Depressive disorders atypical

Treatment of Major Depression. Dmgs commonly used for the treatment of depressive disorders can be classified heuristicaHy iato two main categories first-generation antidepressants with the tricycHc antidepressants (TCAs) and the irreversible, nonselective monoamine—oxidase (MAO) inhibitors, and second-generation antidepressants with the atypical antidepressants, the reversible inhibitors of monoamine—oxidase A (RIMAs), and the selective serotonin reuptake inhibitors (SSRIs). Table 4 fists the available antidepressants. 

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. 

Atypical Antidepressants. None of the so-called atypical antidepressants have been tested in the treatment of AN. However, mianserin, an antidepressant available in Europe, has been found to increase body weight in patients with various depressive disorders. Although bupropion (Wellbutrin, Zyban) has not been tested in the treatment of AN, it is effective in the treatment of BN. However, immediate-release bupropion is associated with an especially high risk for seizures in these patients and is therefore contraindicated in those with eating disorders. The seizure risk associated with sustained-release bupropion remains unclear at this time, as the doses studied have not been as high as those for immediate-release bupropion. 

Bertolino, A., Crippa, D., di Dio, S., Fichte, K., Musmeci, G., Porro, V., Rapisarda, V., Sastre-y-Hernandez, M., and Schratzer, M. (1988) Rolipram versus imipramine in patients with major, minor, or atypical depressive disorder a double-blind study, double-dummy study aimed at testing a novel therapeutic approach. Int Clin Psychopharmacol 3 245-253. 

Clarify atypical or specific subtypes of presentations that may not benefit from standard treatments (e.g., atypical or psychotic depressive disorders). 

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. 

MAOIs may be the treatment of choice for atypical depressive disorders. As noted in Chapter 6, features of this subgroup usually include the following ... 

Mood symptoms of depression are associated with many conditions in addition to major depressive disorder, including mood and anxiety symptoms in schizophrenia, schizoaffective disorder, bipolar manic/depressed/mixed/rapid cycling states, organic mood disorders, psychotic depression, childhood and adolescent mood disorders, treatment-resistant mood disorders, and many more (see Chapter 10, Fig. 10-6). Atypical antipsychotics are enjoying expanded use for the treatment of symptoms of depression and anxiety in schizophrenia that are troublesome but not severe enough to reach the diagnostic threshold for a major depressive episode or anxiety disorder in these cases the antipsychotics are used not only to reduce such symptoms but hopefully also to reduce suicide rates, which are so high in schizophrenia (Fig. 11 — 53). Atypical antipsychotics may also be useful adjunctive treatments to anti-... 

In clinical studies, major depressive disorder has had four specifiers, including melancholic feature, atypical feature, catatonic feature, and postpartum onset. In the future, we should investigate the distributions of the four specifiers of depression among patients with physical illness and discuss which biological markers could link the depressive disorder and the physical illness. 

Although there are papers that discuss the relationships between cholesterol, lipid profiles, and major depression [34-39], there are few data that discuss the association between lipid profiles and depressive disorders with different phenotypes. Huang and Chen investigated the correlation between serum lipid, lipoprotein concentration, and major depressive disorder in patients evaluated for general health screening [41]. They found that analysis of covariance after age adjustment revealed significant differences in patients with melancholic feature and patients with atypical feature in serum concentrations of TG and VLDL in men and HDL in women [41]. However, there are still no reports that discuss the relationships between lipid profiles and major depression with postpartum onset or catatonic feature. In the future, large sample numbers will be needed to clarify the clinical differences in this field. 

Huang TL, Chen JF. Lipid and lipoprotein levels in depressive disorders with melancholic feature or atypical feature and dysthymia. Psychiatry Clin Neurosci 2004 58 295-299. 

MAO inhibitors are indicated for depressed patients who are unresponsive or allergic to tricyclic antidepressants or who experience strong anxiety. Patients with low psychomotor activity may benefit from the stimulant properties of MAO inhibitors. These drugs are also useful in the treatment of phobic states. A special subcategory of depression, called atypical depression, may respond to MAOIs. Atypical depresssion is characterized by labile mood, rejection sensitivity and appetite disorders. 

As we will see later, this type of depressive disorder has been shown to be effectively treated with a particular subtype of antidepressants called monoamine oxidase inhibitors (MAOIs). Recent findings suggest that atypical depressions may also respond to selective serotonin re-uptake inhibitors (SSRIs). 

MAO inhibitors are another group of antidepressant medications that have historically been used to treat major depressive disorders. Currently, this classification of medications is considered a second-line or third-line treatment of depression (Brophy, 1991 Tierney et al., 1997). There are times however, that this group of drugs can be utilized as the first line of treatment for depression of an atypical nature (Tierney et al., 1997). Generally, these medications with their dangerous treatment-effect profiles should only be considered after the tricyclic or the newer classifications of antidepressants have been tried (Tierney et al., 1997). 

Atypical forms Recurrent major depressive disorder Mild, moderate or severe Severe with psychosis Bipolar I (defined by current episode)... 

In conclusion, even under steady state treatment with twice the dose recommended for depressive disorders, only a minimal increase in daylight sensitivity was found along with a mildly enhanced tanning reaction. This ties in with the results of in vitro and animal studies and the fact that only one case of phototoxicity in a patient taking the antidepressive dose has been documented thus far. And even this case is of questionable relevance because of atypical features. 

Major depressive disorder (MDD) with atypical features... 

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 ... 

The drug exerts its therapentie aetion to eombat various types of anxiety disorders viz., generalized anxiety disorders, panie attaeks, phobie disorders, obsessive-compulsive disorder, post-tranmatic stress disorder, and mixed anxiety and depressive disorders. Perhaps the drug acts as a atypical antisychotic agent by virtue of its reduced tendency to produce the extrapyramidal effects. 

The client with major depressive disorder is prescribed nefazodone (Serzone), an atypical antidepressant. The client tells the nurse, I am going to take my medication at night instead of in the morning. Which statement would be the nurse s best... 

Trivedi MH, Thase ME, Fava M, Nelson CJ, Yang H, Qi Y, Tran QV, Pikalov A, Carlson BX, Marcus RN, Berman RM. Adjunctive aripiprazole in major depressive disorder analysis of efficacy and safety in patients with anxious and atypical features. J Clin Psychiatry 2008 69(12) 1928-36. 

Non-motor signs of the disorder are also treatable with symptomatic medications. The frequent mood disorder can be treated with standard antidepressants, including tricyclics (such as amitryptiline) or serotonin reuptake inhibitors (SSRIs, such as fluoxetine or sertraline). This treatment is not without risks in these patients, as it may trigger manic episodes or may even precipitate suicide. Anxiety responds to benzodiazepines, as well as to effective treatment of depression. Long-acting benzodiazepines are favored over short-acting ones because of the lesser abuse potential. Some of the behavioral abnormalities may respond to treatment with the neuroleptics as well. The use of atypical neuroleptics, such as clozapine is preferred over the typical neuroleptics as they may help to control dyskinesias with relatively few extrapyramidal side-effects (Ch. 54). 

Mirtazapine (Remeron). Mirtazapine is the newest of the atypical antidepressants. It mainly works by blocking the alpha-2 negative feedback receptor and thus increases norepinephrine and serotonin activity. In addition, mirtazapine blocks serotonin-2 and serotonin-3 receptors to produce a specific serotonin action like nefazodone. Mirtazapine is approved for the treatment of depression. Its use in the anxiety disorders is being studied. 

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. 

Serotonin-Boosting Antidepressants. The SSRIs have also been studied in the treatment of generalized social anxiety disorder, and paroxetine, sertraline, and venlafaxine are effective. Preliminary data suggests that the serotonin-boosting atypical antidepressants (mirtazapine and nefazodone) may also be helpful. Like the MAOIs, they appear to be effective at doses comparable to those used to treat depression. They may help avoidant patients to gradually increase their social interaction and become more assertive. 

The main limitation to the clinical use of the MAOIs is due to their interaction with amine-containing foods such as cheeses, red wine, beers (including non-alcoholic beers), fermented and processed meat products, yeast products, soya and some vegetables. Some proprietary medicines such as cold cures contain phenylpropanolamine, ephedrine, etc. and will also interact with MAOIs. Such an interaction (termed the "cheese effect"), is attributed to the dramatic rise in blood pressure due to the sudden release of noradrenaline from peripheral sympathetic terminals, an event due to the displacement of noradrenaline from its mtraneuronal vesicles by the primary amine (usually tyramine). Under normal circumstances, any dietary amines would be metabolized by MAO in the wall of the gastrointestinal tract, in the liver, platelets, etc. The occurrence of hypertensive crises, and occasionally strokes, therefore limited the use of the MAOIs, despite their proven clinical efficacy, to the treatment of atypical depression and occasionally panic disorder. 

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