Atypical Depression: Signs, Symptoms, & Treatments

What Is Atypical Depression?

Atypical depression is one of the depressive disorders in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM). The specifier “atypical” can be added to the diagnoses of major depressive disorder (MDD) and persistent depressive disorder (PDD) when certain key features are present in addition to experiencing feeling sad, empty, or hopeless or loss of interest or pleasure most days.

Atypical depression differs from typical depression in that the person’s mood can improve in light of positive events and the disturbances of a person’s functions necessary to maintain life (vegetative symptoms) are reversed from those in typical depression.

Atypical depression can cause hypersomnia (excessive sleep) and increased appetite. Atypical depression also includes the symptoms of leaden paralysis or sensation of heaviness in limbs.

Is Atypical Depression Uncommon?

The inclusion of the term “atypical” in its name does not mean this type of depression is uncommon or unusual. 15%-29% of depressed patients present with atypical features and most present with mixed features of atypical depression and another subtype, melancholic depression.¹ The term “atypical” refers to the unique presentation of symptoms and the markedly better response to MAOIs compared to patients with non-atypical depression.²

Signs & Symptoms of Atypical Depression

Symptoms of atypical depression include mood reactivity and two of the following four symptoms:

• Weight gain or increase in appetite
• Hypersomnia or excessive sleep
• Leaden paralysis or a feeling of heavy limbs
• Long-standing pattern of interpersonal rejection sensitivity

These occur in addition to the symptoms of MDD and PDD such as depressed mood or decreased interest most to all of the day.³

Common signs of atypical depression include:

• Hypersomnia (excessive sleep)
• Leaden paralysis (limbs feel heavy)
• Rejection sensitive dysphoria
• Increased appetite
• Mood reactivity (mood brightens in light of positive events)
• Sadness or depressed mood more often than not
• Loss of interest or pleasure most to all of days
• Feelings of hopelessness, worthlessness, or excessive guilt
• Difficulty concentrating
• Recurring thoughts of death or suicide

Atypical Depression Vs. Bipolar II

Bipolar II is another mental health disorder involving episodes of depression but is distinct in that it also involves hypomanic episodes. Hypomanic symptoms are the same as in a manic episode but are less severe, and include feeling abnormally upbeat or wired, increased activity or agitation, an exaggerated sense of well-being and confidence, decreased need for sleep, unusual talkativeness, racing thoughts, distractibility, and poor decision-making.

Treatments for bipolar disorder II differ from atypical depression so an accurate diagnosis is essential for effective management of symptoms. Treatment for both bipolar disorder and unipolar depression includes medication and psychotherapy, but mood stabilizers used to treat manic symptoms are not as effective for depression and psychotherapy has been found to alleviate depressive symptoms but not those of mania.⁴

Causes of Atypical Depression

There is not an exact known cause for atypical depression but there are risk factors that increase the likelihood of developing a depressive disorder. Two biological risk factors include impairments to neurotransmitters and/or neuroreceptors, the chemicals that carry brain signals to different parts of your body, and a family history of mood disorder(s).

Additional environmental and historical risk factors for atypical depression include a history of traumatic events or adverse childhood experiences (ACEs) such as various types of abuse, violence, or neglect, chronic stress, significant illness, grief after a significant loss, and a history of substance use.⁵

Diagnosis Process for Atypical Depression

A medical or mental health professional can diagnose atypical depression. A diagnostic assessment such as the Patient Health Questionnaire (PHQ) can screen for depressive symptoms and a medical professional can complete a physical exam to assess for weight changes and order blood tests to rule out physical causes for depressive symptoms such as thyroid disease.

A psychiatric evaluation is important for diagnosing any mental health condition as the interview includes questions about medical history, family history, and symptomatology, and is often accompanied by the use of standardized tests. The unique features of atypical depression can make it difficult to diagnose. A thorough evaluation can help correctly diagnose an individual rather than a bipolar misdiagnosis or a misdiagnosis with another similar condition.⁶

Treatment for Atypical Depression

Atypical depression treatment options include medication, psychotherapy (talk therapy) and lifestyle changes. A comprehensive treatment plan will include some or all of these interventions depending on the severity of symptoms. Psychotherapy goals for treating depression include developing coping skills for managing symptoms as well as implementing lifestyle changes that can improve symptoms such as increasing physical activity or reducing recreational substance use.

Effective treatment options for atypical depression include:

Psychotherapy

Psychotherapy treats depression by identifying and challenging thoughts contributing to depressed emotions, developing coping strategies to manage feelings of stress, sadness, or hopelessness, developing thinking patterns that improve mood, outlook, and self-image, and teaching skills to improve the quality of relationships. Psychotherapy also provides a supportive environment to receive psychoeducation, address trauma, and receive emotional support for current challenges related to depressive symptoms.

Psychotherapy options for atypical depression include:

• Psychodynamic therapy: psychodynamic therapy treats atypical depression by identifying and working through unconscious thoughts, feelings, and behaviors contributing to depression. Common techniques include free association, content vs. process, and catharsis.
• Interpersonal therapy (IPT): IPT is based on the premise that mental health is inextricably linked to a person’s relationships. It treats atypical depression by exploring relationship patterns contributing to depression, increasing social support, and resolving interpersonal conflicts.
• Cognitive behavioral therapy (CBT): CBT for depression works by reducing thoughts contributing to depressed mood and developing reward systems to positively reinforce behavior changes that reduce depressive symptoms. Common CBT interventions include cognitive restructuring, activity scheduling, and mindful meditation.
• Dialectical behavior therapy (DBT): DBT for depression works by developing skills that improve quality of relationships and the ability to regulate emotions. Common DBT skills include interpersonal effectiveness, radical acceptance, and focusing on what you can control.
• Mindfulness-based cognitive therapy (MBCT): This approach incorporates mindfulness practices and aspects of cognitive-behavioral therapy. It works for atypical depression by developing present-moment awareness and reducing rumination on depression-related thoughts and feelings.⁷

Medication

There are a few types of medications for depression, such as MAOIs and SSRIs that work by increasing levels of various neurotransmitters in the brain. The neurotransmitters, or chemical messengers, most closely related to depression are dopamine, serotonin, and norepinephrine as they contribute to disturbances in mood, sleep, appetite, motivation, cognition, and energy when levels are low.

Medication options for atypical depression include:

• Monoamine oxidase inhibitors (MAOIs): MAOIs are an antidepressant that works for depression by limiting enzymes that break down the neurotransmitters dopamine, serotonin, and norepinephrine. They have been found to be particularly helpful in treating atypical depression, which is less responsive to treatment with tricyclic antidepressants (TCAs).⁸
• Selective serotonin reuptake inhibitors (SSRIs): SSRIs are an antidepressant that works for depression by stopping the reuptake of serotonin. This allows for more serotonin in the brain, which is crucial for regulating mood, cognition, and vegetative functions such as sleep and appetite. They typically cause fewer side effects than other antidepressants.⁹
• Wellbutrin (bupropion): This medication treats depression by stopping the reuptake of norepinephrine and dopamine in the brain which helps improve mood. Wellbutrin has side effects comparable with SSRIs.
• Tricyclic antidepressants (TCAs): TCAs treat depression by blocking the reuptake of serotonin and norepinephrine. The increase in levels of these neurotransmitters can improve mood and attention. TCAs are a second-line treatment behind SSRIs as they are as effective but come with more adverse side effects.¹⁰

All medications come with potential side effects. As medications that treat depression affect neurotransmitters, various areas of bodily functioning are impacted for better and for worse. Common side effects include drowsiness, headache, nausea, suicidal thoughts, tooth decay, and diabetes. It is important to discuss the risks and benefits of taking any medication with your doctor and discuss any side effects from drug interactions.

Lifestyle Changes

In addition to medication and psychotherapy, lifestyle changes can reduce depressive symptoms and prevent the onset of depression and are a great complement to formal treatment.¹¹ This is empowering as access to therapeutic and pharmacological treatments is not equitable across populations and lifestyle changes can improve depression despite genetic risk factors.

Here are some tips for lifestyle changes that can help with atypical depression:

• Regular exercise: Engaging in moderate physical activity such as a brisk walk for 150 minutes per week or vigorous activity such as jogging for 75 minutes per week can help with atypical depression. It can be a lot to start this much activity all at once so set smaller, doable goals at first to establish habits and increase your activity over time.
• Healthy diet: Food is your brain’s fuel and what you eat impacts how your brain functions. Replacing processed foods with foods that can help with depression such as fish, nuts, leafy greens, and whole grains can help with atypical depression.
• Moderate alcohol consumption: Heavy drinking contributes to depressive symptoms because it impacts brain chemistry. Sticking to moderate drinking, which the Center for Disease Control defines as no more than 1 drink/day for women and no more than 2 drinks/day for men can reduce the risk of depression.
• Healthy sleep: Try getting between 7 and 9 hours of sleep per night. Having a consistent sleep schedule and good sleep hygiene such as reducing electronic use before bed can improve quality of sleep.
• Limit sedentary activities: Many of us spend a great deal of time sitting down in front of a screen. In addition to regular physical activity, getting up to move or stretch every 30-60 minutes after sitting can reduce a depressed mood.
• Abstain from nicotine: Never smoking is best for your mental health and the more you smoke, the higher risk of depression. If you are already a smoker, quitting the habit will reduce your risk of depression and the longer you abstain from smoking, the lower your risk for depression.
• Frequent social connection: Social connection both protects against developing depression and reduces existing depressive symptoms.¹² Joining a social group that meets regularly can improve your mood by increasing connectedness. If this is out of reach, saying “hi” to those you come across is a way to begin building relationships.

Challenges in Treating Atypical Depression

The unique symptom presentation of atypical depression poses challenges in treatment as it risks misdiagnosis and delayed diagnosis. The symptom of leaden paralysis can be misdiagnosed as chronic fatigue syndrome. Atypical depression can also be misdiagnosed as bipolar disorder due to similar symptom presentation. The reversal of vegetative symptoms significantly impacts what types of medication effectively treat symptoms. Effective treatment depends on accurate diagnosis.

Long-Term Outlook for Atypical Depression

Depression in general is a highly treatable condition. Atypical depression tends to last longer than typical depression and often becomes a chronic condition but consistent and effective treatment can successfully manage symptoms. Approximately 70%-80% of people with depression that receive appropriate treatment experience significant improvement in symptoms.⁵ Finding the treatment that works for you can take time, so if your first attempt doesn’t work, keep trying.

A return of symptoms, or relapse, is common among those treated for depression. One study showed as high as 85% of those who, through treatment, no longer met clinical criteria for depression, experienced a return of symptoms and 50% did so within six months of remission when treatment was discontinued.¹³ There are depression relapse prevention strategies including continuing treatment despite improvement in symptoms.

How to Help a Loved One With Atypical Depression

If you have a loved one struggling with atypical depression, offering support can impact their desire to seek and follow through on treatment, which will significantly impact their symptoms and quality of life. Stigma continues to exist for mental health issues and having someone your loved one can safely talk to about their experience can reduce shame that otherwise inhibits them from seeking help.

Here are some tips for how to help a loved one with atypical depression:

• Open and supportive communication: Show genuine interest in learning about your loved one’s experience. Practice active listening and empathy. Refrain from judgment and don’t offer advice unless it’s asked for.
• Provide resources:  Do some of the heavy lifting that comes with pursuing treatment by finding resources that can aid your loved one in getting the help they need. Generate a list of therapists, psychiatrists, depression-help groups, and mental health organizations that can help your loved one with their depression.
• Encourage professional help: Let your loved one know taking medication or attending therapy is a positive rather than shameful act. Offer to attend appointments with them or remind them to take their medication.
• Highlight their strengths: Those with depression often self-criticize and feel badly about themselves. Remind them of their positive qualities, share what you appreciate about them, and positively reinforce the steps they are taking to manage their depression.
• Make plans together: Scheduling enjoyable activities that are easy for your loved one to do can reduce loneliness and increase positive events in their life. This is particularly helpful with atypical depression as their mood does improve with positive events.
• Be patient: Finding the right treatment that provides relief can take time which can be discouraging for your loved one. Showing patience reminds them that just because they haven’t found the right treatment yet doesn’t mean they never will.

When to Seek Professional Support for Atypical Depression

It’s normal for anyone to experience feeling sad, periods of low motivation, or a greater need for sleep some days. It’s important to seek professional support if these symptoms are occurring more often than not and are interfering with aspects of your daily life. You should also seek help immediately if experiencing suicidal ideation. Using an online therapist directory or online therapy for depression platform can help you find a provider to diagnose and treat your depression. Consider seeing a psychiatrist if you are experiencing disturbances in vegetative functions like sleeping and eating, experiencing chronic symptoms, or struggling with suicidal thoughts. Using online psychiatrist options can increase your access to care and in some cases are more affordable than an in-person provider.