Two types of depression that can change treatment
When most people picture depression, they imagine someone who can’t eat, can’t sleep, and can’t get out of bed. But depression has many faces, and two of them, atypical depression and melancholic depression, often get missed because they don’t match that picture at all.
Atypical Depression
Atypical depression got its name back in the 1950s, when doctors thought it was rare. It’s actually one of the most common forms of depression, and the name has stuck even though it’s misleading.
The hallmark of atypical depression is a mood that reacts, sometimes too much. You might feel crushed by a small setback, or you might brighten for a few hours when something good happens, only to sink again later in the day. You are exquisitely sensitive to slights from others (rejection sensitivity). If a friend doesn’t return your call or text, the hurt is intense.
Along with that reactive mood, atypical depression also causes:
- Fatigue that doesn’t lift with rest
- Oversleeping, rather than insomnia
- Overeating, especially sweets and carbs
- A heavy, weighed-down feeling in the arms and legs called leaden paralysis
Atypical depression also tends to come and go in cycles, and it often follows the seasons, showing up in the fall and winter and lifting in spring. If you have atypical depression, standard antidepressants may not be your best bet. Serotonin-based medications and MAOIs, an older class of antidepressants, tend to work better here.
One more thing worth knowing: atypical depression is the most common pattern of depression in bipolar disorder, particularly bipolar II. That doesn’t mean everyone with atypical depression has bipolar disorder. It just means I pay closer attention to mood history when I see this pattern.
Melancholic Depression
Melancholic depression has been described for centuries. It tends to arrive in middle age, and it feels nothing like ordinary sadness.
Patients describe it to me as an emptiness, a bleakness, a darkness that has no clear cause and no motivation behind it. Some feel it physically, as a heavy or painful feeling in the chest or the head. Unlike atypical depression, this mood barely budges, no matter what happens in your life. Good news doesn’t touch it, but it’s often worse in the morning, when people wake up with a nameless dread.
Other signs of melancholic depression:
- Guilt or worry that loops on the same theme, often about having done something terrible, being worthless, or losing money or health
- A loss of pleasure in nearly everything
- Waking two to three hours earlier than planned and not falling back asleep
- Muscles that either slow down or grow agitated, like pacing that won’t stop
- Loss of appetite or weight loss
Psychotic Depression
Depression affects emotions, but in more severe cases, it affects thinking as well. Sometimes, depression can distort thinking so much that it cause people to hear or see things that aren’t there, or have paranoid, rigid, or fixed beliefs. This type of depression (psychotic depression) may respond to medication, but if not, it often responds to ECT (electroconvulsive therapy). ECT essentially resets the brain, bringing over 90% of people with psychotic depression into full recovery.
Why the Difference Matters
Depression rarely looks the same from one person to the next. Recognizing which pattern fits you is often the first step toward a treatment that actually works. Treatments that works for one type of depression may fall flat for another.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
