Correct Treatment May Depend on Proper
Despite the name, atypical depression is
actually the most common subtype, 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.1
Making a correct diagnosis of this subtype is
critical in providing the patient with effective treatment.
Although SSRIs and other newer medications are often the first
line choice for depression treatment due to their favorable
side-effect profiles, very little is yet known about how well
these work for the patient with atypical depression. What is
known is that patients respond well to MAOIs, but not to
tricyclics. Data on newer medications is sparse and
inconclusive.2 How many patients out there may be suffering
through drug trial after drug trial simply because their
physician does not know which medication best treats atypical
depressions or does not recognize this distinct subtype?
What Is Atypical Depression?
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 (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.3
How to Treat It
Current data suggests that those with atypical
depression will respond better to MAOIs (monoamine oxidase
inhibitors) like phenelzine than they will to imipramine (a
tricyclic). Dietary restrictions and side-effects remain a
problem. At the present time, research is concentrating on
finding newer medications with better side-effect profiles to
which these patients will also get a good response.4
Although more research is needed, it seems
that patients may also obtain an adequate response with the
SSRIs, but not all studies seem to back up this assertion. In
one study, the SSRI Prozac was found to have a response only
equal to imipramine, a tricyclic whose comparative response to
phenelzine is well-known.5
Clinical trials are currently being arranged
to test the efficacy of a new drug, Gepirone, at Columbia
University in New York City. Preliminary studies seemed to
indicate that it is effective for those with atypical
depression. This drug is not yet FDA approved. If you are
interested in these trials, please visit Dr.
Ivan's Depression Central for more information.
(This information was last updated by Dr. Goldberg on 7/20/03).
Interestingly, however, drug treatment may not be
necessary at all. A study conducted in 1999 found that patients
receiving cognitive behavioral therapy 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
Implications for the Patient
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. A patient may suffer unnecessarily as his doctor tries
all the wrong medications. Given the very nature of depression,
this only complicates the patient's already depressed feelings.
If the patient is forced by insurance or financial circumstances
to see a primary care physician for their treatment, they must
do the leg work to make up the deficit in their physician's
knowledge. This is not as it should be, certainly, but until
there is a radical change in our healthcare systems, it is
necessary. The educated healthcare consumer who takes an active
role in his or her treatment is less likely to slip through the
1. Clinical Psychiatry News 26(12):25, 1998.
4. Journal of Clinical Psychiatry 59 Suppl
5. American Journal of Psychiatry
157(3):344-350, Mar 2000.
6. Archives of General Psychiatry
56(5):431-47, May 1999.