What Is Melancholic Depression?
Medically reviewed by Steven Gans, MD
Melancholic depression is a form of major depressive disorder (MDD). Melancholic depression is more episodic in nature compared to other forms of depression. This form causes people to lose interest in almost all activities, including ones they used to enjoy. It also presents with a greater risk of suicidal ideation.
It is not always clear why depression develops. Researchers believe a mixture of biological factors, including genetics, are likely at play. Treatment may involve antidepressant medication and psychotherapy (talk therapy).
This article discusses the symptoms and causes melancholic depression, as well as how to diagnose and treat it.
What Is Melancholic Depression?
"Melancholia" was first termed by the ancient Greek physician Hippocrates (460–379 B.C.). In the following millennia, the term went through many changes in its definition and application.
Currently, it is described in the fifth edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5) as a subtype of MDD. It can also be used as a specifier in a bipolar disorder diagnosis.
Melancholic depression tends to be more serious than certain other forms of depression. It can co-occur with other specifiers, such as MDD with a seasonal pattern. As many as 60% of people with MDD experience symptoms of melancholic depression.
Symptoms of Melancholic Depression
Symptoms of melancholic depression are similar to those of MDD but are usually more severe. They also tend to be worse in the morning.
The hallmark of melancholic depression is a total loss of pleasure or ability to enjoy almost all activities. The scope of this loss is more severe than with general MDD. Pleasure is not just diminished, it is gone almost entirely.
In addition to melancholy, there may also be a mixture of physical, behavioral, and psychological symptoms.
Physical Symptoms
Physical symptoms seen in melancholic depression may include:
Musculoskeletal aches, pains, and cramps
Slouched posture
Sweating
Slowed or delayed facial or body movements
Reduced eye movements, such as a fixed gaze, or lack of eye contact
Headaches
Digestive problems, such as upset stomach
Loss of appetite, often leading to weight loss
Sleep disturbances, such as sleeping too much or too little
Early morning waking (at least two hours before typical morning wake time)
Lack of energy
Related: Physical Symptoms of Depression
Behavioral Symptoms
Behavioral symptoms seen in melancholic depression may include:
Increased anger and irritability
Becoming withdrawn, detached, or isolated from others
Engaging in high-risk activities, such as reckless driving or unprotected sex
Greater impulsivity or lack of restraint
Increased use of drugs and alcohol
Inability to maintain or engage in interpersonal relationships
Low sexual desire or problems with sexual performance
Psychological Symptoms
Psychological symptoms seen in melancholic depression may include:
Overwhelming feelings of sadness, despair, or emptiness
Excessive feelings of guilt
Difficulty concentrating and making decisions
Flat affect (showing very little emotional expression or response)
Thoughts about self-harm
Thoughts about (or talking about) death or suicide
Suicide attempts
Help Is Available
If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911. For more mental health resources, see our National Helpline Database.
Related: 9 Common Depression Triggers (and How to Manage Them)
What Causes Melancholic Depression?
The exact cause of melancholic depression is not known, but it is believed to be more biologically based than certain other types of depression. Social and psychological factors are not as associated with melancholic depression as they may be with other forms of depression.
Researchers have noticed some biological factors associated with melancholic depression, including:
Genetics and heritability
Disruption of the hypothalamic pituitary adrenal (HPA) axis (involved in the stress response)
Hypercortisolemia (too much of the hormone cortisol)
More research is needed to explore these associations and to determine if they play a role in causing melancholic depression.
Related: What Is Unipolar Depression?
How Is Melancholic Depression Diagnosed?
There is some debate in the research community about whether melancholic depression should be considered a distinct condition separate from other presentations of MDD.
To meet the diagnostic criteria of melancholic depression as outlined in the DSM-5, a person must demonstrate one or both of the following symptoms:
Loss of pleasure or enjoyment in all, or almost all, activities
Lack of a reaction to things or events that are objectively pleasurable (does not feel much better when something good happens)
Three or more of the following conditions must also be met:
Profound despondency, despair, and/or emptiness that is not linked to loss or grief
Low mood that is regularly worse in the morning
Waking at least two hours earlier than their typical wake time
Psychomotor changes (slowed movement or agitation/physical restlessness)
Significant loss of appetite or weight loss
Excessive or inappropriate guilt
Currently, there is no specific test for melancholic depression. After other causes (such as physical conditions) are ruled out, a diagnosis is made based on a discussion with a healthcare provider or mental health professional.
What May Be Mistaken for Melancholic Depression?
Certain conditions share some characteristics with melancholic depression. Before making a diagnosis, a healthcare provider or mental health professional may want to rule out other possible diagnoses that may better explain your symptoms, including:
Cyclothymic disorder (a milder form of bipolar disorder)
Effects of prescription medication or illicit drugs
A variety of physical ailments
Risk Factors for Melancholic Depression
Some factors associated melancholic depression include:
Being female
Older age
Presence of other mental disorders in which psychotic symptoms are present
People of advanced age with dementia
People who have a family history of mood issues or suicide
How Is Melancholic Depression Treated?
A combination of care from a primary healthcare provider and a mental health professional is often recommended when treating melancholic depression.
The approach to treatment for melancholic depression may differ from first-line treatments for other forms of depression.
Related: What Types of Therapy Are Helpful for Depression?
Medication
Antidepressants are the first-line treatment for melancholic depression.
Research indicates melancholic depression may respond better to tricyclic antidepressants (TCAs) than to newer medications such as selective serotonin reuptake inhibitors (SSRIs).
TCAs work by preventing the neurotransmitters serotonin and norepinephrine from being absorbed back into nerve cells in the brain.
Examples of TCAs include:
Tofranil (imipramine)
Pamelor (nortriptyline)
TCAs tend to cause more side effects than newer antidepressants, but some of these may ease up over time. Side effects include:
Dry mouth
Dizziness
Blurry vision
Difficulty urinating
Drowsiness
Weight gain
Excessive sweating (especially at night)
Heart rhythm problems (arrhythmia), such as noticeable palpitations or a fast heartbeat (tachycardia)
Follow Directions Carefully
It's important to closely follow your healthcare provider's and pharmacist's directions for your medication. Do not stop or change your medication without consulting your healthcare provider.
Discuss with your healthcare provider any side effects you feel while on antidepressants, whether or not you think they are related to the medication.
Psychotherapy
Melancholic depression doesn't tend to respond well to psychotherapy (talk therapy) or social interventions alone. Researchers believe this is due to its strong biological features.
Along with other treatments such as medication, psychotherapy can be helpful as a complementary treatment.
Some therapies that may be recommended include:
Cognitive behavioral therapy (CBT): CBT identifies problematic thoughts and behaviors and, over time, changes them into healthier thought processes and actions.
Interpersonal therapy (IPT): IPT involves improving interpersonal relationships or altering expectations of them, as well as developing a stronger support network.
Family therapy: Family therapy provides a safe space for a group of people who consider themselves family to work through their feelings and improve their communication and interactions.
Related: Types of Therapy for Mental Health
Electroconvulsive Therapy (ECT)
Electroconvulsive therapy (ECT) has been shown to be a safe and effective treatment for melancholic depression, particularly in severe or difficult-to-treat cases. Research suggests people with melancholic depression respond better to ECT than to SSRIs.
ECT involves the administration of a short electrical stimulation to the brain, which causes a controlled therapeutic seizure, typically lasting 20 to 90 seconds. It is performed under general anesthesia with muscle relaxation, with the person being asleep for about five to 10 minutes.
ECT usually involves multiple sessions, but the total number of treatments varies by person.
How Long Does Melancholic Depression Last?
Melancholic depression is episodic in nature. Research suggests people with melancholic depression have more frequent episodes—and episodes that are more severe—than other forms of depression, but that the episodes tend to be shorter in duration. An episode must last at least two weeks to meet the criteria of melancholic depression.
Learn More: Electroconvulsive Therapy Is Safe for Treating Strong Cases of Depression
When to See a Healthcare Provider
If you have symptoms of depression, make an appointment with your healthcare provider or a mental health professional. They can help you determine the cause of your symptoms and work with you to develop a treatment plan.
If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.
Related: What Does Depression Feel Like?
Summary
Melancholic depression is a severe form of major depressive disorder, characterized by extreme difficulty experiencing pleasure. It is often accompanied by psychomotor changes, such as slowed movements or tremors. Melancholic depression has a strong biological association and tends to respond better to tricyclic antidepressants and/or electroconvulsive therapy than to SSRIs or psychotherapy.
Read the original article on Verywell Health.