Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness

Successfully weaving together the long and complex history of melancholic depression as a severe mood disorder with strong biological underpinnings and a distinctive clinical profile.

Michael Alan Taylor and Max Fink; New York:
Cambridge University Press, 2006
544 pages
$150 (hardcover)

Melancholia is a word more often associated with Hippocratic humors and Romantic poets than modern neurobiology.1 In this extensively researched and well-written text, authors Taylor and Fink successfully weave together the long and complex history of melancholic depression as a severe mood disorder with strong biological underpinnings and a distinctive clinical profile.

Melancholia, the authors argue, is to be distinguished from, and has been eclipsed by, the multiplication of diagnostic categories for less evidence-based affective disorders in DSM. It is this failure to recognize melancholia as a disorder with characteristic neuroendocrine and pathophysiological signs and symptoms, which respond to what the authors call "broad-spectrum" antidepressants and electroconvulsive therapy (ECT), that has led to the disappointing results of STAR*D and increasing concerns about treatment-resistant depression.2

In 15 chapters, the book covers the history, definition, psychopathology, laboratory testing, mental status examination, differential diagnosis, suicide risk, role of ECT, pharmacotherapy and alternative treatments, pathophysiology, and future directions of melancholia. What emerges is a picture of an ancient disorder with a strong genetic component and high risk of suicide that often presents with catatonia, psychosis, and neurovegetative symptoms.

The book elegantly integrates genetic predispositions, environmental stressors, temperament, and neurophysiology to both explain what is known about the causes of melancholia and to chart a research agenda. The return of the diagnosis of melancholia restores the utility of the once celebrated, and then rejected, dexamethasone suppression test as a biological marker, and reestablishes the tricyclic antidepressants, lithium, and ECT as the treatments of choice for melancholic depression.

The growing influence of the pharmaceutical industry on psychopharmacological research and clinical practice is identified as one of the most powerful forces underlying this expansion and subsequent attrition of mood-disorder conceptualization and the neglect of evidence-based treatments such as ECT. Although some experts may not agree with the book's inclusion of manic depression as encompassed within the melancholic dimension, or the authors' view of the place of antidepressants in the treatment of bipolar disorder, the overall call for a return to more empirically grounded diagnoses of affective disorders is compelling and timely.

This is a useful book for practicing psychiatrists and other mental health professionals, but it should be required reading for younger clinicians and residents trained under the hegemony of categorical classification systems and serotonin reuptake inhibitors who may never have been exposed to alternative diagnostic modes or older treatment modalities. The chronicity, low response rate, and even lower remission rate for mood disorders demonstrated in recent studies and everyday practice, these authors would argue, is at least in part the result of psychiatry's lack of rigor and consistency in applying the neurobiological model of diagnosis and treatment.3 The most powerful lesson to be learned from Taylor and Fink's exhaustive study is that melancholia is a qualitatively different syndrome for which we ironically have very effective and safe treatments that may reduce the incredible suffering patients with severe depression from Cowper to Solomon have endured.4

References:

References 1. Jackson SW. Melancholia and Depression: From Hippocrates to Modern Times. New Haven, Conn: Yale University Press; 1986.
2. Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163:28-40.
3. Malhi GS, Parker GB, Crawford J, et al. Treatment- resistant depression: resistant to definition? Acta Psychiatr Scand. 2005;112:302-309.
4. SolomonA. The Noonday Demon: An Atlas of Depression. New York: Touchstone; 2002.