Psycho-Babble Medication Thread 4802

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Re: Lofepramine and tricyclics

Posted by Refractory on October 31, 1999, at 10:46:08

In reply to Lofepramine and tricyclics, posted by Andie on April 13, 1999, at 11:07:08

I have read and been told that the tricyclics are actually oftentimes superior to the SSRIs for severe depression or refractory. Psychiatrists are terribly afraid of being sued for any reason, as are all doctors these days. Part of their reluctance nowadays to prescribe TCAs probably has to do with their fear a patient may use the TCA prescription to overdose and thus commit suicide. Thus they try to stay with the newer, "cleaner" antidepressants like the SSRIs whenever possible. As none of these can be used for overdose.

I am sure there are many, many people out there with more severe depression, who would probably be better off on a TCA or even an MAOI but their doctor wont voluntarily put them on one because of the docs fear of overdose and potential lawsuits. Such is the state of modern day medicine.

 

Re: Lofepramine and tricyclics

Posted by Elizabeth on October 31, 1999, at 12:41:11

In reply to Re: Lofepramine and tricyclics, posted by Refractory on October 31, 1999, at 10:46:08

> I have read and been told that the tricyclics are actually oftentimes superior to the SSRIs for severe depression or refractory.

Yes...in particular for the "melancholic" subtype (which often isn't helped by SSRIs).

> Psychiatrists are terribly afraid of being sued for any reason, as are all doctors these days. Part of their reluctance nowadays to prescribe TCAs probably has to do with their fear a patient may use the TCA prescription to overdose and thus commit suicide. Thus they try to stay with the newer, "cleaner" antidepressants like the SSRIs whenever possible. As none of these can be used for overdose.

Well, they can, but the most that's liable to happen is a great deal of vomiting. I think fear that patients will use a medication as a means to attempt suicide is a legitimate concern. Lofepramine is supposed to be much less cardiotoxic than other TCAs, which makes it an attractive choice. (Does anyone happen to know what company markets it in the UK?)

Another risk of tricyclics is that they seem to cause mania (in particular, dysphoric or mixed mania) or rapid cycling than SSRIs and possibly MAOIs. (Hypomania seems to be very common with MAOIs, though.)

> I am sure there are many, many people out there with more severe depression, who would probably be better off on a TCA or even an MAOI but their doctor wont voluntarily put them on one because of the docs fear of overdose and potential lawsuits. Such is the state of modern day medicine.

My impression is that tricyclics are better for the melancholic end of the spectrum, SSRIs for the atypical end, and MAOIs are more versatile. This is, of course, an extremely broad generalization.

 

Re: tricyclics and suicide

Posted by Stephan on November 1, 1999, at 15:24:34

In reply to Re: Lofepramine and tricyclics, posted by Elizabeth on October 31, 1999, at 12:41:11

>I think fear that patients will use a medication as a means to attempt suicide is a legitimate concern.

Of course it is, but it should always be a rational and balanced concern, not an irrational one. The prolongation of pain and misery caused by doctors who are quite willing to subject a patient to every possible non-tricyclic or non-MAOI antidepressant combination in order to lessen their often irrational litigation paranoia is at least as significant as the suicide-attempt risk of prescribing tricyclics. I would venture to say that far more patients have lost their lives due to under and mal-treatment of their depression than because a doctor prescribed them a tricyclic.

 

Re: tricyclics and suicide

Posted by saint james on November 1, 1999, at 18:40:20

In reply to Re: tricyclics and suicide, posted by Stephan on November 1, 1999, at 15:24:34

> >I think fear that patients will use a medication as a means to attempt suicide is a legitimate concern.
>
> Of course it is, but it should always be a rational and balanced concern, not an irrational one. The prolongation of pain and misery caused by doctors who are quite willing to subject a patient to every possible non-tricyclic or non-MAOI antidepressant combination in order to lessen their often irrational litigation paranoia is at least as significant as the suicide-attempt risk of prescribing tricyclics. I would venture to say that far more patients have lost their lives due to under and mal-treatment of their depression than because a doctor prescribed them a tricyclic.

James here....

One months supply of a TCA generally is not enough to kill someone. Doc make this call often, so the write scripts for the smallest amount of time in those that might try suicide.

j

 

Re: Lofepramine and tricyclics

Posted by Refractory on November 1, 1999, at 21:24:13

In reply to Re: Lofepramine and tricyclics, posted by Elizabeth on October 31, 1999, at 12:41:11

> > I have read and been told that the tricyclics are actually oftentimes superior to the SSRIs for severe depression or refractory.
>
> Yes...in particular for the "melancholic" subtype (which often isn't helped by SSRIs).
>
> > Psychiatrists are terribly afraid of being sued for any reason, as are all doctors these days. Part of their reluctance nowadays to prescribe TCAs probably has to do with their fear a patient may use the TCA prescription to overdose and thus commit suicide. Thus they try to stay with the newer, "cleaner" antidepressants like the SSRIs whenever possible. As none of these can be used for overdose.
>
> Well, they can, but the most that's liable to happen is a great deal of vomiting. I think fear that patients will use a medication as a means to attempt suicide is a legitimate concern. Lofepramine is supposed to be much less cardiotoxic than other TCAs, which makes it an attractive choice. (Does anyone happen to know what company markets it in the UK?)
>
> Another risk of tricyclics is that they seem to cause mania (in particular, dysphoric or mixed mania) or rapid cycling than SSRIs and possibly MAOIs. (Hypomania seems to be very common with MAOIs, though.)
>
> > I am sure there are many, many people out there with more severe depression, who would probably be better off on a TCA or even an MAOI but their doctor wont voluntarily put them on one because of the docs fear of overdose and potential lawsuits. Such is the state of modern day medicine.
>
> My impression is that tricyclics are better for the melancholic end of the spectrum, SSRIs for the atypical end, and MAOIs are more versatile. This is, of course, an extremely broad generalization.

Hmmmm that is very interesting. I always heard MAOIs were the drugs for the "atypical" form of depression. How come you say SSRIs are good for atypical depression? Very interesting.

 

Re: tricyclics and suicide

Posted by Elizabeth on November 3, 1999, at 11:57:14

In reply to Re: tricyclics and suicide, posted by saint james on November 1, 1999, at 18:40:20

> > Of course it is, but it should always be a rational and balanced concern, not an irrational one. The prolongation of pain and misery caused by doctors who are quite willing to subject a patient to every possible non-tricyclic or non-MAOI antidepressant combination in order to lessen their often irrational litigation paranoia is at least as significant as the suicide-attempt risk of prescribing tricyclics. I would venture to say that far more patients have lost their lives due to under and mal-treatment of their depression than because a doctor prescribed them a tricyclic.

This is well said, and I agree...you have to balance the risks of prescribing vs. the risks of not prescribing. There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression"), the patient's current level of suicidal ideation and history of suicide attempts, the level of social support available to the patient, etc. As Saint James points out below, you can also write for just a week at a time if the patient is "high-risk."

> One months supply of a TCA generally is not enough to kill someone. Doc make this call often, so the write scripts for the smallest amount of time in those that might try suicide.

This is sort of an oversimplification...because people metabolize tricyclics at widely varying rates (in particular, somewhere around 10% of Caucasians (less in other ethnic groups) are deficient in an enzyme involved in TCA metabolism), the lethal dose varies a lot as well. A month's supply at a starting dose probably wouldn't be lethal for a normal metabolizer, but it could be for a poor metabolizer.

 

Re: Lofepramine and tricyclics

Posted by Elizabeth on November 3, 1999, at 12:05:09

In reply to Re: Lofepramine and tricyclics, posted by Refractory on November 1, 1999, at 21:24:13

> Hmmmm that is very interesting. I always heard MAOIs were the drugs for the "atypical" form of depression. How come you say SSRIs are good for atypical depression? Very interesting.

This was observed pretty early on, I think. My suspicion is that they still don't work as well for atypical depression as MAOIs, though this hasn't been shown.

See, for example:

Pande AC, et al. Fluoxetine versus phenelzine in atypical depression. Biol Psychiatry. 1996 Nov 15;40(10):1017-20.

 

Re: atypical depression and tricyclics

Posted by Stephan on November 3, 1999, at 12:53:45

In reply to Re: tricyclics and suicide, posted by Elizabeth on November 3, 1999, at 11:57:14

> There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression

I know there are a lot of studies that support this, but I'm about as atypical as they come, and tricyclics (desipramine and nortriptyline) have given me a better response than any other antidepressant (with the exception of my first trial of Luvox). Parnate gave me only a modest, transient response.

 

Re: atypical depression and tricyclics-Stephan

Posted by jamie on November 3, 1999, at 14:48:33

In reply to Re: atypical depression and tricyclics, posted by Stephan on November 3, 1999, at 12:53:45

> > There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression
>
> I know there are a lot of studies that support this, but I'm about as atypical as they come, and tricyclics (desipramine and nortriptyline) have given me a better response than any other antidepressant (with the exception of my first trial of Luvox). Parnate gave me only a modest, transient response.

Stephan...nortriptyline and desipramine in combination? Or separately. ???

 

Re: atypical depression and tricyclics-(for Jamie)

Posted by Stephan on November 4, 1999, at 17:13:47

In reply to Re: atypical depression and tricyclics-Stephan, posted by jamie on November 3, 1999, at 14:48:33


> Stephan...nortriptyline and desipramine in combination? Or separately. ???

Separately. I've never heard of them being combined. Not sure if it's ok.

 

Re: atypical depression and tricyclics

Posted by Elizabeth on November 4, 1999, at 23:30:12

In reply to Re: atypical depression and tricyclics, posted by Stephan on November 3, 1999, at 12:53:45

> > There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression
>
> I know there are a lot of studies that support this, but I'm about as atypical as they come, and tricyclics (desipramine and nortriptyline) have given me a better response than any other antidepressant (with the exception of my first trial of Luvox). Parnate gave me only a modest, transient response.

What do you mean when you say you are "about as atypical as they come?" Atypical depression is a specific syndrome -- it doesn't just mean you have an unusual or different presentation.

 

Re: atypical depression and tricyclics

Posted by Stephan on November 5, 1999, at 19:32:02

In reply to Re: atypical depression and tricyclics, posted by Elizabeth on November 4, 1999, at 23:30:12


> What do you mean when you say you are "about as atypical as they come?" Atypical depression is a specific syndrome -- it doesn't just mean you have an unusual or different presentation.

I meant that I seem to have all the classic symptoms of "atypical depression" -hypersomnia, strong cravings for sugary foods, etc.

 

Re: atypical depression and tricyclics

Posted by Scott L. Schofield on November 7, 1999, at 17:26:35

In reply to Re: atypical depression and tricyclics , posted by Stephan on November 5, 1999, at 19:32:02


> I meant that I seem to have all the classic symptoms of "atypical depression" -hypersomnia, strong cravings for sugary foods, etc.

Doesn't it sometimes seem as if the atypical is actually quite typical?

It's funny, but I have not yet come across any literature that presents statistics comparing the occurrences of "typical" versus "atypical" depression. Also, bipolar depression typically appears atypical. Very shortly, I imagine the atypical neuroleptics will typically be the first choice of your typical psychiatrist.

That's typical.


- Scott

P.S. I really would like to know the statistics regarding the various presentations of unipolar depression. Does anyone know what they are?

 

Re: atypical depression -how typical?

Posted by Noa on November 7, 1999, at 19:25:07

In reply to Re: atypical depression and tricyclics , posted by Scott L. Schofield on November 7, 1999, at 17:26:35

My very uneducated guess is that the "typical" presentation of depression ocurrs more frequently in men than in women, and that early studies of depression used male subjects. So the model of what is "typical" depression was based on the acute major depression occuring in the "typical" male subject. When more and more women started showing up for treatment, presenting with "atypcial" features, the symptoms were compared (contrasted) with what was the textbook version of depression (insomnia, lack of appetite, no mood responsivity to social stimulation, etc.) and called them "atypical". I would guess that there are more "atypicals" than textbook major depression.
Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar. some researchers are also looking at the so-called mood based personality disorders as cyclical mood disorders, with hypomania presenting more often as irritability, and depression being of the "atypical" type. I think this is a positive move, because the name "personality disorder" sounds like a character fault, which has moral overtones, in the person who is suffering.

 

Re: atypical depression -how typical?

Posted by Elizabeth on November 8, 1999, at 0:10:12

In reply to Re: atypical depression -how typical?, posted by Noa on November 7, 1999, at 19:25:07

> My very uneducated guess is that the "typical" presentation of depression ocurrs more frequently in men than in women, and that early studies of depression used male subjects.

It appears that older people are more likely to have typical features; that melancholic features occur about equally in both sexes; and that atypical features occur about twice as often in women as in men. (My guess is that adolescents are likelier to present with reversed vegetative signs than adults are.)

> Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar.

Not exclusively (bipolar folks can have "typical" depressions too). I think this mainly applies to bipolar II (which is itself sort of a fuzzy category).

> some researchers are also looking at the so-called mood based personality disorders as cyclical mood disorders, with hypomania presenting more often as irritability, and depression being of the "atypical" type.

This is mainly borderline personality disorder, yes? (Maybe histrionic too.)

> I think this is a positive move, because the name "personality disorder" sounds like a character fault, which has moral overtones, in the person who is suffering.

I think it is sort of supposed to sound pejorative. (It is, after all, the category that includes antisocial personality disorder and narcissistic personality disorder.)

 

Re: atypical depression vs typical -- Eliz?

Posted by dj on November 8, 1999, at 2:10:19

In reply to Re: atypical depression -how typical?, posted by Elizabeth on November 8, 1999, at 0:10:12

Eliazabeth,

Seeing as you seem to be the most informed about these categories (though Noa seemed pretty familiar with them) perhaps when you've a moment to spare you could sketch out the symptoms of both, a bit..as a quick review of the last part of this thread leaves me little clearer as to the exact distinctions.

I have the impression that typical dep. is melancolic, oversleeping and undereating and that typical is perhaps the reverse however I'm not entirely certain about that and would appreciate some elaboration and explanation so I can better understand these categories.

> > It appears that older people are more likely to have typical features; that melancholic features occur about equally in both sexes; and that atypical features occur about twice as often in women as in men. (My guess is that adolescents are likelier to present with reversed vegetative signs than adults are.)
>

 

Re: atypical depression -how typical?

Posted by Scott L. Schofield on November 8, 1999, at 5:39:12

In reply to Re: atypical depression -how typical?, posted by Noa on November 7, 1999, at 19:25:07


> Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar.

Thanks for your more than uneducated reply.

I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive.

- Scott

 

Re: atypical depression -how typical?

Posted by Annie on November 8, 1999, at 9:44:01

In reply to Re: atypical depression -how typical?, posted by Scott L. Schofield on November 8, 1999, at 5:39:12

My "current" psychiatrist is one of the proponents of the theory that there is no such thing as atypical depression. If a person exhibits the atypical subset of symptoms, like me, they are really bipolar whether or not they have ever experienced a manic or hypomanic episode. My irritability is manic, buying things I don't need is manic (hmmm ok maybe), researching my depression online is manic, assertiveness is manic. So now , I have a dx of mixed state bipolar. This explains (to him) why I have not noticed the manic episodes. I was depressed when I had them! This explains my refractory deprssion. I have been on Neurontin for a month. It's still early , but my depression is so severe right now, I'm not sure I will be able to survive long enough to "prove" this is not helping. You know, I just don't care anymore. Let him call it whatever he wants. I'm dying a little bit more every day and soon there won't be enough left to matter. When I am totally gone it won't matter what my dx was.
Annie

> > Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar.
>
> Thanks for your more than uneducated reply.
>
> I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive.
>
> - Scott

 

Re: atypical depression -how typical?

Posted by Scott L. Schofield on November 8, 1999, at 18:25:26

In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01

> > > Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar. > I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive. My "current" psychiatrist is one of the proponents of the theory that there is no such thing as atypical depression. If a person exhibits the atypical subset of symptoms, like me, they are really bipolar whether or not they have ever experienced a manic or hypomanic episode.

... researching my depression online is manic, assertiveness is manic...

...You know, I just don't care anymore. Let him call it whatever he wants. I'm dying a little bit more every day and soon there won't be enough left to matter. When I am totally gone it won't matter what my dx was.
Annie <


Dear Annie,

Although your doctor may be accurate in his appraisal of your illness, I think his characterization of your conducting research as being manic is unfair. Because I have seen at least two recent posts regarding the concept that all presentations of atypical depression are actually bipolar, I decided to do a little research of my own. The attitude I expressed in my previous post may have been unfounded.

I was more than just a little surprised at how few studies have been conducted in this area. There is quite a bit more uncertainty now as to the existence of a true atypical unipolar depression than there was ten years ago. I found a few studies in which sequential patients meeting the DSM IV diagnostic criteria for atypical depression were evaluated for bipolar disorder. At least two studies demonstrated that roughly 40% of those meeting the definition of atypical depression were actually bipolar II.

I would like to see a study in which both the 40% bipolar group and the 60% non-bipolar group are first treated with Depakote alone.

Either way, it might not be a bad idea to act under the premise that you are bipolar. It may lead to a successful trial using other mood-stablizers in addition to antidepressants.

Please care for a little while longer.


- Scott


P.S. Today has been a very upsetting one for me. The story is too long to get into here, but I didn't care a whole hell of a lot either. I hope I'm strong enough to take my own advice.

 

Re: atypical depression -how typical?

Posted by Scott L. Schofield on November 8, 1999, at 19:01:13

In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01

> > > Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar. > I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive. My "current" psychiatrist is one of the proponents of the theory that there is no such thing as atypical depression. If a person exhibits the atypical subset of symptoms, like me, they are really bipolar whether or not they have ever experienced a manic or hypomanic episode.

... researching my depression online is manic, assertiveness is manic...

...You know, I just don't care anymore. Let him call it whatever he wants. I'm dying a little bit more every day and soon there won't be enough left to matter. When I am totally gone it won't matter what my dx was.
Annie <


Dear Annie,

Although your doctor may be accurate in his appraisal of your illness, I think his characterization of your conducting research as being manic is unfair. Because I have seen at least two recent posts regarding the concept that all presentations of atypical depression are actually bipolar, I decided to do a little research of my own. The attitude I expressed in my previous post may have been unfounded.

I was more than just a little surprised at how few studies have been conducted in this area. There is quite a bit more uncertainty now as to the existence of a true atypical unipolar depression than there was ten years ago. I found a few studies in which sequential patients meeting the DSM IV diagnostic criteria for atypical depression were evaluated for bipolar disorder. At least two studies demonstrated that roughly 40% of those meeting the definition of atypical depression were actually bipolar II.

I would like to see a study conducted in which both the 40% bipolar group and the 60% non-bipolar group are first treated with Depakote alone.

Either way, it might not be a bad idea to act under the premise that you are bipolar. It may lead to a successful trial using other mood-stablizers in addition to antidepressants.

Please care for a little while longer.


- Scott


P.S. Today has been a very upsetting one for me. The story is too long to get into here, but I didn't care a whole hell of a lot either. I hope I'm strong enough to take my own advice.

 

Re: atypical depression -how typical?

Posted by Judy on November 8, 1999, at 18:25:10

In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01

> When I am totally gone it won't matter what my dx was.

Annie ~ I'm *sure* that's not true. Have you considered getting a second opinion? ~ Judy

 

Re: atypical depression -how typical?

Posted by Noa on November 8, 1999, at 18:39:00

In reply to Re: atypical depression -how typical?, posted by Scott L. Schofield on November 8, 1999, at 18:25:26

I think it is important to keep some perspective on the whole diagnosis thing. Diagnosis is just a way to organize one's thinking about a presentation of symptoms. Our understanding of all of these illness is still so rudimentary. Whether "atypical" depression is a stand alone category or is somehow akin to the depressions in the bipolar "family" is still up for grabs, and may never be answered, as it is also possible that different people's "atypical" presentations are of different types of underlying illness. Response to medication, I don't believe, is a good enough reason to confirm an absolute diagnosis because so many different problems are responding well to the same medications, and even people with similar presentations respond differently to the same medications.
Annie, it sounds like you feel your doctor is a reductionist in his thinking--everything is chalked up to hypomania, etc. That makes you feel he is dismissing your self advocacy efforts. I agree about the second opinion. Perhaps you would feel better with another doc. Or, bring it up with this doc--tell him how it makes you feel.
My pdoc, though far from perfect (I have issues with him today that I won't go into now) never presents his opinions as unequivocal. He shares his thinking with me and that the issues about atypical vs. soft bipolar signs is not currently resolvable. Again, despite some weaknesses he has, he has been supportive of my getting info online and elsewhere.
Hang in there Annie. I am struggling too, and sometimes feel the effort is futile, but we need to support each other and give each other encouragement to keep trying.

 

Re: atypical depression: Annie

Posted by Elizabeth on November 9, 1999, at 7:11:09

In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01

Annie, you sound so sad...I wish there was something I could do to help. I hope that you can pull together the energy to get a second opinion -- it seems pretty obvious that you know something isn't going right with the guy you're seeing now.

I think that docs who diagnose anyone with mood-reactive or atypical depression as bipolar II (and I seem to keep hearing of instances of this) are probably doing more harm than good. Atypical depression has been well documented, and the proper treatment for it is antidepressants (strong evidence for MAOIs, moderate support for SSRIs), not mood stabilizers. Until there is specific evidence that many patients diagnosed as atypical depressive respond to mood stabilizers (as opposed to meeting the [fuzzy] criteria for bipolar II), this should be a treatment reserved for those who do not improve or who worsen on antidepressants.

I don't recall off the top of my head what antidepressants you've tried (if you even mentioned it), but for what it's worth, MAOIs are supposed to be great for irritability. Another thing that sometimes works for people with atypical presentations is stimulants -- amphetamine, Ritalin, etc.

 

definitions (for dj)

Posted by Elizabeth on November 9, 1999, at 7:39:34

In reply to Re: atypical depression vs typical -- Eliz?, posted by dj on November 8, 1999, at 2:10:19

Hi dj. This is from DSM-IV (paraphrased):

Atypical depression is characterized by "reactive mood" (i.e., can sometimes "cheer up" in response to pleasant experiences) and 2 or more of the following:
- increase in appetite (often with significant weight gain) (may manifest as cravings for sweets)
- hypersomnia
- "leaden paralysis:" feelings of heaviness, especially in arms and legs
- trait rejection sensitivity (not exclusively during depression, but may be worse when depressed)

Atypical depression may be associated with irritability or mood swings (the reactive mood works both ways); substance abuse; personality disorders (e.g., borderline, histrionic, avoidant) or anxiety disorders (e.g., panic disorder, social phobia). Atypical depression occurs 2-3 times as often in women as in men. Onset is often in adolescence or early adulthood. Course tends to be chronic, or episodic with only partial recovery between episodes. Seasonal affective disorder usually presents as atypical.

Melancholia, in contrast, requires that an individual's mood be "nonreactive" (i.e., inability to experience pleasure from previously enjoyable activities; does not cheer up even when something good happens) along with 3 or more of the following:
- depressed mood is experienced as being different from normal moods such as grief, loneliness, sadness, etc.
- depression is generally worst in the morning
- early morning awakening
- psychomotor retardation or agitation (i.e., appears slowed-down or sped-up)
- loss of appetite/significant weight loss
- excessive or inappropriate feelings of guilt or self-reproach

Melancholic features predict greater severity of depression, nonresponse to placebo, and response to ECT or antidepressants. Certain laboratory findings are more common in patients with melancholic depression than in those with nonmelancholic depression. Melancholic depression is equally common among men and women and more common in older people than in younger people.

A third cateogory that is sometimes used is "simple mood-reactive depression." This is just mood-reactive depression without atypical features. I think it's probably the most common kind, and also the least understood.

 

Re: atypical depression: Annie

Posted by Scott L. Schofield on November 9, 1999, at 10:21:55

In reply to Re: atypical depression: Annie, posted by Elizabeth on November 9, 1999, at 7:11:09


> I think that docs who diagnose anyone with mood-reactive or atypical depression as bipolar II (and I seem to keep hearing of instances of this) are probably doing more harm than good. Atypical depression has been well documented, and the proper treatment for it is antidepressants (strong evidence for MAOIs, moderate support for SSRIs), not mood stabilizers. <


--------------------------------------------------


I'm not a big proponent of using drugs that don't work.

Unfortunately, medicine has not yet reached the point where choosing a drug that will work can be determined by some sort of objective test. I know I can't. I know my doctor can't. And I also know that Robert Post can't. Doctors can, however, make an educated guess based upon some of the empirical evidence gleaned from statistics.

From what little I know, Elizabeth's suggestion to try an MAO-inhibitor seems like a good one. The ones most commonly used in the U.S. are Parnate and Nardil. Another MAO-I, Marplan, was recently reintroduced. The old rule-of-thumb was to consider Parnate as a first choice for bipolar depression and Nardil for atypical unipolar depression, particularly if there also exists some social-phobia, panic-attacks, or obsessive-compulsive characteristics. Again, there are no hard rules to adhere to because there are many instances where the reverse is true.

One thing worth mentioning is that low-dose lithium in combination with an antidepressant has been used with some success at treating unipolar depressives. The range of dosages used was between 300 - 600 mg/day. 450 seemed to be the sweet-spot.

There's a bunch more strategies to try.* Hopefully, both you and I will find one that works. Keep researching. Our doctors can use all the help they can get.

* I tend to be more optimistic when it comes to other people's plights than I do for my own. Does anyone else experience this?

- Scott


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