By Rajnish Mago, MD (bio)
In my opinion, the importance of identifying that a patient has a depressive episode “with atypical features” is less in choosing a particular treatment and more because it tells us that we need to assess (or REASSESS, please!) for four things that more likely to be present in a person whose depressive episodes have atypical features. These four things are (in no particular order):
Depressive episodes of bipolar disorders are more likely to be associated with atypical features (Lojko et al., 2015; Benazzi and Rihmer, 2000). If needed, we should repeat the assessment for bipolar disorders included interviewing someone who knows the patient well.
When depressive episodes have a seasonal pattern, this has treatment implications like anticipating episodes, increasing medications prior to the time of the year when an episode is more likely, more frequent use of bright light therapy, and so on. This is why when atypical features are present, we should specifically look for a seasonal pattern since the two tend to travel together.
History of psychosocial trauma
Patients whose depressive episodes are associated with atypical features are also more likely to have a history of psychosocial trauma (Withers et al., 2013). In such situations, we should assess what sequelae of the trauma are still present and make sure the person is being adequately treated for these sequelae.
Borderline personality disorder
Lastly, when atypical features are present in a depressive episode, borderline personality disorder may be present and should be specifically looked for. For how to most efficiently screen for borderline personality disorder, see this article: How to screen for borderline personality disorder
Benazzi F, Rihmer Z. Sensitivity and specificity of DSM-IV atypical features for bipolar II disorder diagnosis. Psychiatry Res. 2000 Apr 10;93(3):257-62. PubMed PMID: 10760384.
Łojko D, Buzuk G, Owecki M, Ruchała M, Rybakowski JK. Atypical features in depression: Association with obesity and bipolar disorder. J Affect Disord. 2015 Oct 1;185:76-80. doi: 10.1016/j.jad.2015.06.020. Epub 2015 Jun 22. PubMed PMID: 26148463.
Withers AC, Tarasoff JM, Stewart JW. Is depression with atypical features associated with trauma history? J Clin Psychiatry. 2013 May;74(5):500-6. doi: 10.4088/JCP.12m07870. PubMed PMID: 23759453.
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