An Overview of Melancholic Depression

Major depressive disorder (MDD) with melancholic features, also called melancholic depression, is a serious form of MDD that causes people to lose interest in almost all activities, including ones they used to enjoy. It is a particular type of MDD that presents with unique characteristics.

This article discusses the symptoms, causes, and treatment for melancholic depression.

What Is Melancholic Depression?

"Melancholia" was first termed by ancient Greek physician Hippocrates (460–379 B.C.). In the following millennia, the term went through many changes in its definition and application.

Currently, it is described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a subtype or specifier of MDD. It can also be used as a specifier in a bipolar disorder diagnosis.

Melancholic depression tends to be more serious than certain other forms of depression. It can co-occur with other specifiers, such as MDD with a seasonal pattern. It affects about 20%–30% of people diagnosed with MDD.

Symptoms of Melancholic Depression

Symptoms of melancholic depression are similar to those of MDD but are usually more severe.

The hallmark of melancholic depression is a total loss of pleasure or ability to enjoy almost all activities. The scope of this loss is more severe than with general MDD. Pleasure is not just diminished, it is gone almost entirely.

Symptoms of melancholic depression may also include:

• Overwhelming feelings of sadness, despair, despondency, or emptiness
• Excessive feelings of guilt
• Flat affect (showing very little emotional expression or response)
• Loss of appetite, often leading to weight loss
• Sleep disturbances, such as sleeping too much or too little
• Early morning waking (at least two hours before typical morning wake time) and worsened symptoms in the morning
• Slowing down of movement or increased movement/restlessness (observable by others)
  
• Difficulty concentrating and making decisions
• Lack of energy
• Musculoskeletal pain
• Thoughts about self-harm
• Thoughts about (or talking about) death or suicide
• Suicide attempts
  

What Causes Melancholic Depression?

The exact cause of melancholic depression is not known, but it is believed to be more biologically based than certain other types of depression. Social and psychological factors are not as associated with melancholic depression as they may be with other forms of depression.

Researchers have noticed some biological factors associated with melancholic depression, including:

• Genetics and heritability
• Disruption of the hypothalamic pituitary adrenal (HPA) axis (involved in the stress response)
• Hypercortisolemia (too much of the hormone cortisol)

More research is needed to explore these associations and to determine if they play a role in causing melancholic depression.

How Is Melancholic Depression Diagnosed?

There is some debate in the research community about whether melancholic depression should be considered a distinct condition separate from other presentations of MDD.

To meet the diagnostic criteria of melancholic depression as outlined in the DSM-5, a person must demonstrate one or both of the following symptoms:

• Loss of pleasure or enjoyment in all, or almost all, activities
  
• Lack of a reaction to things or events that are objectively pleasurable (does not feel much better when something good happens)

And three or more of the following:

• Profound despondency, despair, and/or emptiness that is not linked to loss or grief
• Low mood that is regularly worse in the morning
• Waking at least two hours earlier than their typical wake time
• Psychomotor changes (slowed movement or agitation/physical restlessness)
• Significant loss of appetite or weight loss
• Excessive or inappropriate guilt
  

Currently, there is no specific test for melancholic depression. After other causes (such as physical conditions) are ruled out, a diagnosis is made based on a discussion with a healthcare provider or mental health professional.

Risk Factors for Melancholic Depression

Some factors associated melancholic depression include:

• Being male
• Older age
• Presence of other mental disorders in which psychotic symptoms are present
• People of advanced age with dementia
  
• People who have a family history of mood issues or suicide

How Is Melancholic Depression Treated?

A combination of care from a primary healthcare provider and a mental health professional is often recommended when treating melancholic depression.

The approach to treatment for melancholic depression may differ from first-line treatments for other forms of depression.

Medication

Antidepressants are the first-line treatment for melancholic depression.

Research indicates melancholic depression may respond better to tricyclic antidepressants (TCAs) than to newer medications such as selective serotonin reuptake inhibitors (SSRIs).

TCAs work by preventing the neurotransmitters serotonin and norepinephrine from being absorbed back into nerve cells in the brain.

Examples of TCAs include:

• Tofranil (imipramine)
• Pamelor (nortriptyline)
• Amitriptyline

TCAs tend to cause more side effects than newer antidepressants, but some of these may ease up over time. Side effects include:

• Dry mouth
  
• Dizziness
• Blurry vision
• Constipation
• Difficulty urinating
• Drowsiness
  
• Weight gain
• Excessive sweating (especially at night)
• Heart rhythm problems (arrhythmia), such as noticeable palpitations or a fast heartbeat (tachycardia)

Psychotherapy

Melancholic depression doesn't tend to respond well to psychotherapy (talk therapy) or social interventions alone. Researchers believe this is due to its strong biological features.

Along with other treatments such as medication, psychotherapy can be helpful as a complementary treatment.

Some therapies that may be recommended include:

• Cognitive behavioral therapy (CBT): CBT identifies problematic thoughts and behaviors and, over time, changes them into healthier thought processes and actions.
• Interpersonal therapy (IPT): IPT involves improving interpersonal relationships or altering expectations of them, as well as developing a stronger support network.
• Family therapy: Family therapy provides a safe space for a group of people who consider themselves family to work through their feelings and improve their communication and interactions.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) has been shown to be a safe and effective treatment for melancholic depression, particularly in severe or difficult-to-treat cases. Research suggests people with melancholic depression respond better to ECT than to SSRIs.

ECT involves the administration of a short electrical stimulation to the brain, which causes a controlled therapeutic seizure, typically lasting 20–90 seconds. It is performed under general anesthesia with muscle relaxation, with the person being asleep for about five to 10 minutes.

ECT usually involves multiple sessions, but the total number of treatments varies by person.

When to See a Healthcare Provider

If you have symptoms of depression, make an appointment with your healthcare provider or a mental health professional. They can help you determine the cause of your symptoms and work with you to develop a treatment plan.

Summary

Melancholic depression is a severe form of major depressive disorder, characterized by extreme difficulty experiencing pleasure. It is often accompanied by psychomotor changes. Melancholic depression has a strong biological association and tends to respond better to tricyclic antidepressants and/or electroconvulsive therapy than to SSRIs or psychotherapy.

A Word From Verywell

While melancholic depression can be scary to experience, it is treatable. It may take time to find the right treatment that works for you, but persistence can ensure the best quality of life. If you think you may have melancholic depression, contact your healthcare provider for next steps.