All About Atypical Depression

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), atypical depression — also called “depression with atypical features” — is a “specifier” that mental health professionals may add to the following disorders:

• major depressive disorder (MDD)
• bipolar disorder
• persistent depressive disorder (PDD)

A specifier adds new information to the primary diagnosis. For instance, if you received a diagnosis of major depression with atypical features, you first met the criteria for MDD, and then atypical features were added to clarify your condition further.

To be diagnosed with atypical depression, you must show “mood reactivity,” meaning your mood can improve when something good happens.

In addition to mood reactivity, there should be at least two of the following symptoms for a diagnosis of atypical depression:

• significant increase in appetite
• oversleeping (hypersomnia)
• leaden paralysis, where your arms and legs feel heavy
• a long-term pattern of rejection sensitivity, when you interpret ordinary or slightly negative social cues as rejection

Importantly, atypical depression isn’t always persistent. For example, a person diagnosed with atypical features may begin to experience symptoms of melancholy, which is another depression specifier. People who have depression with melancholic features have anhedonia (an inability to feel pleasure) and show no signs of mood reactivity.

In fact, research shows that depression subtypes diagnoses are stable only 22% to 29% of the time. It’s more common for people to experience fluctuations between atypical and melancholic episodes than to have one type consistently over time.

Overall, it’s important that people with atypical symptoms receive a thorough evaluation before diagnosis.

Atypical depression can be misdiagnosed as borderline personality disorder because of the overlap in symptoms, such as extreme sensitivity to rejection.

The exact cause of atypical depression is unknown, but there are a few theories. The causes of depression are likely similar for different subtypes of depression — a mixture of genetic and environmental factors.

A 2017 review notes the following specific differences that might contribute to atypical depression:

• Differences in the stress response system. The stress response system, called the hypothalamic–pituitary–adrenal (HPA) axis, may act differently in depression with atypical vs. melancholic features. It appears to be overactive in those with melancholic depression, and underactive in those with atypical depression.
• Inflammatory markers. Inflammation appears to be much greater in people with atypical depression compared to other forms of depression and healthy controls. Atypical depression also has different inflammation patterns than melancholy depression.
• Leptin system (a hormone secreted from fat cells). Leptin regulation (resistance) may be an underlying mechanism linking obesity and depression. The concentration of this mood-regulating hormone has been significantly associated with clinical symptoms of atypical depression, such as excessive appetite, increased weight, and leaden paralysis.
• Brain structure or activity. People with atypical depression may have increased blood flow in the frontal, temporal, and parietal lobes of the brain along and decreased blood flow in the occipital lobe.

Atypical depression is more common among people with bipolar disorder. A United States population survey published in 2011 found that people with atypical depression had significantly higher rates of bipolar I disorder than those without atypical features.

In addition, atypical depression can co-occur with other mental health disorders, such as:

• anxiety disorders
• eating disorders
• substance use disorders

When compared to melancholic depression, people with atypical depression tend to have an earlier onset and a more chronic course of the illness. They also are more likely to have family members who have chronic depression.

Some evidence also suggests that atypical depression may be related to seasonal depression and obesity.

Atypical depression is often treated with psychotherapy, medication, or both.

Psychotherapy

Psychotherapy, particularly cognitive behavioral therapy (CBT), is a common treatment for most forms of depression, including atypical depression. CBT teaches clients to identify and change any negative or unhelpful belief patterns.

In a 2013 study, participants with depression were given either a 16-week course of the antidepressant paroxetine or a course of CBT. Both treatments reduced cognitive and suicidal symptoms; however, CBT was more effective at reducing certain atypical symptoms, such as overeating and oversleeping.

Medication

Treatment guidelines for atypical depression are lacking, but historically, monoamine oxidase inhibitors (MAOIs) have been the most effective.

MAOIs aren’t widely used today due to possible side effects, but clinicians may prescribe them with caution to people with atypical depression. They may also prescribe selective serotonin reuptake inhibitors (SSRIs).

Beginning in the late 1950s, researchers observed that people with certain features of depression (now considered atypical features) responded very well when treated with iproniazid, the original MAOI.

Then, a 2006 analysis looked at studies comparing MAOIs with both tricyclic antidepressants and SSRIs. The researchers found MAOIs to be notably more effective than tricyclics, and they found little difference between MAOIs and SSRIs. The researchers say the available data was insufficient.

Wellbutrin (bupropion), a norepinephrine-dopamine reuptake inhibitor (NDRI), may also be effective at improving oversleeping and fatigue, which are symptoms of atypical depression.

If you live with atypical depression, there are several things you can do to assist in your treatment. These include exercise, a healthy diet, and reaching out for support.

Exercise

Exercise may be the last thing on your mind when you’re dealing with the fatigue and heaviness of atypical depression.

But 2016 research shows that people with MDD with atypical features have better treatment outcomes when they engage in aerobic exercise. The authors also report that people with hypersomnia and increased BMI (symptoms of atypical depression) may have a greater response to exercise.

Healthy diet

Several studies over the years have suggested that a healthy diet may play a role in reducing certain types of depression. Similarly, a poor diet, including one full of sweets, processed foods, and refined grains, may contribute to the risk of depression.

A 2018 review of 41 studies found that consistently eating a healthy diet — particularly a traditional Mediterranean diet, or at least avoiding a pro-inflammatory diet — appears to offer some protection against depression.

The Mediterranean diet is characterized by vegetables, fruit, nuts, fish, olive oil, and whole grains.

Researchers suggest that nutrition may affect depression risk through the following pathways:

• inflammation
• gut microbiome
• oxidative stress (too many free radicals in the body)
• neuroplasticity (brain’s ability to adapt)
• mitochondrial function (cell metabolism)

Eating healthy can be particularly challenging when you have depression, especially with the increased appetite often seen in atypical depression — but you can start small.

Consider matching your cravings to healthier choices. For instance, instead of snacking on sweets, grab a handful of dates or strawberries. If you’re craving heavy carbs, opt for whole-grain bread instead of refined bread or crackers.

Join a support group

The simple act of giving and receiving support from others going through similar challenges can be very healing. Consider joining a support group for people with depression.

To read about some options, you can check out Psych Central’s guide to online support groups for depression.

Living with atypical depression isn’t easy, but know that you’re not alone, and the condition is highly treatable.

If you think you have the symptoms of atypical depression, don’t hesitate to reach out to a mental health professional. Together, you and your mental health professional can discuss treatment options to begin your journey toward wellness.