Melancholic depression is a severe form of depression believed to be caused by internal, biological rather than external factors. It is characterized by intense feelings of sadness and hopelessness and an inability to experience pleasure in response to once-pleasurable activities and events.
Melancholic depression may be hard to treat. Common treatments include a combination of medication, therapy, and lifestyle changes.
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Melancholic depression, or melancholia, is a subtype of major depressive disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Those diagnosed with melancholic depression will be classified as having “major depressive disorder with melancholic features.”
Some people may experience the symptoms of melancholic depression more intensely than others. But it is generally characterized by severe and prolonged feelings of sadness, anxiety, guilt, and an inability to find pleasure in positive events and activities. It is also known to affect sleep, appetite, and physical movement.
Melancholic depression can be debilitating and take a toll on your health and all aspects of your life.
Melancholic depression may have more severe symptoms than other forms of depression and may be harder to treat. However, symptoms can be managed, and, in some cases, remission may even be possible with the help of medication, a good treatment plan, and health professionals.
The onset and maintenance of melancholic depression are thought to be highly biological and inherent. Biological causations include genetics, family history, hormones, and brain structure and chemistry. Past trauma and stressful or negative life events may also be contributing factors.
Common causes of melancholic depression are as follows:
It has been observed that melancholic depression is more frequently seen among individuals who have a family history of depressive illness without alcoholism and mood disorders.
Research¹ has shown a connection between elevated levels of the hormone cortisol in the blood and melancholic depression. Raised cortisol levels in the bloodstream are potentially caused by the hypothalamus, pituitary gland, and/or adrenal gland not functioning and interacting with one another as they should.
According to this 2015 study,² a change in neuron (messenger cells within the brain) activity and efficiency may be related to the onset of melancholic depression. This change in the brain network may alter reactions or reduce the inability to react appropriately or at all. A reduction in the size of certain areas of the brain, such as the hippocampus, may also trigger melancholic depression.
Traumatic and stressful life events are not likely to be significant or necessary causes of melancholic disease compared with biological factors. However, it is still important to consider them as a contributing cause, especially among those who are vulnerable or struggle with depression.
Men are more likely than women to be diagnosed with melancholic depression. However, the reasoning behind this is not well understood.
Melancholic depression tends to develop later in life. In some cases, those of advanced age displaying symptoms of melancholic depression can be misdiagnosed with dementia.
The symptoms of melancholic depression are similar to the general symptoms of depression; however, they are likely to be more intense and persistent. Melancholic depression is also characterized by its acute onset, with symptoms that last at least two weeks and impair daily activities.
The two main hallmarks of melancholic depression are:
A complete, or near-complete, inability to find pleasure in positive events, situations, or things that once brought about feelings of joy or happiness
The mood does not improve in response to pleasurable events, situations, or things — not even for a short period
It may be common to experience both symptoms. However, many may experience either one or the other.
Other common symptoms are:
Depression that is consistently worse in the morning (This is a symptom experienced by a high percentage of those suffering from melancholic depression.)
Early morning awakening (This involves waking up at least two hours before the time you usually wake.)
Excessive and inappropriate feelings of guilt
Dread for the future
Disturbances in attention, focus, and concentration
Loss of appetite, which can lead to significant weight loss over a short period
Impaired physical movements due to altered brain activity (These may be either abnormally slow or fast physical movements, as well as physical movements that were not common for you in the past.)
Thoughts of suicide and death
If you suspect you or someone you know may have symptoms of melancholic depression, it is essential to talk to a doctor who can assess you or your loved one’s symptoms, rule out other causes, and recommend treatment options.
The first step to getting a diagnosis is to see your doctor. Your doctor may refer you to a mental health professional, such as a psychiatrist, for a more in-depth assessment.
To meet the diagnostic criteria for major depressive disorder with melancholic features as outlined in the DSM-5, a person must have one or both of the hallmark symptoms as explained above, which are the inability to experience pleasure in response to positive events and lack of mood change when something pleasing occurs.
They must also have three or more of the following symptoms:
Depression that is worse in the morning
Early morning awakening
Decrease in appetite
A doctor or mental health professional will evaluate the nature, severity, and duration of your symptoms. In addition, your doctor may run further tests to rule out any other health conditions contributing to your symptoms.
Your doctor or mental health professional needs to get an in-depth picture of you and your health before making a diagnosis, as a misdiagnosis can harm your health. Some common disorders may be mistaken for melancholic depression, including:
Persistent depressive disorder
Premenstrual dysphoric disorder
In many cases, the patient’s response to certain treatments, particularly antidepressants and electroconvulsive therapy, and their lack of response to psychotherapy and placebos can help to further validate the diagnosis.
Treatment may vary from person to person. However, the most common and effective medications are antidepressants.
Antidepressants work by helping to increase signaling and communication between the cells in your brain. This can help you feel emotionally stable and allows you to follow a normal daily routine.
Antidepressants fall into three different groups depending on their function:
Tricyclic antidepressants: Examples include amitriptyline (Elavil), clomipramine (Anafranil), and dosulepin (Prothiaden).
Selective serotonin reuptake inhibitors: Examples include fluoxetine (Prozac), sertraline (Zoloft), and citalopram (Celexa).
Selective serotonin noradrenaline reuptake inhibitors: This includes venlafaxine (Effexor).
Alongside medication, lifestyle changes and modifications may also be suggested to help manage your symptoms. These include regular exercise, diet modifications, and spending time with loved ones. Psychotherapy or talk therapy may also be useful to some individuals, although it is recommended alongside medication therapy.
In cases where antidepressants are not enough or have failed to help relieve the symptoms, further treatments may be recommended, such as lithium augmentation, neuroleptic medication, or in some rare and severe cases, electroconvulsive therapy.
If you know someone at immediate risk of self-harm, suicide, or hurting another person, call 911 or your local emergency number immediately.
If you are having suicidal thoughts, contact the Suicide and Crisis Lifeline at 988 for support and assistance 24 hours a day, seven days a week.
What you can do as a support person:
Listen without judgment and save your advice for later
Offer reassurance and hope
Understand that their pain is real
Take any conversations around suicide or self-harm seriously
For more mental health resources, see the 988 Suicide and Crisis Lifeline³ webpage.
Melancholic depression can be incredibly difficult to live with and treat. Due to the biological origins of melancholic depression and the severity of the disorder, antidepressants are usually the first line of treatment for those suffering from this illness.
Antidepressants, lifestyle changes, psychotherapy, and following and sticking to all treatment plans may increase your chances of remission and prevent relapse.
The general symptoms associated with melancholic depression and major depression are similar. However, those who suffer from melancholic depression are likely to experience the symptoms much more severely and intensely than those with other forms of depression.
Due to the intense nature of the symptoms, people with melancholic depression may be harder to treat and, consequently, have a lower probability of remission than those with other types of depression.
Melancholic depression differs from major depression in several ways. Firstly, melancholic depression causes a hyperactive stress response and major depression causes a hypoactive stress response.
The second difference is that melancholy is usually acute, whereas depression is chronic. That is, melancholy generally develops suddenly and episodes last a short time. In contrast, major depression develops slowly, and episodes last a long time. However, those who suffer from melancholy will experience more episodes of depression compared to those with major depression.
There is also another difference. Although melancholic and major depression has similar symptoms, not all symptoms are the same. Major depression can cause appetite increase and weight gain, but this is not often seen with melancholy.
Those with melancholic depression tend to feel worse in the morning, while those with major depression generally feel worse in the evening.
Melancholic depression is generally difficult to treat. However, with the right treatment plan and commitment, recovery is possible. Much like any other mental health disorder, after recovery from melancholic depression, some symptoms may reappear or an entire relapse may occur.
However, you will likely have the knowledge and tools to cope with the symptoms, making recovery easier and faster than it is for initial episodes.