A 32-year-old female presents with symptoms of atypical depression, including hypersomnia, hyperphagia, leaden paralysis, and rejection sensitivity. She has failed trials of two different SSRIs and venlafaxine. Which of the following antidepressant classes would be a reasonable next step, considering its particular efficacy in atypical depression?

Explanation

MAOIs, particularly phenelzine, have historically shown superior efficacy in atypical depression compared to other antidepressant classes. Atypical depression is characterized by mood reactivity, hypersomnia, hyperphagia, leaden paralysis, and rejection sensitivity. Given the patient's failure on multiple other antidepressant classes (SSRIs and an SNRI), an MAOI would be a reasonable and often effective next-line treatment, despite their dietary restrictions and drug interaction risks. While TCAs can be effective for severe depression, MAOIs have a more established role in treatment-resistant and atypical depression.