Melancholic depression is a form of major depressive disorder (MDD) which presents with melancholic features. Although melancholic depression used to be seen as a distinct disorder, the American Psychiatric Association (APA) no longer recognizes it as a separate mental illness. Instead, melancholia is now seen as a specifier for MDD — that is, a subtype of major depressive disorder.
MDD is a significant mental health condition characterized by persistent and intense feelings of sadness and hopelessness. The disorder can affect many areas of life, including work, school, and relationships. It may also impact mood and behavior as well as various physical functions, such as appetite and sleep. People with MDD often lose interest in activities they once enjoyed and have trouble getting through the day. Occasionally, they may also feel as if life isn’t worth living.
The severity and type of MDD symptoms vary greatly from person to person. Some people experience traditional symptoms of MDD, while others develop additional syndromes, such as melancholia and catatonia. Most symptoms can be managed with treatment, which may consist of medication and talk therapy.
People with melancholic depression may experience symptoms of MDD, such as:
- persistent feelings of extreme sadness for a long period of time
- loss of interest in activities that were once enjoyable
- having a lack of energy or feeling fatigued
- feeling anxious or irritable
- eating too much or too little
- sleeping too much or too little
- experiencing changes in body movement (for example, jiggling your leg when you didn’t before)
- difficulty concentrating, making decisions, and remembering things
- thinking or talking about death or suicide
- suicide attempt
They may also experience melancholic features of MDD, which include:
- loss of pleasure in all or most daily activities
- lack of reactivity to positive news and events
- deep feelings of despair and worthlessness
- sleep disruptions
- significant weight loss
- persistent feeling of excessive or inappropriate guilt
- symptoms of MDD that are worse in the morning
Melancholic features are more likely to occur in people who frequently experience severe symptoms of MDD. They are also seen more often in those who have MDD with psychotic features.
The APA no longer recognizes melancholic depression as a distinct form of depression, and it is listed as a type of MDD. When someone shows signs of depression and melancholia, the diagnosis is “major depressive disorder with melancholic features.” To make this diagnosis, a doctor will usually ask some of the following questions:
- Do you have difficulty getting out of bed and getting started in the morning?
- Are your symptoms generally worse in the morning or in the evening?
- How do you sleep?
- Has there been a change in your sleep patterns?
- What does a typical day look like for you?
- Has your daily routine changed recently?
- Do you enjoy the same things you once did?
- What, if anything, improves your mood?
- Do you have more trouble concentrating than usual?
MDD is often treated with newer antidepressants, such as selective serotonin reuptake inhibitors (SSRIs). These include well-known medications, such as fluoxetine (Prozac), citalopram (Celexa), or paroxetine (Paxil). However, many people who have MDD with melancholic features may respond better to older antidepressants such as the tricyclic antidepressants or monoamine oxidase inhibitors (MAOIs), as well as serotonin-norepinephrine reuptake inhibitors, such as venlafaxine (Effexor). These medications help inhibit the breakdown of serotonin and norepinephrine in the brain, resulting in higher amounts of these “feel good” chemicals. Sometimes, certain atypical antipsychotics such as Abilify (aripiprazole) may be used to augment the effects of antidepressants.
In addition to medication, talk therapy is commonly used to treat people who have MDD with melancholic features. A combination of these two treatment methods is usually more effective than either approach on its own. Talk therapy involves meeting with a therapist on a regular basis to discuss symptoms and related issues. It can show people how to:
- adjust to a crisis or other stressful event
- replace negative beliefs and behaviors with positive, healthy ones
- improve communication skills
- cope with challenges and solve problems
- increase self-esteem
- regain a sense of satisfaction and control in life
Group therapy can help in a similar way and give you the ability to share your feelings with people who can relate.
In severe cases, electroconvulsive therapy (ECT) may be performed to help relieve symptoms of MDD with melancholic features. This treatment involves attaching electrodes to the head that send electrical impulses to the brain, triggering a mild seizure. ECT is now considered a safe and effective treatment for mood disorders and mental illnesses, but there’s still a stigma surrounding it. As a result, it may not be used as the primary treatment for symptoms of melancholia. However, a combination of medication, talk therapy, and ECT may be the best treatment for MDD with melancholic features.
You asked, we answered
- What is the outlook for someone who has major depressive disorder with melancholic features?
A number of variables will determine the outlook. First and foremost is patient response to medication, therapy, and other treatments. If psychopharmacologic and therapy approaches fail, talk with your doctor about the appropriateness of electroconvulsive therapy (ECT). Although stigma still surrounds this technique, it is actually relatively safe and effective in treating major depressive disorders. It is important to note that the depression can be effectively treated.- Timothy J. Legg, PhD, PMHNP-BC