Melancholic Depression

Melancholic Depression (also known as Major Depressive Disorder with melancholic features in the DSM-5, and previously as “endogenous depression”) is a subtype of depression characterized by a severe loss of pleasure and prominent physical symptoms. Classic melancholic depression features include insomnia, weight loss, and psychomotor changes. The DSM-5 specifier “with melancholic features” is also used as a diagnosis specifier in bipolar disorder.

  • Melancholic depression is considered to be a more “biologically-based” depression.
  • Individuals often have hypercortisolemia and there is a strong genetic and familial association in melancholic depression. Theories on the pathophysiology of melancholic depression include disruption of the HPA axis.[1][2]
  • There is concern from some clinicians that the proper diagnosis and treatment of melancholic depression has been overshadowed by the introduction of mass-marketed SSRIs.[3]
    • There is some evidence to suggest that melancholic depression responds better to TCAs and ECT.[4][5]
  • Females are less affected in melancholic depression, and there is typically an older age of onset.
  • Melancholic depression often progresses into psychotic depression (where delusions are usually nihilistic in nature).
  • Melancholic depression is shorter in duration and more episodic. It also features diurnal variation (early-morning worsening of mood, with an afternoon slump or evening worsening).[6]
Criterion A

1 of the following is present during the most severe period of the current episode:

  1. Loss of pleasure in all, or almost all, activities
  2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)
Criterion B

3 or more of the following:

  1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood,
  2. Depression that is regularly worse in the morning
  3. Early-morning awakening (i.e. - at least 2 hours before usual awakening)
  4. Marked psychomotor agitation or retardation
  5. Significant anorexia or weight loss
  6. Excessive or inappropriate guilt
  • The specifier “with melancholic features” is used if these features are present at the most severe stage of the episode.
  • Melancholy means there is a near-complete absence of the capacity for pleasure, not just diminished pleasure. A tip for evaluating the lack of reactivity of mood is that even highly desired events (e.g. - winning the lottery) are not associated with marked brightening of mood.
    • Either the mood does not brighten at all, or it brightens only partially (e.g. - up to 20% to 40% of normal for only minutes at a time).
    • The “distinct quality” of mood that is characteristic of the “with melancholic features” specifier is experienced as qualitatively different from that during a non-melancholic depressive episode.
    • A depressed mood that is described as merely more severe, longer lasting, or present without a reason is not considered distinct in quality, and does not meet the criteria for melancholic features.
    • Psychomotor changes are nearly always present and are observable by others.
    • Melancholic features has only a modest tendency to repeat across episodes in the same individual.
    • There is typically a lower rates of depressive temperament (i.e., personality traits) in those with melancholic features.[7]
    • Individuals psychiatric inpatients, as opposed to outpatients; are less likely to occur in milder than in more severe major depressive episodes; and are more likely to occur in those with psychotic features.