Depression and work: how to work when you can't — and when not to

By eight she is already at her computer. At ten she has the same email open that she had open at eight. She has read it to the end three times and three times realised she does not know what it says. When a colleague asks whether she is coming for a coffee, she says she has too much work. That is true — except that she cannot bring herself to start it. In the afternoon she goes home, lies down on the sofa and waits for the evening to pass so that she can repeat it all tomorrow.

This is what depression at work looks like for a great many people. Not a dramatic collapse, not crying in the toilets, although that happens too. It is a quiet, persistent draining of strength that almost nobody notices from the outside. The person is there, and yet not there. And because they are there, they think they ought to manage more.

In this post I will write about what depression does to work and to thinking, why your concentration slips away, whom it makes sense to tell, when it is better not to work for a while, and how to come back. But first something important: depression is diagnosed by a doctor, a psychiatrist or a clinical psychologist. This post does not replace an assessment — but it can help you recognise what is happening to you, and help you not to carry it alone.

Present, but not really: presenteeism

When we talk about depression and work, we tend to think first of sick leave. Yet research has long shown that most of the loss lies elsewhere. In a 2003 American study of employees, Walter Stewart and colleagues found that among people with depression roughly 81 per cent of lost productive time came from reduced performance while at work, not from absence. People were at work, but they worked more slowly, with more mistakes and with enormous effort.

We call this presenteeism: being present without really working. Later, an international study by Sara Evans-Lacko and Martin Knapp confirmed it in eight very different countries — from Brazil to Japan. Everywhere, the loss from reduced performance at work was greater than the loss from absence.

I do not mention these figures to talk about costs for employers. I mention them because many people with depression believe they are the only ones dragging themselves through the day like this. They are not. Most people with depression go to work. And most of them experience exactly what you do there: every task demands twice the strength it once did, and the result is worse. That is not laziness. It is a symptom.

Why your mind keeps slipping

Most people imagine depression as sadness. But many who know it from the inside say that what hit them hardest was not the sadness but the fact that they could no longer think. You read a page and do not know what you have read. You start a sentence and forget where it was going. A choice between two equal options takes half an hour.

These are difficulties with executive functions — working memory, planning, switching between tasks and holding attention. A 2014 meta-analysis by Rebecca Rock and colleagues showed that these difficulties are measurable in depression and that in some people they persist even once mood has improved. That is worth knowing: even when things feel a little easier, work may not flow the way it used to for some time yet. It is not a sign that you have relapsed.

On top of that there is rumination — going over the same thoughts in circles: “Why can’t I do it? What will they think? I’ve messed up again.” Rumination swallows exactly the attention you would need for work. That is why you can sit in front of a task all morning and feel you have been thinking the whole time — just not about the task.

Depression or burnout?

Because both show up at work, they are easily confused. Burnout is a response to prolonged overload at work; at its core are exhaustion, cynicism towards work and a sense that you are no longer effective. I wrote about its signs in Burnout is not laziness: signs your nervous system is asking for a break.

With depression, the greyness spills over everything. You lose the will not only for work but also for the things that once brought you joy — friends, hobbies, weekends. If a holiday does not help and the seaside feels as empty as the office, that is important information for your doctor. Of course the two can overlap: prolonged burnout can turn into depression. They need to be told apart by a professional, because the approach to treatment differs.

Whom to tell — and how much

This is one of the hardest questions people bring with them. On one side there is the relief of being understood. On the other, the fear that people will start to see you differently, pass you over for promotion, or that you will become “the one with depression”.

There is no single right answer, but some things are worth thinking through:

• You do not have to disclose the diagnosis. You can say you have a health condition for which you need some adjustments. That is true and it is enough.
• Say what is useful. Rather than describing how you feel, it is often more helpful to say what would help you: fewer early meetings, written instructions, clearer deadlines.
• Choose a person, not a role. Sometimes your manager is the right person, sometimes it is a colleague you trust, or HR. Think about who has responded to other people’s struggles with understanding in the past.
• You do not have to say everything at once. You can start small and see how the person responds.

Hiding has its price too. When nobody knows what is going on, your weaker performance is read as lack of interest or incompetence. And every day you spend extra strength pretending everything is fine. I wrote about how depression stays hidden behind a successful front in High-functioning depression: when everything works outside and it is empty inside.

Talking to your manager

This is how a conversation might go in which someone says enough, but not everything (composite example, not a real person):

“I’ve noticed your reports have been late recently. Is something wrong?”
“I have a health condition I’m being treated for. I’d rather not go into detail, but it affects my concentration.”
“Thank you for telling me. What would help you right now?”
“If I could hand in the reports on Friday instead of Monday, and if you could also send me tasks in writing.”
“We can do that. Let me know if anything else needs to change.”

Of course not every conversation goes like this. Some managers respond with discomfort, others with advice, others with silence. But simply having said what you need gives you back some control. And if you see that there is no room for such a conversation where you work, that too is important information — about the job, not about you.

When not to work

Research shows that for most people work is good for mental health. A review published in 2016 by Matthew Modini and colleagues concluded that employment provides structure to the day, contact with people, a sense of meaning and belonging — all things that depression likes to take away. So withdrawing completely is not always the best path.

But there is a limit. Sick leave makes sense when:

• you can no longer carry out basic tasks, even with great effort,
• the work itself — overload, conflict, harassment — maintains or deepens your distress,
• you are not sleeping, not eating, or cannot get out of bed in the morning,
• thoughts appear that it would be better if you were not here.

In Slovenia, sick leave is issued by your GP. Talking to them is a good first step also because they can refer you to a psychiatrist and judge whether medication might help. I will not describe the legal details of how long sick leave lasts or the procedures here — your doctor and HR are the right people for that.

If suicidal thoughts appear, do not wait. In Slovenia, call the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritans helpline on 116 123 (24 hours). In an emergency, call 112.

Sick leave is not a holiday and it is not a defeat. It is time in which you get treatment — with the help of a doctor, perhaps medication, psychotherapy and a slow return of rhythm. Empty days on the sofa without structure can even deepen depression, so it makes sense to keep a few regular tasks, walks and contacts during your absence too.

Exercise: one day, cut into pieces

If you are at work and the day seems to dissolve into one long fog, try this. It will not cure depression, but it can give you back some sense that the day is at least partly in your hands.

1. In the morning, write down three tasks, not ten. Choose the ones that truly matter today. Write the rest on a separate sheet and put it aside.
2. Break the first task down into the smallest possible step. Not “write the report” but “open the document and type the title”. Depression gets in the way of starting most of all; once you have started, it often gets easier.
3. Work in short blocks. Twenty-five minutes of work, then a five-minute break in which you stand up, drink some water or look out of the window.
4. Tick off every finished piece. On paper, not in your head. Depression likes to erase everything you have done; writing it down does not let it.
5. In the evening, read the list of ticks, not the list of what is unfinished. And tell yourself: “Today I did this with depression, which is harder than it looks.”

This approach is related to behavioural activation — action comes before motivation, not the other way round. You can read more about why drive vanishes just when you need it in Why depression takes your drive exactly when you need it most.

A gradual return

Returning to work after sick leave for depression is often more fragile than people imagine. In the first week things may seem to go better than expected, and then a tiredness arrives that takes you by surprise. That is to be expected: your body and mind are relearning a rhythm that you lived differently for months.

A Cochrane review of research on return to work in depression (Nieuwenhuijsen and colleagues, 2020) showed that two things help in particular: good treatment of the depression itself and adjustments at the workplace. The combination seems better than either alone, although the research is still limited. In practice this means something simple: plan your return together with your doctor and, if possible, with your employer.

A few things that often help people:

• A conversation before the first day. What has changed, what awaits you, who your contact person will be.
• A smaller workload at the start. Fewer responsibilities or shorter hours for the first weeks, where possible — talk to your doctor about the options.
• Protecting what helped. If during sick leave you started going for walks, going to therapy or going to bed at the same time, do not drop it when work comes back.
• Clear boundaries. For the first weeks, do not answer messages in the evening and do not take on extra tasks to “catch up”.

Returning after burnout is similar in many ways but has its own particularities, which I write about in the post on returning to work after burnout.

Where this does not apply

I want to be honest about the limits of what I have written.

Not every lapse in concentration is depression. Attention problems can have quite different causes — lack of sleep, the thyroid, anaemia, the after-effects of an illness, ADHD or simply impossible working conditions. That is why a check-up with your doctor matters before you put anything down to depression.

Not every job is worth keeping. I wrote that work is protective for most people. That holds for work that is at least reasonably decent. If you are humiliated, harassed or systematically overloaded at work, no exercise with ticks will be enough. Then the question is not how to endure, but how to get out — and that is just as legitimate.

The self-employed and people in precarious work often have fewer options for sick leave and adjustments than I describe. Their distress can therefore be even greater. The same applies to them: talking to a doctor is the first step, even if it feels as if they “cannot afford” to be ill.

And finally: this post is about depression that can be carried alongside work. With severe depression, how to work is not the first question. The first question is how you are, and that question belongs with a doctor.

Where psychotherapy can help

Psychotherapy does not issue sick leave or prescribe medication — that is for your doctor and psychiatrist. But it can help elsewhere. With depression that drags on through working days, people often bring beliefs that keep it going: that they must cope alone, that asking for help is weakness, that their worth equals their productivity.

In relational family therapy, in which I am training, we explore such beliefs through their origins too — through the family in which perhaps the only recognition was the kind you earned through achievement. When you can see where the voice saying “you must cope” comes from, it becomes easier to resist. If you are worried about fitting therapy into your schedule when you can barely cope as it is, read “I have no time for therapy”: what it looks like with a job, children and one free evening.

What to remember

• Most people with depression go to work; the biggest loss is in presenteeism, not absence.
• Problems with concentration and memory are a symptom of depression, not laziness — and they can last a while after mood improves.
• You do not have to tell your employer the diagnosis; say what is useful — what would help you.
• For most people work is protective, but when you cannot manage basic tasks or the work itself deepens your distress, it is time to talk to your GP about sick leave.
• Make your return gradual and planned; keep everything that helped you during recovery.