Atypical depression
Atypical depression | |
---|---|
Other names | Depression with atypical features |
Depression subtypes | |
Specialty | Psychiatry |
Symptoms | Low mood, mood reactivity, hyperphagia, hypersomnia, leaden paralysis, interpersonal rejection sensitivity |
Complications | risk of self harm |
Usual onset | Typically adolescence[1] |
Types | Primary anxious, primarily vegetative[1] |
Risk factors | Bipolar disorder, anxiety disorder, female sex[2] |
Differential diagnosis | Melancholic depression, anxiety disorder, bipolar disorder |
Frequency | 15-29% of depressed patients[3] |
Atypical depression is defined in the
Despite its name, "atypical" depression does not mean it is uncommon or unusual.
Atypical depression is four times more common in females than in males.
Pathophysiology
Significant overlap between atypical and other forms of depression has been observed, though studies suggest that there are differentiating factors within the various pathophysiological models of depression. In the endocrine model, evidence suggests the HPA axis is hyperactive in melancholic depression, and hypoactive in atypical depression. Atypical depression can be differentiated from melancholic depression via verbal fluency tests and psychomotor speed tests. Although both show impairment in several areas such as visuospatial memory and verbal fluency, melancholic patients tend to show more impairment than atypical depressed patients.[10]
Furthermore, regarding the
Diagnosis
The diagnosis of atypical depression is based on the criteria stated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 defines atypical depression as a subtype of major depressive disorder that presents with "atypical features", characterized by:
- Mood reactivity (i.e., mood brightens in response to actual or potential positive events)
- At least two of the following:
- Significant weight gain or increase in appetite (hyperphagia);
- Hypersomnia (sleeping too much, as opposed to the insomnia present in melancholic depression);
- Leaden paralysis (i.e., heavy feeling resulting in difficulty moving the arms or legs);
- Long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.
Criteria for depression with
Treatment
Due to the differences in clinical presentation between atypical depression and melancholic depression, studies were conducted in the 1980s and 1990s to assess the therapeutic responsiveness of the available antidepressant pharmacotherapy in this subset of patients.[12] Currently, antidepressants such as SSRIs, SNRIs, NRIs, and mirtazapine are considered the best medications to treat atypical depression due to efficacy and fewer side effects than previous treatments.[13] Bupropion, a norepinephrine reuptake inhibitor, may be uniquely suited to treat the atypical depression symptoms of lethargy and increased appetite in adults.[13] Modafinil is sometimes used successfully as an off-label treatment option.[14]
Before the year 2000, monoamine oxidase inhibitors (MAOIs) were shown to be of superior efficacy compared to other antidepressants for the treatment of atypical depression, and were used as first-line treatment for this clinical presentation. This class of medication fell in popularity with the advent of the aforementioned selective agents, due to concerns of interaction with tyramine-rich foods (such as some aged cheese, certain types of wine, tap beer and fava beans) causing a hypertensive crisis[15] and some – but not all – sympathomimetic drugs, as well as the risk of serotonin syndrome when concomitantly used with serotonin reuptake agents. Despite these concerns, they are still used in treatment-resistant cases, when other options have been exhausted, and usually show greater rates of remission compared to previous pharmacotherapies. They are also generally better tolerated by many patients.[16] There are also newer selective and reversible MAOIs, such as moclobemide, which carry a much lower risk of tyramine potentiation and have fewer interactions with other drugs.[17]
Tricyclic antidepressants (TCAs) were also used prior to the year 2000 for atypical depression, but were not as efficacious as MAOIs, and have fallen out of favor with prescribers due to the less tolerable side effects of TCAs and more adequate therapies being available.[12]
One pilot study suggested that psychotherapy such as cognitive behavioral therapy (CBT) may have equal efficacy to MAOIs for a subset of patients with atypical depression, although the sample size was small and statistical significance was not reached.[18] These are talk therapy sessions with psychiatrists or clinical psychologists to help the individual identify troubling thoughts or experiences that may affect their mental state, and develop corresponding coping mechanisms for each identified issue.[19]
Epidemiology
True prevalence of atypical depression is difficult to determine. Several studies conducted in patients diagnosed with a depressive disorder show that about 40% exhibit atypical symptoms, with four times more instances found in female patients.[20]
[7] Research also supports that atypical depression tends to have an earlier onset, with teenagers and young adults more likely to exhibit atypical depression than older patients.[2] Patients with atypical depression have shown to have higher rates of neglect and abuse in their childhood as well as alcohol and drug disorders in their family.[10] Overall, rejection sensitivity is the most common symptom, and due to some studies forgoing this criterion, there is concern for underestimation of prevalence.[21]
Research
Atypical depression was first thought of as a disorder separate from typical depression in 1959, when doctors E.D. West and P. J. Dally were studying the effects of iproniazid, an MAOI, on patients with depression.[22] They found consistencies among the patients who responded well to the drug in comparison to those who didn't. These patients, who were displaying symptoms of "anxiety hysteria with secondary depression", responded notably well to the iproniazid.[23]
In general, atypical depression tends to cause greater functional impairment than other forms of depression. Atypical depression is a chronic syndrome that tends to begin earlier in life than other forms of depression—usually beginning in the teenage years. Similarly, patients with atypical depression are more likely to have
Recent research suggests that young people are more likely to experience hypersomnia while older people are more likely to experience polyphagia.[24]
Medication response differs between chronic atypical depression and acute
See also
References
- ^ PMID 7092486.
- ^ PMID 21103169.
- PMID 17640153.
- ^ a b c d e American Psychiatric Association. (2000). Mood Disorders. In Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) Washington, DC: Author.[page needed]
- ^ "Atypical depression". Mayo Clinic. Retrieved 2013-06-23.
- ^ Cristancho M (2012-11-20). "Atypical Depression in the 21st Century: Diagnostic and Treatment Issues". Psychiatric Times. Psychiatric Times Vol 28 No 1. 28 (1). Archived from the original on 2013-12-02. Retrieved 23 November 2013.
- ^ PMID 29033570.
- PMID 9515190.
- PMID 17546343.
- ^ S2CID 3983515.
- PMID 29033570.
- ^ PMID 17474800.
- ^ a b "Clinical Practice Review for Major Depressive Disorder | Anxiety and Depression Association of America, ADAA". adaa.org. Retrieved 2019-11-22.
- ^ S2CID 19370803.
- PMID 33085344.
- S2CID 206312008.
- PMID 7905288.
- PMID 1592844.
- ^ "What is Psychotherapy?". www.psychiatry.org. Retrieved 2019-11-21.
- PMID 2990566.
- PMID 15014736.
- S2CID 40284568.
- PMID 13651775.
- S2CID 11514430.
- ^ "Atypical depression - Symptoms and Causes". Mayo Clinic. Retrieved 18 March 2020.
- doi:10.1037/a0036933.
External links
- Stewart JW, Quitkin FM, McGrath PJ, Klein DF (June 2005). "Defining the boundaries of atypical depression: evidence from the HPA axis supports course of illness distinctions". Journal of Affective Disorders. 86 (2–3): 161–167. PMID 15935235.