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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.



Dr Vinay @

So true the discription of the guilt of having a disease rather than just the blues realted to stressors of life. Either you "what is wrong with me" when you're simply reacting in a normal way from the stress sores of life. Melancholy versus depression I have a disease rather than saying oh this is just the things normally would feel and the stress that I've been under and feeling perfectly acceptable about oneself imiage

Victoria @

As a MD and a sufferer of depression I can only tell you my experiences. I have suffered depression off and on in life but generally manageable and recoverable with time. However, I worked exclusively night shifts for over a year and then became exceptionally depressed after a relatively minor stressor.

To me there was some very distinguishable characteristics of this that fit with melancholia. I'll attempt to stress what I felt was different about melancholia vs just depression. Sadness, lack of energy, feelings of wanting to harm oneself can happen with any depression but this was different.

1. Mood is far worse in the a.m. Waking up I just felt terrible, awful. Usually sleep is restorative for me and I feel improved in the morning. But mornings were by far the worst. Then as the slide stated, I "warm up" during the day.

2. Some difficulty concentrating, and remembering things.

3. A strong sense that this was "out of my hands". And that I felt my cortisol system went into complete hyperdrive. This was not at all how I'd felt with previous depressions. This wasn't remediable with sleep and shutting down. After a while this wore off but still left with profound anergia.

4. SSRI trials were totally ineffective, and psychologist appts were similarly useless. Moreover it affected my sleep disturbance from night shifts.

5. Circadian rhythm disruption. Again, not sure how much of this was due to the night shift effect (I've since quit doing nights) but there were times I'd be up for 2-3 days then sleep 30 hours at a stretch.

6. Have since tried psilocybin as medication trials of SSRI SNRI TCA were not effective and it is exhausting trying new medications and the side effects from them (SSRI in particular made it difficult to sleep, caused bruxism, sometimes worsened SI), etc. The psilocybin was partially helpful after one dose. I feel "partially treated".

7. Willing to try ketamine as a next step. Am not a fan of atypical antipsychotics and feared ECT due to possible cognitive effects. But if fails to improve would consider.

In any case, just wanted to share my thoughts that this felt much more "organic" and profound than any previous depression, as this was out of my hands. And the morning symptoms were profound, much different from before. Those may be helpful screening tools, I don't know. I am only a N of 1.

I've continued to work as a physician but trust me, it is not easy to work when you are having these symptoms and although there were no medical mistakes it may be difficult to provide good care when you are feeling that way.

Best, Gordon

gordon @

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 @


Jennie @

I agree wholeheartedly. I think (maybe) I understand the differences as pertaining to different diagnoses! I would certainly as Nassir Ghaemi and Agop Akiskal (my mentors in the Mood Disorders); I would not enter my comments here b/c I might just add confusion and would not want to do that. Nassir and Hagop would more than suredly clarify. And they are not the only ones, they are just my references. I am asking Nassir and will return when I get his response. Greetings and thanks, Dan Pistone, MD Psychiatrist

Daniel @

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 @

also helps depressed mood through stabilization

lisa @

Psychostimulants can be much more effective in treating Melancholia than lithium. I would love to see these drugs being given sooner instead of usually only after many years of suffering.

Jennie @

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 @

"Depression" is a confusing term as well because we shouldn't term a disorder using the same word used to describe an emotion.
Neurotransmitters such as serotonin are implicated in depression? Is that why doctors continue to give patients SSRI's? I don't know of any research that has shown an imbalance of Serotonin is responsible for depression and I haven't seen studies showing SSRI'S are more effective than placebo! Please let me know if I have just missed these studies because I'd LOVE to read them.

Jennie @

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

Amany @

The different types respond differently to different treatments. Example, Melancholia responds to medication better than talk therapy. Depression can be treated using talk therapy.
It helps to know what the patient is suffering from in order to treat them correctly.

Jennie @

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 @

Presently reading a book based on this very topic. If I could photograph and paste the cover I would. It's brilliant. Reviews this history and psycho dynamics around both subject and how to distinguish between the two. Cf.
THE NEW BLACK - Mourning, Melancholia and Depression - Darian Leader

Boni @

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