Anxiety Symptoms and Treating Depression

Michael R. Liebowitz, MD


March 25, 2004

In This Article

Distinguishing Subtype

The first distinction I try to make once I am sure that we are in the unipolar spectrum is whether the patient is suffering from the melancholic subtype of depression. If the patient has appetite loss, middle or terminal insomnia, diurnal variation (worse in the AM), and complete or near complete anhedonia (loss of capacity for joy or pleasure), then he/she meets criteria for melancholia.[2] Such patients do better, I believe, with dual serotonergic-noradrenergic reuptake inhibitors (SNRIs) than they do with SSRIs. Examples of SNRIs are the older tricyclic antidepressants, extended-release venlafaxine, and the still investigational drug duloxetine. I have seen many melancholically depressed patients who showed poor responses to an SSRI do very well when changed to extended-release venlafaxine or augmented with a tricyclic antidepressant. Unfortunately, before coming to me, some of these patients had already been switched from one SSRI to another by other clinicians, greatly delaying the onset of symptom relief. For the unipolar patients with nonmelancholic symptoms, I have not seen strong evidence of a differential response to SSRIs vs SNRIs.

One treatment-relevant subtype of nonmelancholic depression is atypical depression, characterized in DSM-IV by mood reactivity (retention of the ability to be temporarily cheered by pleasant events) and 2 or more of the features of overeating, oversleeping, feelings of leaden fatigue, and extreme sensitivity to rejection or criticism.[2] Such patients were found to respond better to monoamine oxidase inhibitors (MAOIs) than to tricyclic antidepressants,[3] but have not been well studied with regard to their responses to SSRIs or SNRIs. Drugs that enhance dopaminergic activity seem especially useful in this population, either as monotherapy (eg, MAOIs) or more commonly in conjunction with SSRIs or SNRIs (eg, bupropion, amphetamines, or other dopaminergic agonists).


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