When Depression Doesn’t Look Typical – Identifying the Signs

May 25, 2022 at 04:48 pm by pj


Many times, patients self-identify as “depressed” which triggers clinicians to probe deeper in making a proper diagnosis. But often patients are not able to thoroughly assess and communicate their symptoms. What does depression look like when it doesn’t follow the typical pattern? Here we explore the different signs and symptoms that could often lead to an undiagnosed clinical depression.

The DSM V identifies major depressive disorder (MDD) as requiring 5 of the following symptoms: depressed mood, loss of interest, weight loss or gain (5%+), sleep disturbance (insomnia or hypersomnia), psychomotor changes (agitation or slowing), fatigue, worthlessness, difficulty concentrating or making decisions, or suicidal ideation. These symptoms persist most of the day, daily, for 2+ weeks. This form of depression is the most commonly diagnosed. In the United States, the annual prevalence is 7%, with a peak age of onset in the mid 20’s. 18 to 29-year-olds have a prevalence three times higher than individuals 60 and older.  Females have a 2 to 3 times higher rate than males. The course varies greatly ranging from chronic to large episodes of being symptom free, and 50% of depressive episodes are brief and resolve within three months. MDD is associated with chronic medical conditions including heart disease, arthritis, back pain, chronic pulmonary disease, asthma, hypertension, and migraine, and associated lifestyle risk factors include a more sedentary lifestyle, obesity, and cigarette smoking.

But what about symptoms that don’t fit the usual clinical presentation? Atypical depression (AD) has a different presentation which is more difficult to identify. In AD, there is a significant mood reactivity – meaning the patients mood brightens in response to actual or potential positive outcomes. Additional criteria include two or more of the following symptoms: significant weight gain, increase in appetite, hypersomnia, leaden paralysis, and a long-standing pattern of interpersonal rejection sensitivity that results in significant social or emotional impairment. In AD, we can see that the mood reactivity may cause a misleading presentation of the depression and thus may result in the underdiagnosis of depression. Additionally, the interpersonal rejection sensitivity many mislead the clinician to a diagnosis of personality disorder.  AD depression is associated with conduct disorder, social phobia, interpersonal dependency, low self-esteem, and parental substance abuse, and higher rates of early childhood trauma, whereas melancholic depression is not.

When assessing for Atypical depression, it is helpful to remember the acronym RAILS:

  • R- Reactivity in mood
  • A- Appetite increase
  • I- Interpersonal rejection sensitivity
  • L- Leaden paralysis
  • S- Sleep increase

Interview questions that will help to differentiate Atypical Depression from Major Depressive Disorder. These include: Do you notice if your mood improves when people try to cheer you up, or give you a complement? Do you notice that your depression lifts if the situations around you stay positive? Have you noticed an increase in appetite or weight? Have you noticed feeling sensitive about being rejected by others? Has this always been the case? How much more? Have you noticed feeling heavy, or weighted down in your arms or legs a few hours each day? Do you notice that you are sleeping more than usual?

Melancholic depression – AD requires differentiation from other related subtypes including depression with melancholic features. This subtype presents as a near complete loss of pleasure in almost all activities or a lack of reactivity to usually pleasurable stimuli. What differentiates it from the other depressive diagnoses includes the 3 or more additional symptoms required from the following: depressed mood that is worse in the morning, waking 2 hours earlier than usual, observable psychomotor slowing or agitation, significant weight loss or anorexia, or excessive or inappropriate guilt. This subtype is more common in inpatients or those with comorbid psychotic features. It is shorter in duration, more episodic, and features diurnal variation – that is an early-morning worsening of mood, with an afternoon slump or evening worsening.

Catatonic depression – AD requires differentiation from another subtype of depression including catatonic depression. This is characterized by 3 or more of the following psychomotor features during most of the depression episode: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, not influenced by external stimuli, grimacing, echolalia, or echopraxia.

Anger and irritability – The public perception is that sadness is the leading symptom of depression. However, irritability or anger can be the dominant symptom presented. In these individuals, they experience being easily triggered which is well noted by either themselves or those around them. Try asking “is anger something you notice experiencing most days? Have you experience this most of your life or is it new to you?” It is important to consider depression presenting as anger versus the irritability and anger that can be seen in individuals with bipolar disorder.

Vague physical complaints – Many individuals have a hard time identifying their own emotional state. In asking them about mood symptoms, they may minimize or deny their existence. Some patients more readily express physical symptoms. When patients present with vague physical complains, or moving physical ailments without identifiable medical conditions, a diagnosis of depression should be considered. Try asking “when did you start to notice this physical sensation? Can you tell me what life events were going on at that time? Can you tell me what you are thinking/feeling when you notice this physical sensation?”

Treatment – regardless of the presentation type of the depressed patient, a multi-pronged approach is key. Education about the benefits of healthy behaviors including movement, exposure to sunlight, proper sleep hygiene, and social support begins the process. In some cases, a psychiatric medication trial may be necessary. Most importantly, research indicates that participating in psychotherapy (specifically CBT), vs medication alone creates the most optimal and longer lasting therapeutic outcomes. In fact, research indicates that medication monotherapy has a recovery rate of 30%. Identifying the type of depression greatly effects the type of medication treatment utilized. The first line of treatment for Major Depressive Disorder is typically SSRI’s. However, research suggests that Melancholic Depression responds better to TCAs and ECT. IN contrast, Atypical Depression has a poor response to TCAs and ECT, but excellent response to MAOIs. Partnering with a mental health professional can help you identify the specific mental health diagnosis, as well as aid in the development of a treatment plan that will help the patient regain their quality of life.

April Boykin is a Licensed Clinical Social Worker and cofounder of Counseling Resource Services (CRS). Established in 2013, CRS is a community-based in-home integrated behavioral health agency serving the aged and disabled population in Central Florida. As a mental health counselor, she has provided individual, family and caregiver counseling to children, teens and adults.   She can be reached at april@counselingresourceservices.com


Sections: Clinical