Atypical Depression Symptoms and Treatment

In addition to the core symptoms of depression, atypical depression is defined by the ability to feel better temporarily in response to a positive life event, plus any two of the following criteria: excessive sleep, overeating, a feeling of heaviness in the limbs and a sensitivity to rejection.

Patients with atypical depression tend to have an earlier age of onset than those with other subtypes because it often first appears in the teenage years. These patients are also likely to have a history of social phobia, avoidant personalities, and a history of body dysmorphic disorder.

Despite the name, atypical depression is actually the most common subtype of depression, according to Dr. Andrew A. Nierenberg, associate director of the depression clinical and research program at Massachusetts General Hospital, Boston. In a 1998 study, he and his associates found that 42% of participants had atypical depression, 12% had melancholic depression, 14% had both depression subtypes, and the rest had neither. "It's more common than we all think. There's no doubt we underrecognize it," said Dr. Nierenberg.

Making a correct diagnosis of this subtype is critical in providing the patient with effective treatment. Although selective serotonin reuptake inhibitors (SSRIs) and other newer medications are often the first line choice for depression treatment due to their favorable side-effect profiles, patients with atypical depression tend to respond better to monoamine oxidase inhibitors (MAOIs). However, SSRIs may be prescribed first simply because they do not have the potential for serious side effects or dietary restrictions that MAOIs do. 

Interestingly, however, drug treatment may not be necessary at all. A study conducted in 1999 found that patients receiving cognitive-behavioral therapy (CBT) responded just as well as patients receiving the MAOI phenelzine. 58% of patients in both groups responded, in comparison to only 28% of patients in the placebo group.

Another study conducted in 2015 also showed that the treatment effects of both second-generation antidepressants and CBT, either separately or together, were the same in patients with the major depressive disorder. Clearly, more research needs to be done on this.

It is important to see a psychiatrist rather than your primary care physician for treatment. Not all depressions are alike nor do they respond to the same medications. A physician in general practice is not likely to have the experience necessary to differentiate between subtypes of depression or to know which treatment choices are more likely to work. You may suffer unnecessarily as your doctor tries all the wrong medications. Given the very nature of depression, this only complicates your already depressed feelings.

If you are forced by insurance or financial circumstances to see a primary care physician for your treatment, you need to do the legwork to make up the potential deficit in your physician's knowledge. This is not as it should be, certainly, but until there is a radical change in our healthcare systems, it may be necessary. If you educate yourself and take an active role in your treatment, you're less likely to slip through the diagnostic cracks.