Melancholia is a recurrent, debilitating, pervasive brain disorder that alters mood, motor functions, thinking, cognition, perception and many basic physiologic processes. In this way, pathological mood can be described, in pervasive and unremitting apprehension terms, psychomotor disturbance is second characteristic, vegetative functions are disrupted, and psychosis is recognized when the mood is severe in about 30% of patients and is seen as an integral part of melancholia.
These authors are not alone in defining melancholic depression either. Prof Gordon Parker of the Australian “Beyond Blue” organization likewise regards motor disturbances as a hallmark of melancholia (see www.beyondblue.org.au) as well as psychotic melancholia.
Such discussions are astounding in the environment an advanced science such as psychiatry, and are somewhat disturbing evidence to be added to a plethora of works that psychiatric nosological categories are insufficient ecologically to sustain efficient practice. Elements in the FDA report by personal communication that even though drug companies submit multiple compounds to the FDA each year, about 50% have insufficient data to support their approval and in those that are safe, most simply don’t better placebo by more than 10%. This is more likely to represent the filtering effect of using the DSM-IV categories to establish the drug cohorts rather than the drugs: if the target is ill defined, how does one establish which therapeutic arrows are likely to strike home? Here, the authors then take their argument to several related conditions, such as bipolar and post partum disturbances, and demonstrates the logic of their targeted approach.
They point out that the boundaries have been blurred between melancholia and other heterogeneous or “mixed bag” conditions, such as dysthymia or premenstrual syndromes. They conclude that melancholia, from the literature and experience of others, is a distinct syndrome, a specific depressive disorder, and offers a specific paradigm shift in thinking about mood disorder. This shift allows for laboratory testing which lends credence to the idea that this is a ‘real’ rather than tailored entity. The diagnosis leads to tests for it being specific to the entity, rather than trying to find reliable tests for DSM entities, which so far have proved fruitless. HPA tests and those of electrophysiology are put forward for consideration.
Apart from laboratory testing the authors needed to describe the exact clinical approach to examining for mood disorders of this type. This will include examining for vegetative signs and psychotic features, suicidal thoughts, cognitive falloff, personality disorder and so on. Various inventories are also evaluated, with such stalwarts as the Beck Depression Inventory regarded as not being useful for assessing melancholia or in assessing the severity of depressive illness in hospital settings, although it is held to be useful in outpatient settings. The differential diagnosis is also offered, with criteria against non melancholic depression, atypical depression, seasonal affective disorder, dysthymia, adjustment disorder and premenstrual disorder. The concept of the condition in children and adolescents is discussed, with an indication that incidence of comorbidities may be higher. Also discussed here is autism, the elderly, patients with a psychotic disorder, OCD, drug-related conditions, and other typical DSM categories such as general medical conditions. Suicide is taken seriously in melancholia, and so many aspects of this are discussed, with treatment often involving locked ward stays and ECT, as well as medication.