Clinical features of atypical depression in bipolar and recurrent affective disorders, psychogenic depression

Objective: to perform a comparative study of the clinical features of atypical depression (AtD) in affective disorders of various origins: in bipolar affective disorder (BAD), recurrent depressive disorder (RDR) and psychogenic depression (PD).

Patients and methods. A sample of 250 depressed patients aged 18 to 65 years were examined, of which 77 participants (50 women and 27 men) with symptoms of AtD were included to the study. Group 1 included 35 patients with BAD, group 2 – 18 patients with RDR, and group 3 – 24 patients with diagnoses including PD. The patients' condition was assessed using the diagnostic criteria for affective disorders according to ICD-10 and DSM-5 with a Montgomery-Asberg Depression Rating Scale (MADRS).

Results and discussion. AtD detection rate was 30.8%, including 45.4% in BAD, 23.4% – in RDR, and 31.2% – in PD. AtD manifested at the age of about 20 years, and was more common in women. AtD in BAD occurred more often in individuals with cycloid, hyperthymic, and hysterical features. Affective fluctuations before the disease onset, a significantly greater number of depressive episodes in history were characteristic. The most frequent typical depressive symptoms included: daily and seasonal mood fluctuations, morning deterioration of well-being, decreased appetite. High comorbidity with metabolic endocrine diseases was observed. AtD in RDR often began spontaneously in individuals with emotionally labile, psychasthenic, and hysterical features. The most common typical depressive symptoms included melancholy, derealization, weakness, ideas of self-accusation, suicidal thoughts and attempts. A high comorbidity with cardiovascular diseases was found. AtD in PD occurred more often in psychasthenic individuals. The most characteristic symptoms included: increased appetite, anxiety, asthenia, superficial night sleep, hypochondriacal inclusions. Comorbidity with skin and gastrointestinal diseases was observed.

Conclusion. The identified features of the clinical picture and course of AtD in BAD, RDR, and PD can be used for earlier and more accurate evaluation of affective disorders and the adequate treatment administration.

1. West ED, Dally PJ. Effect of iproniazid in depressive syndromes. Br Med J. 1959 Jun 13;1(5136):1491-4. doi: 10.1136/bmj.1.5136.1491

2. Klein DF, Davis JM. Diagnosis and Drug Treatment of Psychiatric Disorders. Baltimore: Williams & Wilkins; 1969.

3. Davidson JR, Miller RD, Turnbull CD, Sullivan JL. Atypical depression. Arch Gen Psychiatry. 1982 May;39(5):527-34. doi: 10.1001/archpsyc.1982.04290050015005

4. Sovner RD. The clinical characteristics and treatment of atypical depression. J Clin Psychiatry. 1981 Jul;42(7):285-9.

5. Lojko D, Rybakowski JK. Atypical depression: current perspectives. Neuropsychiatr Dis Treat. 2017 Sep 20;13:2447-56. doi: 10.2147/NDT.S147317

6. Buzuk G, Lojko D, Owecki M, et al. Depression with atypical features in various kinds of affective disorders. Psychiatr Pol. 2016;50(4):827-38. doi: 10.12740/PP/44680

7. Koyuncu A, Ertekin E, Binbay Z, et al. The clinical impact of mood disorder comorbidity on social anxiety disorder. Compr Psychiatry. 2014 Feb;55(2):363-9. doi: 10.1016/j.comppsych.2013.08.016. Epub 2013 Oct 19.

8. Koyncu A, Ertekin E, Ertekin BA, et al. Relationship between atypical depression and social anxiety disorder. Psychiatry Res. 2015 Jan 30;225(1-2):79-84. doi: 10.1016/j.psychres.2014.10.014. Epub 2014 Nov 11.

9. Tav A, Demir Berkol T, Yildirim YM, et al. Can Comorbid Bipolar Disorder Be Associated with Atypical Depression in Patients with Social Anxiety Disorder? J Neurobehav Sci. 2019;6(1):130-5.

10. Matza LS, Revicki DA, Davidson JR, Stewart JW. Depression with atypical features in the national comorbidity survey: classification, description, and consequences. Arch Gen Psychiatry. 2003 Aug;60(8):817-26. doi: 10.1001/archpsyc.60.8.817

11. Angst J, Gamma A, Benazzi F, et al. Melancholia and atypical depression in the Zurich study: epidemiology, clinical characteristics, course, comorbidity and personality. Acta Psychiatr Scand Suppl. 2007;(433):72-84. doi: 10.1111/j.1600-0447.2007.00965.x

12. Lee S, Ng KL, Tsang A. Prevalence and correlates of depression with atypical symptoms in Hong Kong. Aust N Z J Psychiatry. 2009 Dec;43(12):1147-54. doi: 10.3109/00048670903279895

13. Tyuvina NA, Balabanova VV, Voronina EO. Gender features of depressive disorders in women. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2015;7(2):75-9. doi: 10.14412/2074-2711-2015-2-75-79 (In Russ.).

14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.

15. Benazzi F. Atypical bipolar II depression compared with atypical unipolar depression and nonatypical bipolar II depression. Psychopathology. Mar-Apr 2000;33(2):100-2. doi: 10.1159/000029128

16. Tyuvina NA, Korobkova IG. Comparative clinical characteristics of depression in bipolar affective disorders types I and II. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2016;8(1):22- 8. doi: 10.14412/2074-2711-2016-1-22-28 (In Russ.).

17. Mitchell PB, Wilhelm K, Parker G, et al. The clinical features of bipolar depression: a comparison with matched major depressive disorder patients. J Clin Psychiatry. 2001 Mar;62(3):212-6; quiz 217.

18. Bowden CL. Strategies to reduce misdiagnosis of bipolar depression. Psychiatr Serv. 2001 Jan;52(1):51-5. doi: 10.1176/appi.ps.52.1.51

19. Petrun'ko OV, Shvetsova AV, Magonova EG, Khamarkhanova AA. Atypical symptoms of bipolar depression. Sibirskii meditsinskii zhurnal. 2009;(5):72-5 (In Russ.).

20. Akiskal HS, Benazzi F. Atypical depression: a variant of bipolar II or a bridge between unipolar and bipolar II? J Affect Disord. 2005 Feb;84(2-3):209-17. doi: 10.1016/j.jad.2004.05.004

21. 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. doi: 10.1038/sj.mp.4001032

22. Blanco C, Vesga-Lopez O, Stewart JW, et al. Epidemiology of major depression with atypical features: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). J Clin Psychiatry. 2012 Feb;73(2):224-32. doi: 10.4088/JCP.10m06227. Epub 2011 Sep 6.

23. Novick JS, Stewart JW, Wisniewski SR, et al. Clinical and demographic features of atypical depression in outpatients with major depressive disorder: preliminary findings from STAR*D. J Clin Psychiatry. 2005 Aug;66(8):1002-11. doi: 10.4088/jcp.v66n0807

24. Stewart J. Atypical depression: history and future. Psychiatr Ann. 2014;44:557-62.

25. Brailean A, Curtis J, Davis K, et al. Characteristics, comorbidities, and correlates of atypical depression: evidence from the UK Biobank Mental Health Survey. Psychol Med. 2020 May;50(7):1129-38. doi: 10.1017/S0033291719001004. Epub 2019 May 2.

26. Agosti V, Stewart JW. Atypical and nonatypical subtypes of depression: comparison of social functioning, symptoms, course of illness, co-morbidity and demographic features. J Affect Disord. 2001 Jun;65(1):75-9. doi: 10.1016/s0165-0327(00)00251-2

27. Stewart JW, Mcgrath PJ, Fava M, et al. Do atypical features affect outcome in depressed outpatients treated with citalopram? Int J Neuropsychopharmacol. 2010 Feb;13(1):15-30. doi: 10.1017/S1461145709000182. Epub 2009 Apr 3.

28. McGinn LK, Asnis GM, Suchday S, Kaplan M. Increased personality disorders and Axis I comorbidity in atypical depression. Compr Psychiatry. Nov-Dec 2005;46(6):428-32. doi: 10.1016/j.comppsych.2005.03.002

29. Lasserre AM, Glaus J, Vandeleur CL, et al. Depression with atypical features and increase in obesity, body mass index, waist circumference, and fat mass: a prospective, populationbased study. JAMA Psychiatry. 2014 Aug;71(8):880-8. doi: 10.1001/jamapsychiatry. 2014.411. Erratum in: JAMA Psychiatry. 2014 Sep;71(9):1079.

30. Sokolovskaya LV. Asteniya – tipologiya, dinamika, pogranichnyye sostoyaniya i endogennyye zabolevaniya. Avtoref. … diss. kand. med. nauk [Asthenia – typology, dynamics (borderline states and endogenous diseases): Author's abstract. Dis. Cand. Med. Sci.]. Moscow; 1991. 17 p. (In Russ.).

31. Zelenina YeV. Somatovegetativnyy simptomokompleks v strukture depressiy (tipologiya, klinika, terapiya): Avtoref. … diss. kand. med. nauk [Somatovegetative symptom complex in the structure of depression (typology, clinic, therapy): Author's abstract. Dis. Cand. Med. Sci.]. Moscow; 1997. 23 p. (In Russ.).

32. Lasserre AM, Strippoli MF, Glaus J, et al. Prospective associations of depression subtypes with cardio-metabolic risk factors in the general population. Mol Psychiatry. 2017 Jul;22(7):1026-34. doi: 10.1038/mp.2016.178. Epub 2016 Oct 11.

33. Lapin IA, Rogacheva TA. Atypical depression (analysis of links between individual atypical symptoms and sociodemographic and clinical variables). Sotsial'naya i klinicheskaya psikhiatriya. 2020;30(3):17-25 (In Russ.).

34. Angst J, Gamma A, Benazzi F, et al. Atypical depressive syndromes in varying definitions. Eur Arch Psychiatry Clin Neurosci. 2006 Feb;256(1):44-54. doi: 10.1007/s00406-005-0600-z. Epub 2005 Jul 27.

35. Perugi G, Akiskal HS, Lattanzi L, et al. The high prevalence of “soft” bipolar (II) features in atypical depression. Compr Psychiatry. Mar-Apr 1998;39(2):63-71. doi: 10.1016/s0010-440x(98)90080-3

36. Benazzi F. Testing DSM-IV definition of atypical depression. Ann Clin Psychiatry. 2003 Mar;15(1):9-16. doi: 10.1023/a:1023272408562

37. Seemüllera F, Riedela M, Wickelmaiera F, et al. Atypical symptoms in hospitalised patients with major depressive episode: frequency, clinical characteristics, and internal validity. J Affect Disord. 2008 Jun;108(3):271-8. doi: 10.1016/j.jad.2007.10.025. Epub 2007 Dec 31.

38. Smulevich AB. Depressii v obshchei meditsine: Rukovodstvo dlya vrachei [Depression in General medicine: a guide for doctors]. Moscow: MIA; 2007. 256 p. (In Russ.).

39. Pae CU, Tharwani H, Marks DM, et al. Atypical depression: a comprehensive review. CNS Drugs. 2009 Dec;23(12):1023-37. doi: 10.2165/11310990-000000000-00000

40. Stewart JW, Mcgrath PJ, Quitkin FM, Klein DF. DSM-IV depression with atypical features: is it valid? Neuropsychopharmacology. 2009 Dec;34(13):2625-32. doi: 10.1038/npp.2009.99. Epub 2009 Sep 2.