uestion: Does the patient have depression with the Atypical Features Specifier according to DSM-IV? (mood reactivity is not required.¹)

• Yes
• No

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Help: This syndrome was recently validated by a twin study.² The patient should have two out of four of:

1. Increased appetite with weight gain of 10 lb or more when depressed
2. Hypersomnia of 10 hours or more per day or 2 hours more sleep than usual amount of sleep when not depressed
3. Heavy, leaden feelings in arms and legs
4. Longstanding pattern of interpersonal rejection sensitivity, not limited to episodes of depression, that results in significant social or occupational impairment

This syndrome is now well established as being significantly more responsive to an MAOI in comparison with a tricyclic.³ It also responds well to an SSRI, but that will have already been adequately tried by this point. If you respond "yes," the option of considering an MAOI will be presented, although bupropion and phototherapy will be given some consideration.

¹Thase ME et al. Clinical significance of reversed vegetative subtypes of recurrent major depression. Psychopharmacol Bull 1991; 27:17-22.

²Kendler KS et al. The identification and validation of distinct depressive syndromes in a population-based sample of female twins. Arch Gen Psychiatry 1996;53:391-399.

³Quitkin FM et al. Columbia atypical depression: a subgroup of depressives with better response to MAOI than to tricylic antidepressants or placebo. Br J Psychiatry 1993; 163(suppl. 21), 30-34.