An Overview of Atypical Depression

Atypical depression is a type of depression that does not follow what was thought to be the "typical" presentation of the disorder. In general, people with atypical depression experience similar symptoms as those with major depressive disorder (MDD) but with one crucial difference: mood reactivity. In other words, a person's mood is able to improve if something positive happens.

Atypical depression, which is now referred to as major depressive disorder with atypical features, is actually quite common. Unlike other forms of depression, people with atypical depression may respond better to a type of antidepressant known as a monoamine oxidase inhibitor (MAOI). MDD with atypical symptoms also has an early onset age, and typically diagnosed in the teenage years.

In addition to the core symptoms of depression, people with atypical depression may also experience the following symptoms:

• A mood that temporarily brightens after a positive event or happy news
• Increased appetite and weight gain
• A heavy feeling in the arms or legs
• Body aches
• Sleeping for long periods at night or during the day (hypersomnia)
• Extreme sensitivity to rejection or perceived criticism

Less common symptoms include:

• Insomnia
• Headaches
• Eating disorders
• Poor body image

The reason why some people experience atypical depression is not known. A potential cause of atypical depression is an imbalance in certain neurotransmitters, including dopamine, serotonin, and norepinephrine, which all influence mood.

Other factors that can raise your risk for atypical depression include:

• Family history. You are more likely to experience symptoms of atypical depression if others in your family also have depression or another type of mood disorder.
• Certain medical conditions. You may be more likely to experience atypical depression if you have a history of bipolar disorders, anxiety disorders, avoidant personalities, body dysmorphic disorder, or social phobia.
• Substance use. Having a history of substance use can also increase the likelihood of depression. 

Making a correct diagnosis is a critical step in getting the treatment you or your loved one needs. Unfortunately, unlike many other health conditions, there isn’t a lab test, X-ray, or physical exam that can provide a definitive diagnosis. Instead, your doctor will need to make a clinical diagnosis that requires taking into account your family history, risk factors, symptoms, and any underlying health concerns.

To rule out any health conditions that may cause symptoms of depression or be an underlying cause, you may be given a blood test, drug screen, and imaging tests (such as a CT scan or MRI of the brain).

You may also likely undergo a depression test, which can be done orally during the exam by a physician or mental health professional or via paper or a digital device before seeing the physician. Some doctors compare your answers and symptoms to the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—but that's only part of the diagnostic puzzle.

According to the DSM-5, to be diagnosed with depressive disorder with atypical symptoms a person has to exhibit the ability to feel better temporarily in response to a positive life event (mood reactivity), plus any two of the following criteria for a period of two or more weeks:

• Excessive eating or weight gain
• Excessive sleep
• Fatigue, weakness, and feeling "weighed down"
• Intense sensitivity to rejection
• Strongly reactive moods

Although selective serotonin reuptake inhibitors (SSRIs) and other newer medications are often the first-line choices for depression treatment due to their favorable side effect profiles, patients with atypical depression tend to respond better to monoamine oxidase inhibitors (MAOIs).

Some common MAOIs include:

• Nardil (phenelzine)
• Parnate (tranylcypromine)
• Marplan (isocarboxazid)
• Emsam (selegiline)

Still, SSRIs may be prescribed first simply because they do not have the potential for serious side effects or dietary restrictions that MAOIs do. For example, to prevent potentially fatal high blood pressure spikes, it is necessary to avoid foods and beverages high in tyramine while taking MAOIs.

Wellbutrin ((bupropion) is another medication used in the treatment of atypical depression and is often prescribed along with other antidepressants to help counter any sexual side effects found in those medications.

Psychotherapy, or talk therapy, is also an important part of a treatment plan for atypical depression. Cognitive-behavioral therapy (CBT) has been scientifically proven to be effective in treating symptoms of depression.

Other types of psychotherapy that may be used for atypical depression include:

• Behavioral therapy
• Cognitive therapy
• Dialectical behavioral therapy
• Individual, group, and family therapy
• Interpersonal therapy
• Psychodynamic therapy

Along with medication and psychotherapy, treatment for atypical depression may also include 30 to 45 minutes of light therapy (phototherapy) each morning, using a light box with a minimum power rating of 10,000 lux.

If atypical depression is interfering with your daily activities, working with your doctor to develop a treatment plan that involves medication and psychotherapy is a great first step. Beyond that, there are lifestyle modifications that may help ease the symptoms and help you better cope. 

• Prioritize nutrition and exercise. Doing your best to stick with a healthful diet and regular exercise program will improve your overall health and help decrease the symptoms of atypical depression. Aim to exercise five days a week, for 30–60 minutes a day.
• Practice mindfulness meditation and deep breathing. Deep breathing exercises combined with mindfulness meditation can teach you to become aware of your thoughts and feelings without reacting to them.
• Write in a journal. Journaling, or expressive writing, is a highly recommended tool for dealing with depression. Whether you do it daily or weekly, making journaling a habit can help allow you to explore your feelings and counteract many of the negative effects of stress.
• Seek support. Perhaps the most important thing you can do to cope with depression and prevent isolation is to develop strong social support. This can include trusted family and friends or an online or in-person depression support group with whom you can connect with and share your feelings and experiences. 

It is important to see a mental health professional rather than your primary care physician for treatment. Not all types of depression 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 the subtypes or to know which treatment choices are more likely to work.

If you are forced by insurance or financial circumstances to see a primary care physician for your treatment, do the legwork to make up the potential deficit in your physician's knowledge. If you educate yourself and take an active role in your treatment, you're less likely to slip through the diagnostic cracks.