Depression atypical symptoms

Those patients presenting with atypical symptoms of depression (i.e., rejection-sensitivity, hypersomnia, hyperphagia, and hysteroid personality types] were confirmed as a unique subgroup responsive to MAOls including phenelzine (Liebowitz et al. 1988]. There are indications that atypical symptomatology may also be responsive to the RlMAs such as moclobemide (Lonnqvist et al. 1994 Paykel 1995] however, results are preliminary. 

In addition, certain clinical symptoms may be more predictive of response to light therapy. For example, Terman et al. ( 161) found that depressed responders were characterized by more atypical symptoms such as... 

A 38-year-old divorced woman who lived alone visited a psychiatrist because she was depressed. Her symptoms included low self-esteem, with frequent ruminations on her worthlessness, and hypersomnia. She was hyperphagic and complained that her limbs felt heavy. An initial diagnosis was made of a major depressive disorder with atypical symptoms. Treatment was initiated with amitriptyline, but after 2 months the patient had not improved significantly. Which one of the following drugs is MOST likely to have therapeutic value in this depressed patient ... 

It is common for both the depressive and manic phases to occur simultaneously in what is termed a mixed state or dysphoric mania. During these mixed episodes, the patient s mood is characterized by symptoms of both a depression and mania. Mixed episodes often have a poorer outcome than classic euphoric mania and, as a rule, respond better to certain anticonvulsants and atypical antipsychotic drugs than to lithium. As many as 50% of admissions to inpatient psychiatric facilities for the treatment of manic episodes appear to be for mixed manic states. The recognition... 

Major Depressive Disorder (MDD) with Atypicai Features. The anhedonia of MDD is often manifested by social withdrawal. In contrast to social anxiety disorder, the social withdrawal of MDD is desired by the patient, at least during the major depressive episode, and does not persist when the episode remits. Atypical depression is characterized by another symptom reminiscent of social anxiety disorder—a longstanding pattern of sensitivity to interpersonal rejection. The interpersonal sensitivity associated with atypical depression is often characterized by stormy relationships and overly emotional responses to perceived slights. Such social lability is seldom observed in patients with social anxiety disorder. 

Antidepressants. In the early 1980s, the recognition that depression is a frequent comorbid feature of BN coupled with the observation that appetite changes are a common feature of depression led researchers to evaluate antidepressant treatment for BN. Since that time, a series of controlled studies have demonstrated efficacy for a wide assortment of antidepressants including the TCAs imipramine (Tofranil) and desipramine (Norpramin), the MAOl phenelzine (Nardil), the SSRl fluoxetine (Prozac), and the atypical antidepressants trazodone (Desyrel) and bupropion (Wellbutrin). Overall, approximately two-thirds of antidepressant-treated patients with bulimia experience symptomatic improvement while nearly one-third achieves complete remission of binging and purging. In addition, the improvement in the symptoms of BN is not dependent on the presence of comorbid depression. 

Insomnia Due to Another Psychiatric Illness. Insomnia is often a symptom of mood and anxiety disorders. Depression is classically associated with early-morning awakening of the melancholic type, whereas so-called atypical depression leads to hypersomnia. Anxiety commonly leads to problems falling asleep. These patterns are not invariable. One should therefore always perform a thorough assessment for anxiety or depression in patients complaining of insomnia. 

Among these choices, bnspirone is preferred if the patient is also experiencing anxiety. If the patient is depressed and agitated, a SSRI should be tried first. Second line choices inclnde carbamazepine (Tegretol) or one of the atypical antipsychot-ics—ziprasidone (Geodon), risperidone (Risperdal), olanzapine (Zyprexa), quetiap-ine (Seroquel), or aripiprazole (Abilify) can be tried. If psychotic symptoms are present, one of the atypical antipsychotics should be tried first. 

In the United States, the three MAOIS available for the treatment of psychiatric conditions are phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). All three agents have indications for adult major depression (>16 years old) and, more specifically, atypical depression (anergia, hypersomnia, hy-perphagia, somatization, and anxiety symptoms). Although not indicated for anxiety, the MAOIs can also be particularly helpful in treatment of these disorders. Selegiline or L-deprenyl (Eldepryl) is also available in the United States and indicated for symptoms of Parkinson s disease and depression. 

In this chapter the basics of the available atypical antidepressants and those that may soon to come on the market have been reviewed. The atypical antidepressants are less readily used, and their benefits for treating depression and anxiety are not fully appreciated. The atypical antidepressants may provide benefit for conditions such as ADHD or offer an alternative to other antidepressants with problematic side effects (i.e., activation on SSRIs). They may also provide specific relief for troublesome symptoms (i.e., nefazodone s normalization of sleep architecture). 

Because of the improved tolerability and safety of newer antidepressants, MAOIs are not currently used as first-line agents. However, MAOIs remain excellent medications for patients whose symptoms do not respond to the newer antidepressant drugs. Patients with atypical depression, characterized by oversleeping and overeating, show a preferential response to MAOI therapy compared with TCAs (Liebowitz et al. 1984 Quitkin et al. 1979 Ra-varis etal. 1980 Zisook 1985). 

Although hypomanic and manic episodes are discussed comprehensively in Chapter 9, it is important to note that the disturbance in mania (and hypomania), as well as in depression, includes the same core symptoms, differing only in the direction of change. Complicating the diagnosis, unipolar patients may also present with classic melancholia or atypical (nonclassic) symptoms. The latter, in particular, can overlap considerably with hypomania. Similarly, bipolar patients in a depressive phase may demonstrate classic or nonclassic symptoms (Table 6-5). 

Reports vary as to the predominant picture, which ranges from one quite similar to melancholia to one more consistent with an atypical depressive disorder or a bipolar II disorder (Table 6-5). Complaints usually involve a diminution in energy, followed by an increased need for sleep, increased appetite and weight, and a lack of involvement or interest in one s activities. Only toward the end of the episode onset does the patient become aware of the depressed mood and such classic symptoms as poor concentration, feelings of self-worthlessness, and multiple somatic complaints. Insomnia often develops over the next 1 to 2 months. Whereas this atypical picture is more characteristic of the early phases of the illness, reminiscent of certain bipolar subtypes, the affective episode appears to evolve toward a more classic depressive syndrome as it progresses over multiple seasons. 

Overall, the ratio of atypical to classic symptoms of depression, rather than severity per se, was the best predictor of a positive response to bright light therapy. 

As with depression in late life, mania can be divided into early onset and late-onset types. It is estimated that 5% to 10% of elderly patients with affective disorders have manic symptoms (296). Presentation tends to be more atypical, with secondary mania being a much more common phenomenon in the elderly versus younger patient population. As with the younger cohort, mania may be recurrent and disabling in some older patients. 

---