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6 Key Questions When You Suspect Melancholia

6 Key Questions When You Suspect Melancholia

  • Most depressed people acknowledge impaired concentration and other related symptoms—but skilled clinicians can distinguish between non-melancholic depression and melancholia. How? They ask the right questions. Scroll through the slides for more on melancholia.

  • DSM-5 accords melancholia the designation of a “specifier” rather than giving it subtype status. To some, this compromises its differentiation from major depression. In DSM-5, psychomotor disturbance, early morning awakening, weight loss, anhedonia, excessive or inappropriate guilt are criteria for both melancholia and major depression.

  • In this model, all criteria are essentially viewed as carrying equivalent weight. However, skilled clinicians operate formally or informally to a prototypic model (employing a pattern analytic approach and asking themselves whether the patient’s clinical features approximate the condition being scrutinized) and a Bayesian model wherein they assign differential weights to different clinical features.

  • The likelihood of melancholia is increased if there is a family history of depression, bipolar disorder, or suicide; if episodes are likely to “come out of the blue” and are more severe and persistent than expected in relation to any stressors; and if the patient acknowledges a loss of agency (that it feels more like an imposed “disease” rather than a logical reaction to life stressors).

  • In exploring the possibility of melancholia, the clinician can ask general questions and then move to closed questions. Observe the patient. In severe melancholia, he or she may be monosyllabic and slow to move. In assessing a new patient, seek information from a corroborative witness—a relative or friend. If the patient has a melancholic pattern, he will be described or acknowledged as insular and asocial during episodes and, often on specific questioning, as “losing the light in his eyes.”

  • Those with severe melancholia may report total mood non-reactivity, but most patients will acknowledge some level of reactivity—such as when they see their grandchildren. The key issue is that any mood reactivity is transient and/or superficial.

  • DSM-5 symptom criteria for melancholic features—anhedonia, non-reactive mood, early morning wakening, depression worse in the morning, psychomotor disturbance, loss of appetite and weight—capture most of the historically favored endogeneity symptoms. Anhedonia can again be absolute but, if not so, still tends to be distinctive.

  • Anergia, and not simply fatigue, weighs heavily in assessment, and those with true melancholia might state that it is distinctive—they may just move from the bed to the couch in front of the TV. Ask if they neglect their hygiene. Those with true melancholia, even if punctilious about their hygiene when euthymic, may not wash for days.

  • The majority of those with melancholia will report mornings as distinctly worse, and that they “warm up” as the day progresses. A small percentage report a secondary drop at sunset.

  • Most depressed people will acknowledge impaired concentration. In those with non-melancholic depression, it is usually a reflection of worrying thoughts and distractibility; in melancholia, the patient describes an inability to take in and register information—thus, the “fogginess” descriptor.

  • This question seeks to determine whether there is a distinct psychomotor disturbance. There is no laboratory test or definitive diagnostic strategy for melancholia. The diagnosis relies on skilled clinical assessment. However, in terms of prognosis, we can be far more confident that, unless the melancholia has a structural cause, symptom remission is an achievable clinical objective.

  • For more information, see An Update on Melancholia, by Gordon Parker, MD, on which this slideshow is based.

View the slides in PDF format.


Let's read: "DSM-5 symptom criteria for melancholic features—anhedonia, non-reactive mood,
early morning wakening, depression worse in the morning, psychomotor disturbance, loss of appetite and weight".

Half of the criteria symptoms are mood related - anhedonia, non-reactive mood, depression worse in the morning. The others - early morning wakening, psychomotor disturbance [assuming agitation], loss of appetite and weight - are symptoms of high (very high) arousal.

The criteria for Major Depression is confusing because it covers all subtype of the disorder under one diagnosis. They (criteria) must be bewildering for a non-psychiatrist prescriber. How could it be that the same diagnosis covers insomnia or hypersomnia (which one?), psychomotor agitation or retardation (which?), significant weight loss and also weight gain, decrease and also increase the appetite? How can we treat divergent symptoms with a medication approved for "depression" as a whole? And what are the medications that work equally well on the opposite sides of the spectra?

We need to fix the classification (make it more biological, less descriptive and dynamic) to avoid these conundrums in the future.

Michael @

I am bewildered by some of the vehemence and negativity in the responses to a valid exploration of different types of depression, each type responding to in fact differing types of treatment. The differentiation isn't, in my experience, so difficult but appropriate management of the wayward neurotransmitters can be.

Marion @

I was thinking the very same thing, Marion! Anyone who has interviewed a number of generally depressed patients discerns that there are distinct flavors of depression. Why could this be important to know? One reason, melancholics respond better to certain drug regimens than non-melancholics (e.g. augmentation with a small dose of lithium).

Ashley @

The first half of the message posted all of its own accord . . .

But what is really, seriously, surprising are the number of folks seeming to be criticizing anyone even for examining such a topic. It was always my impression that most of us went into this broad field because of being intrigued by the workings of human brains, whether they are functioning well or abysmally. I remain so—even after a quite long while of practicing.

Perhaps, Marion, it is just the time period in which we find ourselves. So many people seem to be angry about almost anything and everything, and feel the need to vent it publicly. This may be just another instance.

Ashley @

So would we also be looking to trat melancholic depression? I think maybe melancholy could be left alone, and dealt with talk therapy alone, where as clinical depression might need medication or more intense treatments....

hm. this is interesting.

Karolina @

lithium? for melancholia? it is a stabilizer, not an antidepressant

Getting @

Melencholia is an outdated medical term! It is antiquated and by mid-century it was shuned and only used in poetry and art to depict atmosphere and mood. Freud and a lot of great thinkers also stated it was a normal part of the grieving process. Why would we want to cure a natural process that occurs due to loss?

I do not think this has anything to do with neurotransmitters, and if it does are we not forgetting our own intirinsic, built in capabilities to heal on our own?

Karolina @

There is such a thing as mental illness. There is such a thing as diagnosing. Not everyone is on a continuum so natural healing doesn't bring everyone back to normal. Suffering is real. Not all suffering is treatable, yet, but we do know a few things and we ought to keep records and share what we think we've figured out.

anna @

Hello @Karolina so are you saying in all the years of research and development of mental illness after freud , his opinion is current? and that the author only ever treats patients whose dog died yesterday?

phillip @

Why do we have to differentiate bet. Depression é or w/out melancholic feature?

Amany @

Ellie Grennan

helen @

Better to use a QEEG brain map to predict medication response.

Gary @

Wow. Distinguishing between depression and melancholia looks like a toughie.

David @

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