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mood:1-depression:melancholic [on April 30, 2020]
mood:1-depression:melancholic [on August 9, 2023] (current)
psychdb [Primer]
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 ===== Primer ===== ===== Primer =====
-**Melancholic Depression** (also known as **Depression ​with melancholic features**) is a DSM-IV subtype ​of clinical ​depression. The specifier ​with melancholic features” is applied ​if these features are present at the most severe stage of the episode. ​There is a near-complete absence of the capacity for pleasure, not merely a diminution. A guideline ​for evaluating the lack of reactivity of mood is that even highly desired events are not associated with marked brightening of mood. Either mood does not brighten at all, or it brightens only partially (e.g. - up to 20%-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 nonmelancholic ​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. Psychomotor changes are nearly always present and are observable by others. Melancholic features ​exhibit ​only a modest tendency to repeat across episodes in the same individual. ​They are more frequent ​in 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.+**Melancholic Depression** (also known as **Major Depressive Disorder ​with melancholic features** ​in the DSM-5, and previously as "​endogenous depression"​) is a subtype of [[mood:​1-depression:​home|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:​bipolar-i|bipolar disorder]]. 
 + 
 +== History == 
 +  * 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.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC149795/​|Levitan,​ R. D., Vaccarino, F. J., Brown, G. M., & Kennedy, S. H. (2002). Low-dose dexamethasone challenge in women with atypical major depression: pilot study. Journal of Psychiatry and Neuroscience,​ 27(1), 47.]])][([[http://​www.psychiatrictimes.com/​electroconvulsive-therapy/​endocrine-psychiatry-dexamethasone-suppression-test-and-electroconvulsive-therapy|Kellner,​ C. H. (2011). Endocrine psychiatry: the dexamethasone suppression test and electroconvulsive therapy. Psychiatric Times, 28(3), 57-57.]])] 
 +  * 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.[([[http://​www.nejm.org/​doi/​full/​10.1056/​NEJMbkrev57417|Taylor,​ M. A., & Fink, M. (2006). Melancholia:​ the diagnosis, pathophysiology and treatment of depressive illness. Cambridge University Press.]])] 
 +    * There is some evidence to suggest that melancholic depression responds better to TCAs and ECT.[([[http://​www.psychiatrictimes.com/​cme/​update-melancholia/​page/​0/​5|Psychiatric Times: An Update on Melancholia]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​8835647|Perry,​ P. J. (1996). Pharmacotherapy for major depression with melancholic features: relative efficacy of tricyclic versus selective serotonin reuptake inhibitor antidepressants. Journal of affective disorders, 39(1), 1-6.]])] 
 + 
 +== Epidemiology == 
 +  * Females are less affected in melancholic depression, and there is typically an older age of onset.  
 + 
 +== Prognosis == 
 +  * Melancholic depression often progresses into psychotic depression (where [[teaching:​delusions-hallucinations|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).[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3181887/​|Wirz-Justice A. Diurnal variation of depressive symptoms. Dialogues in Clinical Neuroscience. 2008;​10(3):​337-343.]])] 
 + 
 +===== Specifier Criteria ==== 
 +== Criterion A == 
 +''​1''​ of the following is present during the most severe period of the current episode: 
 +  - Loss of pleasure in all, or almost all, activities 
 +  - 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:​ 
 +  - A distinct quality of depressed mood characterized by profound despondency,​ despair, and/or moroseness or by so-called empty mood, 
 +  - Depression that is regularly worse in the morning 
 +  - Early-morning awakening (i.e. - at least ''​2''​ hours before usual awakening) 
 +  - Marked psychomotor agitation or retardation 
 +  - Significant anorexia or weight loss 
 +  - Excessive or inappropriate guilt 
 + 
 +===== Signs and Symptoms ==== 
 +  * 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.[([[https://​pubmed.ncbi.nlm.nih.gov/​37399577/​|Tamada,​ Y., Inoue, T., Sekine, A., Toda, H., Takeshima, M., Sasaki, M., ... & Ohmae, S. (2022). Affective Temperaments in Differentiation Between Melancholic and Nonmelancholic Depression: A Case-Control Study. The Journal of Nervous and Mental Disease, 10-1097.]])] 
 +    * 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.