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Atypical depressionBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/atypical-depression/DS01181
Any type of depression can make you feel sad and keep you from enjoying life. However, if you have atypical depression, certain key signs and symptoms tend to occur. These include increased hunger, weight gain, sleeping a lot, feeling that your arms and legs are heavy, and difficulty maintaining relationships.
Atypical depression often starts in the teenage years and is more common in women than in men. Despite the name, atypical depression isn't uncommon or unusual. Similar to other forms of depression, treatment for atypical depression includes medications, psychological counseling (psychotherapy) and lifestyle changes.
Depression of any kind can cause feelings of sadness and a decreased ability to enjoy life. But atypical depression includes these main signs and symptoms:
- Depression that temporarily lifts when you're cheered up by good news or positive events but returns later
- Increased appetite with unintentional weight gain
- Increased desire to sleep, usually more than 10 hours a day
- Heavy, leaden feeling in your arms and legs that lasts an hour or more in a day
- Trouble maintaining long-lasting relationships because of sensitivity to rejection or criticism, which affects your relationships, social life or job
When to see a doctor
If you feel depressed, make an appointment to see your doctor as soon as you can. Depression may get worse if it isn't treated. Untreated depression can lead to other mental and physical health problems or problems in other areas of your life. Feelings of depression can also lead to suicide.
If you're reluctant to seek treatment, talk to a friend or loved one, a health care professional, a faith leader, or someone else you trust.
If you have suicidal thoughts
If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:
- Reach out to a close friend or loved one.
- Contact a minister, a spiritual leader or someone in your faith community.
- Call a suicide hotline number — in the United States, call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255) to reach a trained counselor. Use that same number and press 1 to reach the Veterans Crisis Line.
- Make an appointment with your doctor, mental health provider or other health care provider.
When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.
If you have a loved one who is in danger of committing suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.
It's not known exactly what causes atypical depression. As with other types of depression, a combination of factors may be involved. These include:
- Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. When these chemicals are out of balance, it may lead to depression symptoms.
- Inherited traits. Depression is more common in people whose biological (blood) relatives also have the condition.
- Life events. Events such as the death or loss of a loved one, financial problems, and high stress can trigger depression in some people.
- Early childhood trauma. Traumatic events during childhood, such as abuse or loss of a parent, may cause changes in the brain that make you more susceptible to depression.
Many factors seem to increase the risk of developing or triggering depression, whether it's atypical or not. Risk factors include:
- Depression that started when you were a teen or child
- History of bipolar disorder
- Abuse of alcohol or illegal drugs
- Physical or sexual abuse
- Traumatic childhood experiences
- Certain personality traits, such as low self-esteem or being overly dependent
- Serious illness, such as cancer or heart disease
- Certain medications, such as some high blood pressure medications or sleeping pills (talk to your doctor before stopping any medication)
- Financial problems
Family history and issues with family or others may also increase your risk of depression:
- Biological (blood) relatives with a history of depression, bipolar disorder or alcoholism
- Stressful life events, such as the death of a loved one
- Depression after giving birth (postpartum depression)
- Family members who committed suicide
- Few friends or other personal relationships
Like other types of depression, atypical depression is a serious illness that can cause major problems. Atypical depression can result in emotional, behavioral and health problems that affect every area of your life. Complications associated with atypical depression may include:
- Excess weight or obesity, which can lead to heart disease and diabetes
- Alcohol or drug abuse
- Anxiety and panic disorder or social phobia
- Family conflicts, relationship difficulties, and work or school problems
- Social isolation
- Suicidal feelings or suicide
Preparing for your appointment
You may see your primary care doctor, or your doctor may refer you to a physician who specializes in mental health (psychiatrist). Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
These steps can help you make the most of your appointment:
- Write down any symptoms you've had, including any that may seem unrelated to the reason you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, vitamins and supplements that you're taking.
- Take a family member or friend along, if possible — someone who comes with you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Prepare a list of questions ahead of time, from most to least important in case time runs out. Basic questions to ask your doctor include:
- Is depression the most likely cause of my symptoms?
- What are other possible causes for my symptoms or condition?
- What kinds of tests will I need?
- What treatment is likely to work best for me?
- What are the alternatives to the approach that you're suggesting?
- I have these other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Should I see a psychiatrist or other mental health provider?
- Are there any possible side effects or other issues with the medications you're recommending?
- Is there a generic alternative to the medicine you're prescribing?
- Do you have printed material that I can have? What websites do you recommend?
Don't hesitate to ask questions anytime you don't understand something.
What to expect from your doctor
Be ready to answer questions from your doctor to reserve time to discuss your concerns. Your doctor may ask:
- When did you or your loved ones first notice your symptoms of depression?
- How long have you felt depressed? Do you generally always feel down, or does your mood fluctuate?
- How severe are your symptoms? Do they interfere with your daily life or relationships?
- Does your mood ever swing from feeling down to feeling euphoric and full of energy?
- How do you react to good news or positive events?
- How do you react to criticism or rejection?
- Do you constantly feel hungry or regularly overeat?
- How much do you sleep every day?
- Do you often feel tired or irritable?
- Do you ever have suicidal thoughts?
- Do you have any biological (blood) relatives with depression or another mood disorder? What treatment has helped them?
- What other mental or physical health conditions do you have?
- Do you drink alcohol or use illegal drugs?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
Tests and diagnosis
These exams and tests can help rule out other problems that could be causing your symptoms, pinpoint a diagnosis and check for any related complications:
- Physical exam. Your doctor may do a physical exam and ask in-depth questions about your health to help determine what may be causing your depression. In some cases, depression may be linked to an underlying physical health problem.
- Lab tests. For example, your doctor may do a blood test called a complete blood count (CBC) or test your thyroid to make sure it's functioning properly.
- Psychological evaluation. To check for signs of depression, your doctor or mental health provider will talk to you about your symptoms, thoughts, feelings and behavior patterns. Your doctor may have you fill out a written questionnaire to help answer these questions.
Diagnostic criteria for atypical depression
To be diagnosed with atypical depression, you must meet the symptom criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.
For a diagnosis of atypical depression, you must first meet the general DSM criteria for major depression — such as feeling down most of the day and losing interest or pleasure in activities you once enjoyed. You'll also need to meet other specific criteria for atypical depression.
For a diagnosis of atypical depression you must have this symptom:
- Depression that temporarily lifts when you're cheered up by positive events
In addition, you must have at least two of these symptoms for diagnosis:
- Gaining weight or having a noticeable increase in appetite
- Sleeping too much
- Being sensitive to rejection by others so that it affects your work or relationships
- Having a heavy feeling in your arms and legs
Atypical depression has a specific definition as a diagnosable condition. But some doctors and mental health providers use the term more loosely. Ask for a definition if it isn't clear what your doctor or mental health provider means when he or she says "atypical depression."
Treatments and drugs
Treatment for atypical depression is generally the same as for other types of depression. In some cases, a primary care doctor can prescribe medications to relieve symptoms. However, many people with atypical depression need to see a psychiatrist. Most people also benefit from seeing a psychologist or other mental health counselor. Usually the most effective treatment is a combination of medication and psychotherapy.
Atypical depression most often occurs as part of mild, long-lasting depression. However, it can cause more severe symptoms in some people, such as feeling suicidal or not being able to do basic day-to-day activities.
Here's a closer look at your treatment options.
Many types of medications are available to treat depression. They include:
- Selective serotonin reuptake inhibitors (SSRIs). Doctors often start treatment by prescribing an SSRI. These medications are safer and generally cause fewer side effects than do other types of antidepressants. SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro). The most common side effects include decreased sexual desire and delayed orgasm. Other side effects may go away as your body adjusts to the medication. They can include digestive problems, jitteriness, restlessness, headache and insomnia.
- Serotonin and norepinephrine reuptake inhibitors (SNRIs). These medications include duloxetine (Cymbalta), venlafaxine (Effexor XR) and desvenlafaxine (Pristiq). Side effects are similar to those caused by SSRIs. These medications can cause increased sweating, dry mouth, fast heart rate and constipation.
- Norepinephrine and dopamine reuptake inhibitors (NDRIs). Bupropion (Wellbutrin) falls into this category. It's one of the few antidepressants that doesn't cause sexual side effects, and it usually doesn't cause weight gain. At high doses, bupropion may increase your risk of having seizures.
- Atypical antidepressants. These medications don't fit neatly into another antidepressant category. They include trazodone and mirtazapine (Remeron). Both are sedating and usually taken in the evening. A newer medication called vilazodone (Viibryd) has a low risk of sexual side effects. The most common side effects of vilazodone are diarrhea, nausea, vomiting and insomnia.
- Tricyclic antidepressants. Tricyclic antidepressants — such as imipramine (Tofranil) and nortriptyline (Pamelor) — tend to cause more severe side effects than newer antidepressants. So tricyclics generally aren't prescribed unless you've tried an SSRI first without improvement. Side effects may include low blood pressure, dry mouth, blurred vision, constipation, urinary retention, fast heartbeat, confusion or weight gain, among others.
- Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate) and phenelzine (Nardil) — may be prescribed as a last resort, when other medications haven't worked, because they can have serious side effects. Use of MAOIs requires a strict diet because of dangerous (or even deadly) interactions with foods — such as certain cheeses, pickles and wines — and some medications including birth control pills, decongestants and certain herbal supplements. Selegiline (Emsam), a newer MAOI that you stick on your skin as a patch, may cause fewer side effects than other MAOIs. These medications can't be combined with SSRIs.
- Other medications. Other medications may be added to an antidepressant to enhance antidepressant effects. Your doctor may recommend combining two antidepressants or medications, such as mood stabilizers or antipsychotics. Anti-anxiety and stimulant medications might also be added for short-term use. In addition, the FDA approved a medical food — a prescription that provides dietary management for a disease or condition — called Deplin, which contains L-methylfolate, a form of the vitamin folate. Studies have shown that adding Deplin to an antidepressant can be helpful, especially in women and those who can't process (metabolize) folate — a condition identified through a genetic test.
Finding the right medication
If a family member has responded well to an antidepressant, it may be one that could help you. You may need to try several medications before you find one that works. This requires patience, as some medications need eight weeks or longer to take full effect and for side effects to ease as your body adjusts.
If you're bothered by side effects, don't stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause withdrawal symptoms unless you slowly taper off, and quitting abruptly may cause a sudden worsening of depression. Don't give up until you find a medication that's suitable for you.
If antidepressant treatment doesn't seem to be working, your doctor may recommend a blood test called the cytochrome P450 (CYP450) to check for specific genes that affect how your body processes antidepressants. This may help identify which antidepressant might be a good choice for you, although these genetic tests may not be widely available and they have limitations.
Antidepressants and pregnancy
If you're pregnant or breast-feeding, some antidepressants may pose an increased health risk to your unborn child or nursing child. Talk to your doctor if you become pregnant or are planning to become pregnant.
Antidepressants and increased suicide risk
Most antidepressants are generally safe, but the Food and Drug Administration (FDA) requires that all antidepressants carry "black box" warnings, the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. So these age groups need close monitoring by loved ones, caregivers and health care providers. If you — or someone you know — have suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.
Psychotherapy is a general term for treating depression by talking about your condition and related issues with a mental health provider. Psychotherapy is also known as talk therapy, counseling or psychosocial therapy.
Through these talk sessions, you can learn how to identify and make changes in unhealthy behavior or thoughts, explore relationships and experiences, find better ways to cope and solve problems, and set realistic goals for your life. Psychotherapy can help you regain a sense of satisfaction and control in your life and help ease depression symptoms such as hopelessness and anger.
Hospitalization and residential treatment programs
In some people, depression is so severe that a hospital stay is needed. Inpatient hospitalization may be necessary if you can't care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves. Partial hospitalization or day treatment programs also are helpful for some people. These programs provide the support and counseling you need while you get symptoms under control.
Other options include:
- Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain. This procedure is thought to affect levels of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don't work. The most common side effect is confusion, which can last from a few minutes to several hours. Some people also have memory loss, which is usually temporary. ECT is usually used for people who don't get better with medications, can't take antidepressants for health reasons or are at high risk of suicide.
- Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven't responded to antidepressants. During TMS, you sit in a reclining chair with a treatment coil placed against your scalp. The coil sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Typically, you'll have five treatments each week for up to six weeks.
- Vagus nerve stimulation. This treatment uses electrical impulses with a surgically implanted pulse generator to affect mood centers of the brain. This may be an option if you have long-term, treatment-resistant depression.
Lifestyle and home remedies
Depression generally isn't an illness that you can treat on your own. But in addition to professional treatment, these self-care steps can help:
- Stick to your treatment plan. Don't skip psychotherapy sessions or appointments. Even if you're feeling well, don't skip your medications. If you stop, depression symptoms may come back, and you could also experience withdrawal-like symptoms.
- Learn about depression. Education about your condition can empower you and motivate you to stick to your treatment plan. Encourage your family to learn about depression to help them understand and be more supportive of you.
- Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your depression symptoms. Make a plan so you know what to do if your symptoms get worse. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Ask family members or friends to help watch for warning signs.
- Get exercise. Physical activity reduces depression symptoms. Consider walking, jogging, swimming, gardening or taking up another activity you enjoy.
- Avoid alcohol and street drugs. It may seem like alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your doctor or therapist if you need help with alcohol or drug abuse.
Make sure you understand the risks as well as possible benefits if you pursue alternative or complementary therapy. Don't replace conventional medical treatment or psychotherapy with alternative medicine. When it comes to depression, alternative treatments aren't a substitute for professional care.
Herbal remedies and supplements
Examples of herbal remedies and supplements that are sometimes used for depression include:
- St. John's wort. This herb is not approved by the Food and Drug Administration to treat depression in the United States, but it's a popular depression treatment in Europe. It may be helpful if you have mild or moderate depression, but St. John's wort should be used with caution. It can interfere with a number of medications, including antidepressants, HIV/AIDS medications, drugs to prevent organ rejection after an organ transplant, birth control pills, blood-thinning medications and chemotherapy drugs.
- SAMe. Pronounced "sam-EE," this dietary supplement is a synthetic form of a chemical that occurs naturally in the body. The name is short for S-adenosylmethionine (uh-den-o-sul-muh-THIE-o-neen). Like St. John's wort, SAMe isn't approved by the FDA to treat depression in the United States, but it's used in Europe as a prescription drug to treat depression. SAMe may be helpful, but more research is needed. In higher doses, SAMe can cause nausea and constipation.
- Omega-3 fatty acids. These healthy fats are found in cold-water fish, flaxseed, flax oil, walnuts and some other foods. Omega-3 supplements are being studied as a possible treatment for depression. While considered generally safe, the supplement can have a fishy taste, and in high doses, it may interact with other medications. More research is needed to determine if eating foods with omega-3 fatty acids can help relieve depression.
Because some herbal and dietary supplements can interfere with prescription medications or cause dangerous interactions, talk with your health care provider before taking any supplements.
Complementary and alternative medicine practitioners believe the mind and body must be in harmony for you to stay healthy. Examples of mind-body techniques that may be helpful for depression include:
- Yoga or tai chi
- Guided imagery
- Massage therapy
- Relaxation techniques
- Music or art therapy
Relying solely on these therapies is generally not enough to treat depression. They may be helpful when used in addition to medication and psychotherapy.
Coping and support
Talk with your doctor or therapist about improving your coping skills, and try these tips:
- Simplify your life. Cut back on obligations when possible, and set reasonable goals for yourself. Give yourself permission to do less when you feel down.
- Write in a journal. Journaling, as part of your treatment, may improve your mood by allowing you to express pain, anger, fear or other emotions.
- Read reputable self-help books. Your doctor or therapist may be able to recommend helpful books.
- Locate helpful organizations. Many organizations, such as the National Alliance on Mental Illness (NAMI) and the Depression and Bipolar Support Alliance (DBSA), offer education, support groups, counseling and other resources to help with depression. Employee assistance programs and religious organizations may also offer help for mental health concerns.
- Don't become isolated. Try to participate in social activities, and get together with family or friends regularly.
- Take care of yourself. Eat a healthy diet, exercise regularly and get plenty of sleep.
- Learn ways to relax and manage your stress. Examples include meditation, progressive muscle relaxation, yoga and tai chi.
- Structure your time. Plan your day. You may find it helps to make a list of daily tasks, use sticky notes as reminders or use a planner to stay organized.
- Don't make important decisions when you're down. Avoid decision making when you're feeling depressed, since you may not be thinking clearly.
There's no sure way to prevent depression. However, these strategies may help.
- Take steps to control stress, to increase your resilience and to boost your self-esteem.
- Reach out to family and friends, especially in times of crisis, to help you weather rough spells.
- Get treatment at the earliest sign of a problem to help prevent depression from worsening.
- Consider getting long-term maintenance treatment to help prevent a relapse of symptoms.
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