6 Key Questions When You Suspect 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.