What Is Melancholic Depression?

Symptoms and Causes

Older people are at increased risk for melancholia
Older people are at increased risk for melancholia. MarcelTB/Moment/Getty Images

Melancholia is a profound presentation of severe depression. With this form of depression, there is a complete loss of pleasure in all or almost everything.

The term 'melancholia' is one of the oldest terms used in psychology. It has been around since Hippocrates introduced it in the fifth century B.C., and it means "black bile" in Greek. This is fitting because Hippocrates believed that an excess of black bile, one of what he labeled "The Four Humours," caused melancholia.

The symptoms he categorized under melancholia are nearly identical to the symptoms we use today, including fear, not wanting to eat, insomnia, restlessness, agitation, and sadness. 

Causes 

The start of these episodes is usually not caused by a specific event, and even when something good happens, the individual's mood does not improve, not even for a short time.  

To clarify the type of mental health disorder you have, your doctor may use specifiers. For instance, if you have severe depression with symptoms of melancholia, you may be diagnosed as having major depressive disorder (the broader illness) with melancholic features (the specific symptoms).

Other issues that may be considered include:

  • Bipolar disorder
  • Cyclothymic disorder
  • Persistent depressive disorder
  • Disruptive mood dysregulation disorder
  • Premenstrual dysphoric disorder
  • Depression that's caused by illicit drugs, prescribed medications or some physical illness

    Older people, inpatients, and those who exhibit psychotic features are at greater risk for melancholic depression.

    Symptoms 

    To be diagnosed with melancholic features, you must have at least three of these symptoms:

    • A distinct quality of depressed mood characterized by profound despondency, despair, or emptiness: You're not simply sad or down due to a life event, such as the death of a loved one. What you're feeling is greater than that.
    • Depression is consistently worse in the morning
    • Early morning waking of at least two hours earlier than normal
    • Psychomotor disturbances of either retardation, the slowing of normal movement, or agitation, increased and/or irregular movement
    • Anorexia or weight loss
    • Excessive or inappropriate guilt

    Treatment 

    For melancholic depression, medication is almost always a must because it seems to have a biological root. In other words, since it is usually not triggered by outside circumstances, the causes appear to be mainly due to genetic makeup and brain function, necessitating a medication that works on biological causes like brain function.

    Types of antidepressants that may be used for melancholic depression include:

    • Selective serotonin reuptake inhibitors (SSRIs): These medications work by changing the way the neurotransmitter serotonin works in the brain, improving mood. Typical kinds include Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), and Lexapro (escitalopram).
    • Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs affect the way both serotonin and norepinephrine work in the brain. Common kinds are Cymbalta (duloxetine) and Effexor (venlafaxine).
    • Norepinephrine and dopamine reuptake inhibitors (NDRIs): Wellbutrin (bupropion) is the only medication in this class that affects norepinephrine and dopamine.
    • Atypical antidepressants: These medications affect brain chemicals which seem to improve mood. Examples of medicines in this category are Remeron (mirtazapine), Oleptro (trazodone), Brintellix (vortioxetine), and Viibryd (vilazodone).
    • Tricyclic antidepressants (TCAs): These are first-generation of antidepressants and may have more side effects than newer versions. This class includes Tofranil (imipramine), Pamelor (nortriptyline), and amitriptyline.
    • Monoamine oxidase inhibitors (MAOIs): This is another older class of antidepressants that can have serious side effects but may be a good option for certain people. The main medications in this class are Parnate (tranylcypromine), Nardil (phenelzine), and Marplan (isocarboxazid).

      Sources:

      Telles-Correia, D, Marques, JG. "Melancholia before the twentieth century: fear and sorrow or partial insanity?" Frontiers in Psychology. 2015;6:81. 

      Dewhurst WG. "Melancholia and Depression: From Hippocratic Times to Modern Times." Journal of Psychiatry and Neuroscience. 1992;17(2).

      "Depression (major depressive disorder)." Mayo Clinic (2015).

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