In everyday language, melancholy refers to a state of gloom and wistfulness.
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In 400 B.C., the Greek philosopher Hippocrates theorized that the human body contained four major fluids: blood, black bile, yellow bile, and phlegm. A human grew sick when these fluids were out of balance in their body. An excess of black bile would cause someone to become despondent and fearful. The Greeks call this condition melancholia. It became the first term used for depression and the first way it was ever studied or diagnosed.
During the Renaissance, Europeans considered melancholia a sign of creative genius. They glorified it through art, fashion, and written works. But by the 18th century, the term returned to its clinical roots. Around the 19th century, people used the term depression synonymously with melancholia. Sigmund Freud’s writings in On Murder, Mourning and Melancholia helped modernize the concept of melancholia into what we know today as melancholic depression.
Today, melancholia is no longer listed as a standalone mental health issue. Instead, it is listed as a specifier for depressive disorders. Rather than receiving a diagnosis for melancholia, a person is more likely to receive a diagnosis of major depression (MDD) with melancholic features.
The DSM states melancholic depression is more likely to occur in people receiving inpatient care or those who have experienced major depression. It may appear alongside seasonal affective depression in some people, since its prevalence is greater when sunlight and temperature levels are low. The condition might also co-occur with postpartum depression or psychosis. In older individuals, melancholic depression is sometimes mistaken for dementia.
To be diagnosed with melancholic depression, a person must present at least one of the following symptoms:
- Loss of enjoyment from all (or nearly all) activities
- Lack of positive response to objectively pleasurable events
And at least three of the following:
- Depression that is not linked to loss or grief
- Loss of appetite or significant weight loss
- Physical agitation or slowed movement
- Waking at least two hours earlier than normal
- Excessive guilt
- Depressed mood that is worse in the morning
Melancholic depression prompts various biological changes in the body. People with melancholic depression spend more time in the REM phase and less time in the deep sleep phase. They often have elevated cortisol levels, chronic inflammation, and psychomotor issues.
The condition can also affect cognitive processing and performance. Research suggests it impedes working memory, visual learning, and problem solving. These effects are specific to cases of depression with melancholic features.
Like major depression, melancholic depression is often more resistant to treatments than other forms of depression. Medication and electroconvulsive therapy (ECT) are usually the most effective therapies. Experts recommend using psychotherapy as a supplementary treatment. Group therapy and cognitive behavioral therapy can help, especially if the person has co-occuring mental health concerns.
Psychiatrists usually treat melancholic depression with antidepressants. This type of depression often responds better to the older drugs (MAOIs and TCAs) rather than the newer drugs (SSRIs). However, the older drugs tend to have more side effects, so people should take the pros and cons of each drugs into account. People taking medication for mental health concerns are typically advised to continue working with their therapist or counselor while taking medication. Any side effects can be addressed with one's therapist or counselor.
Electroconvulsive shock therapy has also been utilized as an effective treatment for melancholic depression. In ECT, doctors deliver electrical currents to a person’s brain, causing short, controlled seizures. Doctors may use ECT in severe cases of depression that don’t respond to other treatments. Since there is a lack of research on ECT’s potential side effects, experts only recommend it as a last resort.
- Melancholia and disaffected mood: Lenn, 62, seeks counseling to help with a perpetual state of worry. Ze is always anxious about something, whether it’s an upcoming dental appointment, bad weather, or house repairs. The transition into colder weather has made these feelings even more prominent, and Lenn has noticed it's lately been difficult to wake up and function properly in the morning. Though Lenn is not diagnosed with melancholic depression, a therapist works with zo to sort through challenging feelings and adjust, emotionally and physicially, to the change in weather. Lenn invests in a lamp designed to ease seasonal depressive issues and commits to journaling every morning, which is when the fears and worry ze experiences are strongest. Lenn continues to engage in talk therapy to examine underlying issues and maintain general well-being.
- Melancholic depression and antidepressants: Yasmin, 32, has just had her second child. She feels buried under the weight of postpartum depression. Her depression is much worse than it was after her first child, and her partner urges her to seek a psychiatric evaluation and psychotherapy. An assessment determines that in addition to postpartum depression, Yasmin is experiencing melancholic symptoms. Those include a disinterest in spending time with her children, inhibited motor skills, and constant guilt. In addition to therapy, her psychiatrist recommends an antidepressant medication. As she is not breastfeeding, Yasmin decides to begin with a low dose. She also joins a group therapy session of other mothers with postpartum depression. Their stories help ease Yasmin’s guilt, and gradually she regains her enthusiasm about family events and maintaining friendships.
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