Atypical depression spectrum disorder – neurobiology and treatment

Abstract

Depressive syndromes are a group of heterogeneous disorders. Atypical depression (AD) with reversed vegetative signs, such as hyperphagia or hypersomnia, is traditionally neglected, demonstrated by the fact that in the most widely used depression scales, such as the Hamilton Depression Scale (HAMD), melancholic symptoms have a specific weight, while, by contrast, reversed vegetative signs are not included. However, epidemiologically and phenomenologically related disorders to AD do exist, such as somatoform disorders, neurasthenia (chronic fatigue syndrome) and fibromyalgia (FM). In this spectrum, here called the AD spectrum, instead a decrease in hypothalamus–pituitary–adrenocortical (HPA) axis activity seems to exist. This has similarities to Cushing's disease, where a suppression of central HPA system activity is accompanied by features of AD and somatization in a considerable number of patients. Opposite vegetative features might therefore be related to the opposite dysregulation of the HPA system. The psychopharmacological intervention in the AD spectrum should therefore differ from that used in typical major depression. MAO inhibitors, low-dose tricyclic antidepressants and 5-HT3 antagonists demonstrated therapeutic efficacy, but the existing studies focused on different aspects. Hypericum extracts might be an alternative pharmacological intervention, which demonstrated therapeutic efficacy in the symptom range of the spectrum.