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  • Anthony D. Smith LMHC

A Practical Guide to Major Depression

... and the particular dangers of atypical major depression.


  • Major depressive disorder has eight subtypes.

  • Each subtype has unique treatment considerations.

  • Some subtypes are associated with increased suicide risk.

  • Others can indicate endocrinological complications and others harbingers of bipolar disorders.


Major depressive disorder (MDD), perhaps the most common form of depression (APA, 2013), has many subtypes, each with its unique characteristics and treatment needs.


I was recently reviewing this with a supervisee, who felt it was important to know subtypes but found it overwhelming to study them all. I provided a cheat sheet of the most salient points to help them gain basic familiarity. That experience led to this post for people who may be in the same part of the learning curve on MDD.


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Basic Major Depressive Disorder

First, the basic format of MDD is defined as at least five of the following symptoms, present for two or more weeks; one of the symptoms must be one of the first two listed:


  1. Depressed/unpleasant mood (dysphoria)

  2. Lack of ability to experience pleasure (anhedonia)

  3. Inability to concentrate

  4. Preoccupation with worthlessness or feelings

  5. Increased or decreased sleep

  6. Increased or decreased appetite

  7. Fatigue

  8. Agitated or markedly slowed movements.

  9. Thoughts of death, suicidal ideation


MDD Subtypes

MDD subtypes follow the above algorithm but are marked by concentrations of particular symptoms or occur at a particular time. Each of these is briefed below, along with notes about specific interventions and connections to other mental illnesses. Each is linked to an earlier post reviewing the subtype, with references, in-depth.


Anxious Distress: Depression and anxiety have a 60 percent co-occurrence rate, so it’s not surprising that anxiety can be present while someone is depressed. However, anxious distress indicates that anxiety not normally present arises during the MDD episode, or that baseline co-occurring anxiety is significantly exacerbated during the episode. Common expressions of anxiety in the anxious distress form include ongoing panic attacks, or a package of feeling on edge, being tense, and having worrisome thoughts. This obviously compounds the depression and is thus associated with increased suicide risk. Providers ideally focus on dampening the anxiety while addressing the depressive episode. (See "What is Major Depression with Anxious Distress?")


Atypical Features: This MDD is marked by excessive sleep, overeating, weight gain, fatigue to the point of feeling paralyzed, and the ability of the patient’s mood to brighten for some time in the presence of good news and positive events. It is called atypical because it was considered “atypical” to the usual melancholic depression that people went to doctors for centuries past. This subtype tends to have the most enduring episodes and is thus associated with suicide completions. It is also the most common form of depression in bipolar disorders. This means that providers should be vigilant for emerging manic or hypomanic episodes if someone’s MDD fits this profile. (See "Can Atypical Major Depression Signify Bipolar Disorder?")


Catatonic Features: This is when the person experiences a state of waxy flexibility with unresponsiveness, stupor, or agitation that can include echoing what others say and do (echolalia and echopraxia, respectively). I once had a patient who would become so depressed, that he would periodically shut down, lose muscular control, and soil himself. The etiology of catatonia remains poorly understood but responds well to benzodiazepines. Given catatonia can incapacitate someone, it can be dangerous if they live alone, for they might not eat or be able to escape danger. Further, catatonia might be mistaken for marked agitation, present in many with MDD, but not respond to typical interventions. Thus, careful evaluation of agitation should occur, as ECT, an effective catatonia treatment, may be indicated. (See "How to Recognize Catatonia in MDD.")


Melancholic Features: The melancholia profile is marked by a palpably dark and brooding mood, severe insomnia with a tendency for early morning awakening, significant loss of appetite, weight loss, excessive and inappropriate guilt, and sufferers tend to be highly agitated or slow in their movements. Melancholic MDD is a genetic condition, and what is termed a purely “endogenous” depression, meaning it arises from within, in the absence of any psychosocial stressor. It is believed to be generated by significant disruption in the hypothalamic-pituitary-adrenal (HPA) axis. It thus does not respond favorably to psychotherapy alone and requires psychiatric intervention, including electroconvulsive therapy (ECT). In fact, mecancholic MDD sufferers make up the bulk of ECT cases. (See "The Darkest Mood.")


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Houston Major Depressive Online Therapy Appointment

Mixed Features: This indicates that there are at least a few manic-hypomanic symptoms superimposed on the MDD episode. For instance, while depressed, the person might have racing thoughts, feel energized despite lack of sleep, and be impulsive. It is not unusual for people with bipolar disorders to have mixed feature episodes. However, some MDD sufferers never advance to fully mixed episodes (MDD with a full superimposed manic or hypomanic episode) or cycle with manic-hypomanic episodes to make a bipolar diagnosis. However, providers should be vigilant for an emerging true bipolar pattern. Further, this form of depression responds well to mood stabilizer medications that are used in bipolar disorder. Lastly, the added impulsivity and agitation can increase suicide risk if someone is considering suicide. (See "The Spinning World of MDD with Mixed Features.")


Peripartum: This is more than the baby blues, common to many new mothers. Peripartum MDD are episodes directly related to gestation and delivery timeframes. Of course, women prone to MDD while not pregnant are more prone to this experience, but it can happen to any woman. Episodes can be anxious distress, mixed features, or psychotic features. Provided the correlation with mother-child bonding disruption and failure to thrive in extreme cases, or with psychosis leading to infanticide in the most severe instances, anyone working with pregnant women prone to depression should carefully monitor the patient for the slightest emerging symptoms of depression. It is important to collaborate with a psychiatrist, OGBYN, and midwife if available, to best support the woman. (See "Is it Peripartum Major Depression or Just the Baby Blues?")


Psychotic Features: Symptoms like hallucinations and delusions, most associated with schizophrenia, aren’t uncommon in other disorders. About 20 percent of people with MDD experience one or both during their depressive episode, but only while depressed. It is pervasive enough that psychiatry is inevitable for antidepressant and antipsychotic medications, and sometimes ECT. Oftentimes, the content of the hallucinations or delusions can inform clinicians about the root of the depression, for they involve themes of paranoia and guilt, which point to disavowed parts of the self the person is struggling with. (See "MDD Can Include Psychotic Features.")


Seasonal Pattern: This last category relates to MDD, which tends to arise with a decrease or increase in sunlight. While the latter is much rarer than winter depression, some patients, instead of feeling dysphoric as daylight fades, experience an onset with increased light. Individuals can be so sensitive to the season, that the mood can begin changing in the early fall or spring. Once established, seasonal depression is predictable and a person can be prepared for it. A patient with seasonal depression might have a first aid kit: Return to therapy or increase frequency, exercise more, socialize more, perhaps change their diet for more depression-fighting foods, and be evaluated for vitamin D levels in case supplementation is required, as a deficiency is correlated to seasonal patterns. (See "3 Seasonal Depression Myths.")


Houston Major Depressive Therapy Appointment

To find a therapist, visit the Psychology Today Therapy Directory.

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual’s provider or formal supervision if you’re a practitioner or student.


Anthony Smith, LMHC

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