Atypical depression Puzzled? How to piece together symptoms and treatments
When do depressive symptoms become ‘atypical,’ and which antidepressants are most effective? Though evidence is incomplete, these authors recommend a clinical approach.
In our clinical experience, the combination of venlafaxine and bupropion can be effective for both depression and excessive eating in these patients, many of whom also exhibit other atypical features. A possible explanation is that the combined pharmacologic effect of venlafaxine and bupropion resembles that of the MAOIs (increased synaptic availability of serotonin, norepinephrine, and dopamine) without many MAOI side effects, such as weight gain.
We have, however, also observed treatment-emergent hypomania when using this drug combination, which is consistent with:
- the idea that mood reactivity and rejection sensitivity may be markers for bipolar disorder
- the often-reported high rate of bipolar II disorder among patients with atypical depression.5
In obese patients with bipolar II disorder, we have found that adding topiramate to mood stabilizer therapy can help treat both mood instability and overeating.31,32 same preferential response to MAOIs as the mood-reactive group. Patients with typical vegetative symptoms did not show this differential response.
Related resources
- Parker G, Roy K, Mitchell P, Wilhelm K, Malhi G, Hadzi-Pavlovic D. Atypical depression: a reappraisal. Am J Psychiatry 2002;159(9):1470-9.
- Gold PW, Chrousos GP. Organization of the stress system and its dysregulation in melancholic and atypical depression: high vs. low CRH/NE states. Mol Psychiatry 2002;7(3):254-75.
- Nierenberg AA, Alpert JE, Pava J, Rosenbaum JF, Fava M. Course and treatment of atypical depression. J Clin Psychiatry 1998;59(suppl 18):5-9.
Drug brand names
- Bupropion • Wellbutrin
- Fluoxetine • Prozac
- Moclobemide • Manerix
- Phenelzine • Nardil
- Sertraline • Zoloft
- Topiramate • Topamax
- Venlafaxine • Effexor
Disclosure
Dr. Nelson receives grant/research support from Eli Lilly & Co. and Wyeth Pharmaceuticals and is on the speakers bureau of Wyeth Pharmaceuticals.
Dr. McElroy is a consultant or scientific advisor to Abbott Laboratories, Bristol-Myers Squibb Co., Elan Corp., GlaxoSmithKline, Janssen Pharmaceutica, Eli Lilly & Co., Novartis Pharmaceuticals Corp., Ortho-McNeil Pharmaceutical, UCB Pharma, and Wyeth Pharmaceuticals. She receives research support from Forest Laboratories, GlaxoSmithKline, Elan Corp., Eli Lilly & Co., Merck & Co., Ortho-McNeil Pharmaceutical, Pfizer Inc., Sanofi-Synthelabo, and UCB Pharma.
