say that they're sad. They'll say I'm angry, but it really is a depression. So they'll cope with that, with drinking to escape whatever they're running from.

There's a lot of comorbidity with trauma, so people who have unprocessed trauma and not trauma in terms of what meets criteria for PTSD, post-traumatic stress disorder. Trauma in terms of emotional pain.

So, to meet criteria for PTSD in the DSM-5, the diagnostic manual I told you about, it has to be life-threatening or it has to be something like a sexual assault, right? Or combat, you had to have experienced it or witnessed it to meet the criteria. 

But there are other things that classify as traumas that are not in the DSM-5. For example, I had patients during the pandemic who told me that they experienced their loved one having prolonged cancer. Well, that's traumatizing, but it didn't meet criteria for DSM-5, but no one would deny that that is trauma, right? 

Or people who've been through terrible divorces or bankruptcies. I mean, that's traumatizing, but it doesn't meet criteria for the DSM-5 diagnosis of PTSD. 

So, a lot of painful emotional experiences that have shaped who you are and how you perceive yourself in the world, those are traumas. A lot of times, we don't. Talk about them because one of the symptoms of trauma is shame.

We somehow believe that we did something to deserve it. So you hide it and you turn on yourself. You cope in negative ways, like drinking a lot, by yelling at people.

With high-functioning depression, anhedonia, and not processing your pain are key, and we're not having those conversations. We are being okay with people getting through life, just working and then dying. 

But what's the point, right? What is the point of life if there is no purpose and meaning? And so I may sound more like a spiritual leader than a physician.

Jonathan: I was actually loving that. I think my parents would say, my parents are both workaholics. I love them very much. They're complete workaholics, Judith.

Prof. Sarah Berry: So are you Jonathan. 

Jonathan: Well, I wonder where that comes from. So my parents are both workaholics, and I think they would be like, What do you mean? That there is some purpose other than work, surely that is the primary… and they care about their family as well.

But it's interesting that you mentioned that while also telling me maybe I am high-functioning depressive. So this is all somehow linked. Is that what I feel like this is becoming a therapy session for me now, Sarah. 

Prof. Sarah Berry: Well, I'm identifying a lot of this in me as well. 

Dr. Judith Joseph: Well, a lot of high achievers. You're doing wonderful things, and people depend on you. 

You were just telling me you're one of the top [nutrition] podcasts in the U.K. You can't let your followers down.

It's not uncommon for leaders like yourself to experience it. 

Jonathan: And Sarah, this is ZOE, and you are one of the world's leading nutrition professors. Do we know if depression can be influenced by what we eat? 

Prof. Sarah Berry: So if you'd have asked me that 20 years ago, I'd say nothing. 

But it's phenomenal now how much our knowledge is growing around how food impacts our mood, our mental health, anxiety, depression, and so forth. There's still so much more to learn, but we now know that we need to stop thinking about just how food impacts our body below our neck.

That actually it has such a profound impact also on the way our brain functions, and we know from studies, for example, that there can be up to a 30% reduction in rates of depression just by changing our diet.

There's a fantastic study called the SMILEs study, which was run by Professor Felice Jacka, who we've had on the show before, who randomly allocated people who had major depressive disorder, either to follow a kind of Mediterranean diet or follow just a control typical diet.

They saw really huge reductions in rates of depressive symptoms. 30% of people actually were able to meet the criteria for coming off their medication. 

So that's in people who have clinically diagnosed depression. In addition to that, we know that food impacts our general mood, our general levels of happiness, and contentedness.

And we know this even from our own research, Jonathan. So Judith, we recently published a study where we compared individuals who are following the ZOE program, which is a personalized nutrition program, versus the average U.S. diet. And what we found was that for those who are following the ZOE program, over 30% of people reported significant improvements in their mood.

This is people who don't necessarily have any kind of clinical diagnosis, but are saying that, yes, I feel better. We also know this from another study that we recently published, which was looking at a whole food supplement that we have called Daily 30, which acts as a prebiotic, that again, we saw these really big improvements in mood as well.

We are starting to understand that, partly, it's to do with inflammation, it's to do with reductions in oxidative stress. But what we're also really starting to understand, I think this is what's really exciting, that there's a link between our microbiome, which we know is heavily influenced by food, and our brain function. Particularly related to the mood areas of this as well.

Jonathan: Judith, when I first co-founded ZOE eight years ago, if you told me that this food could have any impact really on how I feel, I would've said that's some crazy Californian thing, totally mad.

I think even three years ago, when we were talking about setting up that randomized control trial, and Sarah and my co-founder, Professor Tim Spector basically said, you have to do this randomized control trial of ZOE membership. If you don't prove that it works properly, like you would with anything other scientific, we won't keep working with you.

So I was like, huh. Okay, we'll have to do it. So it's a bit scary, right? Because you have to publish the results, as you know, as a scientist and as a CEO of a company, I was like, so if it proves it doesn't work, I have to publish to everybody and tell them it doesn't work. It was very scary. 

So I was very pleased when it turned out that ZOE membership really works. But we were very focused on long-term health. A lot of this was around improving your gut microbiome and how this would change long-term health. 

We were not focused, and you weren't focused, right, Sarah, around how would you change mood and energy and sleep. But actually, what's amazing is these were some of the biggest changes that we saw. Now you are nodding as if you are not surprised. 

Dr. Judith Joseph: Well, there's a whole field called nutritional psychiatry dedicated to that, and there are studies out of Harvard that show the key brain foods. I'm sure you know, like those leafy greens, blueberries, and foods rich in omega-3 fatty acids. 

Eating foods that don't promote inflammation, right? The foods that are processed, those are inflammatory foods. So knowing where your food comes from is also important. 

A lot of us don't know where our food comes from, and I'm from the Caribbean, so my father used to say, Make sure your plate is colorful, and he knew what he was talking about, right? 

Jonathan: Did he really say that?

 Dr. Judith Joseph: He really did? Yes. 

Jonathan: We say that a lot at ZOE, but I have to say that none of my parents or grandparents ever told me that my plate should be colorful. That may be growing up in the United Kingdom versus elsewhere. 

So, yes, he clearly did know, so that's really interesting. 

Dr. Judith Joseph: Well, in Trinidad, I remember because I was born there, I remember waking up, and I heard the milkman coming and the fishman coming. Everything was fresh, and so when we moved to the United States, my dad would be like, We have to keep eating fresh foods.

I don't think he knew about nutritional psychiatry because he is a pastor. But there's something to it. Having fresh food that's not processed, that's not promoting inflammation in your body, because inflammation is not just bad for your body, it's bad for your brain.

We're learning that food is truly medicine. So when we think about the biopsychosocial model, there's an overlap between biology and social because of our social habits, picking the foods that we eat overlaps with our biology. So when you look at that diagram, they overlap because the oxidative stress that inflammation can impact the way that you feel.

But it's really hard to change what you eat. These programs that you're talking about, these studies, they're controlled. You have people on these plans, but it's really difficult to implement that in your home for some individuals. 

So it's something that you don't just give a book. With my patients, I recommend two or three books from authors that I personally know who are leaders in nutritional psychiatry.

But I tell them it's not just about reading a book. You really do have to practice it because sometimes, if you're not feeling great in life, if you're feeling stuck, you fall back into patterns. So you do need that reminder. 

Jonathan: I completely agree with that, and I think one of the things we really hope is that ZOE membership can provide people a better way to build life-changing lifelong nutrition habits that actually stick.

Because I think we see what a problem is to not only get somebody to make a change, but also to make a change in a way that is sustainable. 

Prof. Sarah Berry: I think that's the big challenge, that we know that low mood, and what accompanies low moods, the kind of factors you've talked about. So, for example, poor sleep as well, that alters how our brain thinks about food.

So we know that if you have low mood, if you have poor sleep, for example, the reward centers in your brain are crying out, saying, okay, I need a quick fix. They're crying out for those refined carbohydrates, those sugary foods, for example. 

All the foods that we know are going to make our mood even worse. But also set us up on a rollercoaster that day that we're having these foods, of these peaks and troughs in blood glucose, then set off inflammation, et cetera as well. 

So I think it is that real kind of catch-22, and we have to work really hard, I think, to enable people to understand just how important food is for mood and give them small, actionable insights and tips that they can take forward.

Dr. Judith Joseph: Yeah, I think what you're talking about is similar to metacognition. Learn to think about the way that you think. 

So with myself, I know when I'm stressed, I want to reach for that sugary processed food, but then I'm like, Wait, I'm thinking that way because I'm stressed. So then I'm like, I really have to stay away from that, and I just eradicate it from my house.

I think when you work with your patients, or at least when I work with my clients, I really teach them all right, let's think about the way that we think, and let's not have those items within reach, because you are going to reach for those things. 

Studies show that when you're stressed and anxious, you are going to make those poor decisions. So, let's not keep it in the house whatsoever. 

Jonathan: Sarah, one of the things that we've been talking a lot more about just in the last couple of years is ultra-processed foods as opposed to just junk food in the way that we've all known about it since we were children. 

Is there any evidence that suggests that ultra-processed foods might be having an impact on mental health beyond just the fact that they've got lots of sugar or fat in them?

Prof. Sarah Berry: Yes, this is, and again, an emerging area of research because it's a relatively new term, the term ultra-processed food. 

There's some interesting research, particularly in children and adolescents, and this is where there's some quite robust findings now that there is a relationship between mood and depression in children and in adolescents in relation to the amount of ultra-processed food that they're having.

We need to now do studies in adults, and these are the kind of studies that, as far as I understand, are ongoing at different institutions, like at the Food and Mood Center that Felice Jaka runs as well. 

So I think we are just going to see more and more evidence come out about the relationship of these unhealthy ultra-processed foods and our mood and depressive disorders.

Jonathan: Judith, I'd love to start talking about actionable advice now, because I think you've painted this picture around high-functioning depression. I bet there are loads of people like me and apparently Sarah, who's been listening, saying like, Oh, maybe I at least have some aspect of that. 

Could we maybe start actually with those listeners? Imagine they are thinking about this and saying, maybe I do have high-functioning depression, I feel like some of what Judith is describing resonates. How can they identify it? 

Dr. Judith Joseph: Well, I do think that I have this rating scale on my website where I break down high-functioning depression into symptoms and scores, and anhedonia. And so you'll get a score of anhedonia, which is that lack of pleasure of feeling, and you can get a score of high functioning. 

So one of the most common things I see, I'll ask my clients, What did you eat for lunch today? Can you describe it? Sandwich. Okay. What did it taste like? It's good. Let's go more into that.

Well, I don't really know. I didn't think about it. Okay. Well, tomorrow when you have lunch, I want you to close that computer, no phones on, and I want you to just focus on that food and practice something I call 5, 4, 3, 2, 1. 

It sounds super cheesy and granola, but it works. So I want you to really immerse yourself in that experience of eating that sandwich that you said was just good. And I want you to tell me five things that you can see. I'm going to ask you about this next time. So I want you to describe it. 

So you may see this red tomato, and you see the green lettuce, you get the idea. I. Four things that you can feel. So it could be the bread or the texture of it, or you know, whatever you're drinking. Three things that you hear, and I want people to be intentional about that experience. Two things you can smell, one thing you can taste. 

When I practice that with people, even in my office, I'll have these little mints or a raisin, and they're doing that. They're not thinking about anything else. They're present in that moment. And they actually start to enjoy it, versus the shoveling the food in the face and just eating to get through the day. 

It sounds so simple, but it's very difficult for people to do. That's a very quick and dirty way to start challenging and pushing back on anhedonia.

What it does, is forces you to slow down. It forces you to savor a moment and to actually find pleasure in something that we all have access to. We all have access to food, hopefully.

Once you start with those baby steps, then I move on to people in their lives. Right? People, a lot of times, the mothers that I work with, they'll say like, I just, I get home and I'm just so tired, I don't want to put my kid well. 

We're going to teach you how to be present even in that five-minute interaction with your child. And the more you do these things that you're intentional and mindful and still in these things, you actually start deriving pleasure again. You start feeling again. 

But remember how I said that anhedonia, that numbing is probably a product of not processing pain, or this, it's a coping mechanism. When you don't process, when you don't feel that pain, you're not going to be able to feel joy. So it is a step in feeling again and being human again. 

Another common thing I hear is, I'll ask my clients, how many times did you use the bathroom today? And they'll be like, maybe once. Maybe when I got here.

Well, I want you to be mindful, and I want you to set alarms in your phone. You are going to take bathroom breaks like you did when you were in the first grade. 

And it sounds funny, but how many of us have just powered through, and we had to really go, Why are we doing this to ourselves? Who's benefiting? What's the worst thing that will happen if we actually listen to our bodies and we're kind to ourselves and use the bathroom?

So these sound like very simple things, like, Oh, I don't need a psychiatry degree to know that. But sometimes you do. You need a reminder to just start feeling your body again, to start being human again, to enjoy those basic things, those basic sensations again.

Prof. Sarah Berry: I think a lot of what you're describing to me sounds like just slow it down, and I think what really resonates is the being present. And it's something that I've really struggled with my children.

They're now getting to their teens, and I look back and I even during, while they were children, I kept thinking, I wish I could be more present. And I tried to be very conscious about being more present, but I still really struggled. 

Now in your book, you reveal that there's five ways that we can tackle high-functioning depression. Could you talk us through those? 

Dr. Judith Joseph: So, a lot of what I talk about with psychiatry is eradicating disease, but we don't cultivate joy.

Well, I'm not the only one. There are a lot of people, not a lot, but there are a couple people like me who want to focus on joy. 

The first V is validation. So I mentioned that when I was going through my periods of high-functioning depression, I was just pushing through pain. And I remember sitting at my desk and giving a talk to healthcare providers who were really stressed. It was April 2020, they were in the pandemic. No one knew what this thing was.

I'm talking to them and I'm supposed to be helping them through this, and I'm just thinking, I don't even know what to say. I'm scared too. But that was the first time I actually said it out loud, I am afraid, I think I'm depressed.

That validation, the first V is validation. Acknowledging your pain. We don't acknowledge our pain. We don't acknowledge our negative feelings for whatever reason. Could be cultural, could be the way that we're raised, but the first step is really acknowledging it. 

Prof. Sarah Berry: And could that be just even acknowledging it to yourself? You might not yet be ready to acknowledge it externally.  

Dr. Judith Joseph: The second is venting, so that's when you actually start talking about it. So some people have someone to talk to, but others don't feel just ready yet. 

If you have a therapist, great, but good luck with that. The wait list is very long, at least in America. But you can start venting by writing.

I had one patient who was a singer, and she would just start belting out notes. Some people express it in art, but get it out. And the definition of venting is, you know, you letting out air, but we have to let it out. Because then we're holding it all in, and there's that saying that the body keeps the score right.

Then the third is values. I used to think that collecting all these degrees was important. I have two Ivy League degrees. I have all these certifications. You go to my office, it's degrees everywhere. I used to think that was what was important in life. 

But I'm an island girl at heart, and when I visit Trinidad and I put my feet in the sand and I look at the water, I'm like, wow, I value nature. Why don't I get enough of this? I grew up in this, why am I running from it? So now I make it a point to be out in nature with my daughter.

I value family, so I'm not going to stay in the office 30 minutes later just to do some paperwork that when I'm on my deathbed, I'm not going to be thinking about that paperwork, that file. I'm going to be thinking, why didn't I have 30 more minutes with my child? 

So, really think about what you value in life and invest in that. The things that you thought were valuable, you're not going to be missing those when you're on your deathbed.

And then vitals. This is where you come in with your nutrition expertise. So the things that support our body. Food that feeds our brain and our body, that decreases inflammation.

Movement. That's another thing that people with high-functioning depression often neglect because they're working so hard, they don't get to move.

Our relationship with technology. I think that's a vital, that's missed in medicine, you know, decreasing that.

And also sleep, it's very important. It's restorative. So there are things that support our bodies that we tend to neglect when we're busying ourselves. 

I stuck into vitals, relationships, because like I mentioned, if you have a toxic person in your life, you know, relationships are the number one predictor of longevity. So think about who you want to spend your time with. You may not be able to cut people out completely, but you can limit the amount of exposure to them. 

And then the last one is vision. We don't tend to celebrate our wins. You know,  you have the top podcast. Put moments in the calendar to celebrate it as a team, take the time to savor a win. 

If you got a good research study result, celebrate it. Don't just send an email, look, this is what our study showed. Okay. What's for dinner? Celebrate your wins. 

Prof. Sarah Berry: Where are we going for dinner tonight, Jonathan? Judith, you’re welcome to join us.

Jonathan: Are you taking me out for dinner, Sarah?

Prof. Sarah Berry: I think we've got a month's worth of dinners for our wins. 

Jonathan: We are a long way behind on celebrating our wins. 

Prof. Sarah Berry: No, ZOE’s very good, actually I think.

Dr. Judith Joseph:  And not just the big ones, if I get my daughter to school on time, because her school is strict, I'll come home and I'll sip a cup of coffee and take time and savor and like wow, I got her to school on time, that was hard. 

It's not just the big ones, you know.

Prof. Sarah Berry: I love that, the small wins, because it's the small wins that I don't think we acknowledge, but it's the things that are occurring hour after hour, day after day, that are challenging. 

Jonathan: And Sarah just listening to that, on the food side, I just wanted to follow up on one thing, which is I think a lot of listeners think of this will be, Well, if I am worrying about my mental health, are there any specific foods or way of eating or anything that can actually help?

Prof. Sarah Berry: So I think there's no specific way of eating that would be different to what we would recommend for everyone, specifically for mood. 

So we would recommend for everyone's physical and also mental health to be following the kind of diet we encourage at ZOE. So this is a diet rich with whole foods, whole plant-based foods, lots of color, as your dad told you, Judith. 

So a diversity of different plant-based foods that are rich in color because they contain all these magical chemicals called polyphenols, which we know act on anti-inflammatory pathways. 

Lots of fiber-rich foods, so whole grains, legumes, and pulses. Foods that also contain omega-3, and Judith touched on this as well. Omega-3 is a particular kind of fat; it's found in high amounts in oily fish, and that's really important because we know it has a really important functional role in our brain, as well as avoiding certain foods. 

I know that we want to think about what we should encourage, but I do think we need to acknowledge, particularly when it comes to mental health and depression, that actually having these very high refined carbohydrates, high sugar foods, heavily processed foods like your salamis, your heavily processed red meats, for example. We know that that increases the chances of having mental health issues, of having depression, of having low mood.

Jonathan: So your dad was completely right about eating the sort of food that he was eating before you came to the States, it sounds like. 

Dr. Judith Joseph: Yes. I tell my patients, if you can't pronounce it, don't eat it. 

Jonathan: Which, if you look on most food labels, is quite limiting. 

Jonathan: Judith and Sarah, thank you. That's been amazing, really interesting.

I would like to do a quick summary, and Judith, will you correct me if I get this wrong, because it's a completely new topic for me. 

So I think you started with that basically, you've been trained like most doctors with this idea of eradicating disease and not worrying about creating joy with people who don't have joy.

But actually, there's sort of this epidemic of people who are managing to function, but just have got their joy switched off. And if they don't do anything about it, they can end up getting worse. 

You end up treating them because it's gone to a full depression or something like that. So for you, that doesn't make any sense. And actually, this is a real thing, this high-functioning depression. 

If you can help people to identify it, there are things that can be done. The men and women don't necessarily express it in the same way. 

We then talked a bit about food, and that food really does make a difference for mental health. This is not some woo-woo thing, as I thought it was a decade ago, but it's real. 

Sarah just shared something I'd never heard before, which is this latest research showing that there's actually a link specifically between ultra-processed food and depression, you said.

Prof. Sarah Berry: Mood disorders in children and adolescents, 

Jonathan: Which I think is again, this sign that the food that we're eating is doing really terrible things, I think that none of us understood.

Then you talked about the fact that you can do something about this. I think my takeaway was, your number one thing you're trying to say is, can you start to be present? If you can be more present, you might be able to start to connect and start to source joy. 

You talked about this noticing lunch and paying attention to it with this rule, which I love and I know is in the book. 

Then you talked about these different Vs, and interestingly, there's a sort of pathway it sounded like between just acknowledging yourself that you're unhappy and in pain.

Being able to talk about it, which if you were brought up with a stiff British upper lip and a family that didn't talk about emotions is really hard. It's not at all, you know where you are, even if it's in a very loving family. It's not what you are supposed to do. 

Doing the things that you actually value. You talked about the family and all the rest of it, because this obsession to work hard, actually maybe pulls you away from the things that you really care about.

Look after your body. 

And then I love the last one, actually go and celebrate your wins, because I think that is really interesting what you said. I was thinking back to this description, I was saying about times that I felt at ZOE, unable to celebrate any of those wins of things that were going on. It's definitely part of how I would describe how I was feeling. 

Dr. Judith Joseph: Excellent. That is spot on. 

Prof. Sarah Berry: And Jonathan, may I celebrate? What you have done in the last seven years is incredible. I'm sorry, Judith. I know this is about high-functioning depression.

Dr. Judith Joseph: It’s his therapy session.

Prof. Sarah Berry: But honestly, the joy that you have brought to all the ZOEntists that have the pleasure of working with you, for you, the joy that you brought to my life, the phenomenal science we have produced. 

Honestly, I always talk about our research at ZOE as being like science on steroids. It's just crazy and fun and incredible. The breakthroughs, everything. 

And then what you are doing to all of the people that get to listen, the millions of people that listen to your wonderful podcasts, the hundreds of thousands of people that have actually done ZOE, that are following the ZOE diet and the new discoveries that are helping hundreds of thousands of menopausal women as well. So well done. 

Jonathan: You’re going to make me cry now. Thank you, Sarah. I appreciate that, Judith. Well, we don't normally do that on the podcast. I'm really embarrassed and not in touch with my emotions, but I appreciate it.

We're going to go and have a private consultation, I think, after this. Judith, thank you so much for coming on the show. 

Dr. Judith Joseph: Thank you. It was my pleasure. 

Jonathan: It was a real pleasure.  

Prof. Sarah Berry: Thank you, Judy.