The Darkest Mood: Major Depression With Melancholic Features

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As you are starting to see, major depressive disorder (MDD) has many flavors. None is more pleasant than the next, and each comes with important treatment implications. Perhaps the darkest character in the MDD line-up is melancholic features.

Unfortunately, patients can also experience more than one specifier at a time during their MDD episodes. Melancholic MDD with mood-congruent psychotic features is the ultimate depressive damnation.

The term melancholia, or "black bile," was coined by the ancient Greeks. In those times, it was believed imbalances in bile influenced personality and mood, and too much black bile brought on this dark mood state. Today, melancholia, or melancholic features, is indeed recognized as an endogenous mood problem. This means it is generated from within, or genetic; one does not develop Melancholic depression as a reaction to a psychosocial stressor.

In fact, some researchers agree that those with melancholic features exhibit significant in relation to the hypothalamic-pituitary-adrenal (HPA) axis with corollary increases in the stress hormone, cortisol (e.g., Fink & Taylor, 2007; Parker, et al., 2010; Juruena et al., 2018), making an even stronger case for biological underpinnings. Given these unique traits, it has been argued over the years by some that melancholic depression is unique enough to be its own standalone depression syndrome instead of an MDD specifier.

The prevalence of melancholic features is not well-documented. However, some researchers, such as Parker et al. (2010), believe the condition often goes unrecognized in evaluations. In 2017, Łojko & Rybakowski noted that approximately 25-30% of MDD sufferers seem to meet criteria. It is feasible this could lead to the patient being labeled as having "untreatable depression." This is because Melancholia requires a particular intervention, as you'll see.

On another note, it is mentioned in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), that melancholic features aren't necessarily present across all MDD episodes in people prone to this specifier. While speculative, this could be due, for example, to melancholia being a more endogenous depression, and, while in remission from melancholia, they might encounter a psychosocial stressor that leads to a more "basic" MDD episode.

The presentation

Melancholic features are particularly marked by a palpably "heavy" mood, serious appetite loss, and psychomotor abnormalities often in the form of agitation. To witness such a patient, it sometimes seems anxious distress is built into melancholia. Take the case of Bobby:

Dr. H received a desperate call from Bobby's wife, Sharon, asking for an appointment. She never saw her husband so down. In person, Bobby's presentation was beyond sad; it was gloomy and dark, and seemed to emanate from him. Dr. H felt a palpable heaviness in the office. His poor patient was entirely sleep-deprived and confessed to getting only a few hours of broken sleep and wandering about the house til sunrise. Although only in his mid-20s, he looked as worn as a starved animal. Sharon, who came to the appointment with Bobby, explained that she would find him on the couch half asleep at 6 a.m., and he would brood about how he was ruining her life, crying in her lap. Sometimes he would call her at work and apologize further. At bedtime, she would try to arouse Bobby sexually to see if he would brighten, but despite her advances, Bobby remains cold to her pursuit. Usually an avid photographer, he hasn't picked up a camera in over a month.

Not only this, Bobby usually loved to eat, but lately, he mostly pushed his food around the plate. In the morning he would take a couple cups of strong coffee to try to feel more alert. Unfortuantely, it added to his feeling of resltessness and inability to sit still. He constantly shifted on the couch and wrang his hands in Dr. H's office. Bobby told Dr. H he remembered, as a late teen, having a similar gloomy feeling and serious insomnia, but not nearly this intense. Dr. H, recognizing the melancholia presentation, explained to Bobby that he'd be happy to help see him through this. First, however, the nature of Bobby's depression warranted an emergency medication appointment with a psychiatrist.

In the DSM-5, for a patient to meet a melancholic features specifier, they must present:

At least one of the following:

• Anhedonia, or inability to experience pleasure
• No mood reactivity, meaning that the mood doesn't brighten even in response to wonderful things

And at least three of the following:

• A gloomy, despondent mood. It has often been described as "palpable to others" and markedly different from sadness or a "normal" depressed mood
• Depression is usually worse in the morning
• Early morning awakening
• Psychomotor agitation (restlessness) or retardation (slowing)
• Significant weight loss
• Excessive or inappropriate guilt

Additionally, researchers Parker et al. (2010) noted that, while psychotic features haven't traditionally been a diagnostic criterion for melancholic features, they are not unusual in the presentation, and tend to involve themes of guilt, sin, and ruination. They also noted profound difficulty with concentration in many melancholic features patients.

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Treatment implications

As mentioned above, this form of MDD has strong biological underpinnings. Therefore, mood experts agree that psychotherapy is not an effective starting point for treating this flavor of depression, and should never be a first line of defense once the condition is identified. Psychotherapy can of course be helpful for managing the stress of the condition, and family therapy can be helpful given the global havoc it may wreak.

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Immediate referral to psychiatry is important, as melancholic feature patients seem to respond well to certain antidepressants. In particular, tricyclic antidepressants (a large family of older medications including Elavil, Pamelor, and Tofranil) seem quite effective according to available research on the topic (e.g., Perry, 1996; Bodkin & Goren, 2007; Vermeiden et al., 2018). This makes sense, as these medications often increase appetite and sedation, and can also relieve anxiety/restlessness. Severe cases of melancholia may require other biological interventions, namely electroconvulsive therapy (e.g., Kellner & Fink, 2017; Vermeiden et al., 2020) or perhaps transcranial magnetic stimulation (e.g., Baeken et al., 2009; Anderson et al., 2016). It was noted in Kaplan (2010) that about 60% of depressed patients referred for ECT have melancholic features.

As noted in the previous post on MDD with anxious distress, anxious agitation adds a significant risk factor for suicide. Now, if you can imagine the melancholic despondency, insomnia, and relentless agitation coupled with psychosis, the gravity of the situation is easy to understand. Patients in such condition frequently require hospitalization. Carefully evaluating depressed patients for melancholic features could quite literally be a lifesaver.

On Friday, Oct. 15, readers will learn how not everyone with MDD is shrouded in a constant bad mood. Stay tuned to learn about atypical features.