Whither Melancholia?

After formulating and signing “Melancholia: A Declaration of Independence,” an international cadre of psychiatrists recently launched a campaign to have the upcoming DSM-V recognize melancholia as a distinct syndrome rather than as a specifier for the mood disorders of major depression and bipolar disorder.

Australian psychiatrist Gordon Parker, MD, PhD, sent a position paper, “Whither Melancholia? The Case for Its Classification as a Distinct Mood Disorder,” written by 17 experts^a in the field, to David J. Kupfer, MD, chair of the DSM-V Task Force, and to members of the DSM-V Mood Disorders Work Group.

Jan Fawcett, MD, work group chair, explained to Psychiatric Times that the work group has 4 major subgroups: major depression, bipolar disorder, suicide risk assessment dimension, and anxiety dimension. He gave the “Whither Melancholia?” position paper to the major depression subgroup to let them “chew on it.”

William Coryell, MD, head of the major depression subgroup and the George Winokur Professor of Psychiatry at the University of Iowa’s Carver College of Medicine, has communicated with Parker, lead author of the position paper, Fawcett said. Parker, who is executive director of the nonprofit Black Dog Institute at the Prince of Wales Hospital in Australia and who has conducted extensive research on melancholia and other mood disorders for more than 2 decades, was asked to provide additional evidence. Parker is also Scientia Professor of Psychiatry at the University of New South Wales.

The concept of melancholia is centuries old, said Max Fink, MD, one of the paper’s coauthors and professor emeritus of psychiatry and neurology at Stony Brook University, Stony Brook, NY. Melancholia was encapsulated into Emil Kraepelin’s concept of manic-depressive illness and accepted as such for decades, he added. In DSM-IV, it became a specifier for mood disorders.

“Rush and Weissenburger¹ reviewed the literature on melancholia and its implications for DSM-IV, and concluded that melancholia should be a specifier but not a separate entity,” Fink said. “Yet when Michael Taylor [University of Michigan psychiatrist] and I read the paper, it clearly presented good evidence for melancholia as a separate entity.”

Taylor and Fink² compiled and analyzed studies about melancholia and published their book, Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness in 2006. That same year in May, Fink with Parker joined Edward Shorter, MD, of the University of Toronto, and Tom Bolwig, MD, of Copenhagen University, to launch the Copenhagen conference, “Melancholia: Beyond DSM, Beyond Neurotransmitters.”

“The participants of that conference agreed that the syndrome was best separated from the amorphous descriptions of ‘major depression’ and ‘bipolar disorder’ and recommended it be a separate entity in the DSM-V,” said Fink.

The reports on the study of melancholia and current research were published in a 2007 supplement to Acta Psychiatrica Scandinavica.³

“The DSM-V work group members,” Fink said, “will describe major depression according to formulated criteria. We urge their consideration of melancholic depression as a specific type of depression that should be identified separately. It should have its own classification number and be considered a distinct entity, because it is an identifiable syndrome with recognizable clinical signs, verifying laboratory tests, and validating treatment responses.”

Melancholic depression is a severe illness. Most of those affected end up in hospital settings, Fink said, adding that some 60% of the patients with depression referred for electroconvulsive therapy (ECT) have melancholia.

The current melancholia specifier in DSM-IV does not properly demarcate melancholia, Fink contended.

The position paper authors stated that many of the specifier’s symptoms (eg, anhedonia, psychomotor agitation or retardation, weight loss, excessive or inappropriate guilt) are also criteria for major depression. Thus, they compromise attempts to distinguish melancholia and to clarify its etiological and treatment differences.