A number of factors conspire to put successful executives at special risk for depression:

• The dirty little secret is that success itself is a letdown. The thrill is in the striving. The brain circuits that shape our moods are wired to generate positive emotions as we approach a goal. "Success is an ending," says Steven Berglas, Ph.D., a psychologist and executive coach who teaches entrepreneurial psychology at the University of Southern California business school. "You're no longer in the achieving mode. When you're working toward a goal your body produces a set of biochemical responses that create euphoria and make you resistant to pain."

  The realization that success does not automatically bring happiness compounds the disappointment, says psychologist Terry Real. "It's a contrast from the way you think you're supposed to feel; you get depressed about feeling depressed."

  Further, success primes you to feel like a has-been. "Everything is referenced to 'look at what he did,' not 'what he is doing'," adds Berglas, who writes about the underside of success in his book, Reclaiming the Fire.

  Entrepreneurs are almost never prepared for "the psychological trauma that follows success," he adds. They're only happy in the struggle. Further, the entrepreneur has the fantasy of living in a wholly controlled universe of his own making. But "as soon as you get something, you have to bring in accountants and managers. You can't control it all, and the psychological high is over."

• Being in the end zone of success flips the brain's emotional switch from positive to negative. "Life is no longer based on whether you're going to get it but on whether you're going to lose it," says Real. No matter what drives success, those who get to the top are governed by a fear of losing all they've won—their position, their wealth, their viability.

  Being on top makes the successful conservative and risk-averse, says Berglas. There are economic incentives to do the same thing over and over, resulting in lack of stimulation. "Entrepreneurs have no pain working with no capital or support. But they have tons of anxiety when they have to protect a lead. It's easier to climb from the bottom to the top than to hold onto the top, because you become defensive, which interferes with skilled behavior of any sort. It's also physiologically depressing to have nothing to strive for."

• Among the highest achievers, identity and self-esteem are perched—almost exclusively and therefore precariously—on achievement. What they often don't have much of is an internal sense of worth, the capacity to hold yourself in high regard while fully recognizing your human imperfections.

  Equating one's value as a human being with achievements only makes you as good as your last deal. "When you're no longer in the achieving mode, and your self-worth is built on achieving, you feel worthless," says Berglas. He points to George Eastman, founder of Kodak. His company was phenomenally successful, yet he ended his own life. His suicide note said, "My work is done; why wait?"

  By some psychological sleight, landing at the top can actually make winners feel like losers. "What happens is your reference group changes," says Real. "You can feel like a failure because you're measuring yourself against the CEO of a company even bigger than yours. And there's almost always someone younger, swifter, bolder nipping at your heels. Welcome to male privilege. CEOs with depression are men who have followed the masculine agenda and have won, and tasted its bitter fruit."

• Those most driven to succeed are propelled by dark inner forces. Often, says Berglas, the entrepreneur is trying to disprove negative feedback, perhaps a punitive father's reproach that 'you'll never amount to anything'." Real sees it in the makeup of top corporate executives as well. "Part of the drive is running from their own vulnerabilities, or trying to compensate for them."

  Scripps' Gene Ondrusek points to evidence that CEOs are "supersurvivors." A disproportionate number of them come from dysfunctional backgrounds; the incidence of alcoholism in their family histories is three times that in the general population. "These people often faced circumstances growing up that galvanized them to become supersuccessful.

• The ecology of emotions sabotages them. Those for whom achievement becomes all-encompassing are adept at denying pain. They commonly believe their success actually hinges on their ability to distance themselves from their emotions. Being so unfamiliar with feelings, they are terrified that by "giving in to them" they will be sucked into a black hole. "You're scared you'll feel sorry for yourself," observes John Sage, a former CEO. "You're afraid everyone will pass you by if you're not in action all the time."

  But emotions work in exactly the opposite way. Feelings that are never acknowledged build up force underground, consuming internal resources, creating stress and eventually blindsiding people in the form of crippling anxieties and panic attacks, sleeplessness and depressions, and assorted physical ills, depending on where their system is weakest.

• Highly driven success typically comes at the cost of intimate relationships. "You have to make huge sacrifices on the way to the top," says Burguieres. "You're not aware of it as you're doing it." But it leaves CEOs unable to share themselves, magnifying the job's isolation. True, executives reaching a certain level get some perks and can arrange a more sane life. "But by that time," says Real, "a lot of damage has been done."

  It's not that CEOs don't have terrific people skills. "On the job, these guys are very gifted with people, but they're gifted at how to work other people's vulnerabilities," says Real. "The demands of human relationships outside the job require you to have and deal with your own vulnerabilities, your very humanity. You have to be sad. You have to show fear or disappointment. And you have to let somebody comfort you. Hard-driven men are not generally conversant with or even friendly towards their own human vulnerabilities."

  "The reason why the masculine agenda is so hollow," he notes, "is that there is something that actually makes you happy deep down in your core. It's intimacy. What makes human beings happy is other human beings."

• The coping strategies of successful CEOs work against them. Feelings of depression are warnings that you're not being rewarded at a self-esteem level, and you need to find a better way of sustaining self-esteem. "But successful males usually don't respond to early signals of pain adaptively," says Berglas. "They push the business paradigm to the point of exhaustion in an attempt to mollify the pain. The underlying vulnerability is only exacerbated. Ultimately, they burn out." It's "striking" how worn out executives get, says Jon Allen, Ph.D., a psychologist at the Menninger Clinic in Topeka, Kansas. "By the time they get into care they're in bad shape."
• People at the top have the power, the resources—and the temptations—to mask their problems. Depressed CEOs so often get into disastrous affairs that such behavior can be looked on as a symptom of distress. Observes Atlanta's Frank Pittman: "It's an adrenaline fix. You know that you are down. You don't know that it's depression. You think it's the routine, the lack of excitement in your life. So you do something that jump-starts you. It would be so much safer to go bungee-jumping or shark-wrestling."
• Not just anyone can help them. It takes a special breed of professional, one who is not intimidated, envious or overly impressed by their power, prestige or purse. An envious therapist will be hostile, an impressed one fawning. "Either way they will fail to connect with the horrible loneliness inside the guy," says Pittman. "And the guy will come into therapy and do what he usually does, which is to be charming and superficial. He won't be challenged to get real."