uestion: Is the patient's dysthymic disorder or depression NOS characterized by a reactive or non-reactive mood?

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Help: A small number of patients with dysthymia or depression NOS (but not meeting criteria for major depression) have a non-reactive mood. This subgroup has much in common with patients who meet criteria for melancholia (1). If you choose "non-reactive" the assessment and treatment steps will be the same as for major depression, melancholic type. We will then ask if the depression is of marked severity: if so, the patient will be considered for first-line use of a tricylic or comparably powerful antidepressant (e.g. - venlafaxine or mirtazapine) rather than an SSRI.

Assessment of mood reactivity A mood non-reactive depression is one in which mood does not recover, even temporarily, to 50% of normal in response to recreational or social events that normally improve mood (2). Determine if the precipitants have only slightly improved mood in the direction of normal (< 50% = mood nonreactive) versus substantially restored mood (> 50% = mood reactive). Consider patient self-report, clinicians' observations, and reports of others who know the patient well. In the inpatient setting, depressions are melancholic or mood non-reactive in perhaps 10-20% of cases (3). In outpatient settings, the percentage is lower, probably not more than 5-10%. Clinical experience suggests that the distinction is easily made with most patients. Rarely, a patient appears hard to classify because mood improves to about 50% of normal in response to positive events. Consider such patients to be mood non-reactive.

1. Osser DN. A systematic approach to the classification and pharmacotherapy of nonpsychotic major depression and dysthymia. J Clin Psychopharmacol 1993; 13:133-144.

2. Quitkin et al. Phenelzine and imipramine in mood reactive depressives: further delineation of the syndrome of atypical depression. Arch Gen Psychiatry 1989;46:787-93.

3. Schildkraut JJ. Neuropsychopharmacology and the affective disorders. Boston: Little,Brown, 1970.

Clinical Confidence Discussion: Most dysthymic disorder and depression NOS patients have reactive mood. Clinical experience suggests that occasionally the mood is non-reactive. Such patients may have a depression that is similar to a melancholic depression. However, the DSM-4 does not offer melancholia as a specifier for dysthymia or depression NOS.

Loss of mood reactivity has been found to be one of the most characteristic symptoms of melancholic or "endogenous" depressions across the various diagnostic approaches to these entities.¹ Hence, it would seem reasonable to include patients with loss of mood reactivity, even if "only" dysthymic, in the algorithm pathway for melancholia. Indeed, when some of the proposed criteria for melancholia were compared for their ability to predict tricyclic response, mood non-reactivity stood out as a highly predictive symptom.²

Melancholia reflects the most biologic/genetic and severe, and least related to "neuroticism," of the depressive disorders.³ The treatment suggestions will reflect this. Mood reactivity seems like the best marker for who to include in this category.

¹Nelson JC, Charney DS. The symptoms of major depressive illness. Am J Psychiatry 1981;138:1-13.

²Maier W et al. Diagnostic determinants of response to treatment with tricyclic antidepressants: a polydiagnostic approach. Psychiatr Res 1989;30:83-9.

³Kendler KS. The diagnostic validity of melancholic major depression in a population-based sample of female twins. Arch Gen Psychiatry 1997;54:299-304.