The 8 Subtypes of Major Depressive Disorder

Source: Ahmed Nishaath/Pexels

October is National Depression Screening Month, and this series of posts will focus on identifying and understanding the palette of variation in major depressive disorder (MDD).

In the United States, MDD is the leading cause of disability for ages 15-44 (Anxiety and Depression Association of America, 2021), and depression in general is the second leading cause of death for ages 10-34 (National Institute of Mental Health). Despite this, the disease still often goes unrecognized, as noted in the earlier posts The Many Faces of Depression, Childhood Depression Can be Tricky to Identify, and Recognizing Depressed Senior Citizens.

The fact that there are subtypes to some forms of depression can contribute to misidentification.

In my years of teaching and supervising, I’ve noticed that many people familiar with depression are aware that there are different depression diagnoses. These usually are narrowed to MDD and dysthymia. Indeed, many are interested to learn that there are other depressive spectrum conditions, including premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation disorder of childhood (DMDD). People seem most surprised, however, to learn that MDD has many subtype manifestations and each has treatment implications.

The Basic MDD Presentation

Usually, students are familiar enough with the basic MDD picture. This, of course, is at least a two-week period where a minimum of five of the following symptoms are experienced (one of which must be depressed mood or anhedonia):

• Depressed mood
• Anhedonia (inability to experience pleasure/lack of interest in previously-enjoyed activities)
• Sleep disturbance (excessive sleep or insomnia)
• Appetite disturbance (significant increase or decrease to the point of noticeable weight gain or loss)
• Fatigue
• Slowing or agitation of movement
• Suicidal thinking/attempts
• Inability to concentrate
• Feelings of guilt or worthlessness

MDD Specifiers and Subtypes

Sometimes, students are also familiar with the fact that MDD can have specifiers for severity of episode, if it is a first or recurrent episode, or in partial or full remission. However, it’s a rare occasion students and supervisees are familiar with recognizing the eight subtype specifiers of MDD. These can be arranged into three categories, as follows:

1. Features superimposed on the MDD episode:

• Psychotic
• Catatonic
• Anxious Distress
• Mixed (implying the presence of some manic/hypomanic symptoms while depressed)

2. A specific period of symptom occurrence:

• Seasonal
• Peripartum

3. Significant nuance to the basic MDD picture:

• Melancholic features
• Atypical features

Melancholic and atypical features are unique in their unusually marked changes in sleep, appetite, and psychomotor activity.

Subtypes Can Vary in Same Patient

While some patients’ subtype of MDD is consistent, many may experience a variety of encounters in their depressive “career.” This can be of a mix-and-match experience wherein a person encounters multiple specifiers at once. For example, Jane may be prone to MDD episodes at any time, but for both of her children’s births, she developed MDD with psychotic features of guilt delusions. She would be diagnosed as experiencing major depressive disorder, recurrent, most recent episode of peripartum onset with psychotic features.

Once understood, it becomes apparent why it’s so important to treatment that these subtypes are recognized. If there is an onset pattern to their occurrence, we can help patients prepare. Other subtypes like melancholic and catatonic types are more biological in nature and require more biologically-based intervention before any talk therapy would be successful. As you'll read in upcoming posts, atypical and mixed features are signs that we should be extra-vigilant for emerging bipolar disorders.

In the upcoming eight-part series about MDD subtypes, readers will not only learn, in detail, how to identify the subtypes, but what treatment implications come with each. We’ll begin Monday, October 4 with the haunting experience of MDD with psychotic features.