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Reversed diurnal variation in depression: associations with a differential antidepressant response, tryptophan:large neutral amino acid ratio and serotonin transporter polymorphisms

Background. Although diurnal variation of mood is a widely recognized symptom of depression, the clinical, neurobiological and psychopharmacological significance of this symptom has not previously been reported. Method. A total of 195 depressed out-patients underwent a detailed clinical and neurobiological assessment, and were then randomized to treatment with either fluoxetine or nortriptyline. Results. Of the 195 depressed patients, 62 had a pattern of reversed diurnal variation (i.e. worse in the evening). Those with reversed diurnal variation had a poorer response to a serotonergic antidepressant, were less likely to have bipolar II disorder, had a higher tryptophan:large neutral amino acid ratio and had different allele frequencies of the polymorphisms in the promoter region of the serotonin transporter. Conclusions. These findings raise the possibility of serotonergic influence on diurnal variation, and that the symptom of reversed diurnal variation is of relevance to antidepressant prescribing.