The empirical status of melancholia: Implications for psychology

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Abstract

The concept of a subtype of depression with a biological rather than a psychological set of causes has been more prominent in the psychiatric literature than in the psychological literature on depression. There has been dispute as to whether research on melancholia supports the distinction of a separate subtype with a distinct symptomatic profile characterized by marked anhedonia, psychomotor difficulties, excessive guilt or hopelessness, suicidal features, and appetite and weight disturbances. Research suggests that individuals with melancholic depression are qualitatively different from those with non-melancholic depression in their symptomatology. Examination of biological functioning, personality traits, responsiveness to treatment, and suicidality also tend to support the melancholic–non-melancholic distinction. This paper reviews the status of the melancholia concept and explores its implications for psychological research and practice.

Introduction

Depression has been conceptualized as a heterogeneous mixture of conditions and disorders, but finding meaningful groupings has been a difficult endeavor. The idea of somatogenesis, manifest disease arising from internal biological dysfunction, is at least as old as Hippocrates' writings in the 5th century BC. Melancholia preceded the term depression to describe human despondency. The word is derived from the Greek term “melaina chole” or “black bile,” the bodily humor that was identified with black moods. In recent history, the idea of a somatic genesis for depression has been contrasted with a psychological genesis, and the terms “endogenous” versus “exogenous” or “reactive” have been used to contrast these two sources of depression.

Establishing subgroups of patients based on putative etiology has long been a goal of diagnostic classification. Those with endogenous symptoms should lack precipitating events, although a number of investigators have failed to find group differences in the incidence of stressful life events between individuals with endogenous and non-endogenous symptomatic profiles (e.g., Forrest et al., 1965, Lafer et al., 1996, Leff et al., 1970, Thomson & Hendrie, 1972). In fact, Mundt, Reck, and Backenstrass (2000) demonstrated that stressful experiences often precede onset of melancholic episodes. Findings from other investigations indicate that depressed individuals with melancholic symptomatology may undergo more adverse experiences than non-melancholic individuals (Harkness & Monroe, 2002, Willner et al., 1990). Two studies have provided support for the idea of fewer precipitating events in depressive episodes with endogenous symptoms (e.g., Kohn et al., 2001, Tomaszewska et al., 1996). Overall, the inconsistencies across investigations demonstrate the difficulty in establishing groupings based on supposed etiology.

Section snippets

The constructs of endogeneity and melancholia

The term endogenous has been used to identify a syndrome of depression identified by symptoms of pervasive anhedonia, anorexia, weight loss, early morning awakening, diurnal variation of mood, psychomotor agitation or retardation, guilt, and sometimes psychotic features (Coplov et al., 1986). The grouping of a separate melancholic subtype of depression was introduced in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III; American Psychiatric Association, 1980).

Biological factors in melancholia

When it was introduced, the dexamethasone suppression test (DST; Carroll, Martin, & Davies, 1968) was offered as a specific laboratory test and biological marker for the presence of melancholia in depression. In normals, dexamethasone suppressed cortisol whereas a non-suppression response, indicative of a pituitary–adrenal hypothalamic dysfunction, was associated with melancholic depression (Carroll et al., 1981). Although these findings were only correlational and could not demonstrate a

Psychological factors in melancholia

A number of assessment techniques have been used to determine whether an individual meets criteria for melancholic depression. The standard for research is to conduct a semistructured interview, such as the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1995) to obtain both a diagnosis of depression and the specifier “with melancholic features.” While DSM-IV criteria are the most frequently used, expanded criteria were proposed in the Research Diagnostic Criteria

Suicide in melancholic patients

Melancholic patients may have a heightened risk for suicide. Van Praag and Plutchik (1984) studied suicide attempts, depression type, and depression severity in hospital patients with non-psychotic depression. Their data showed that violent suicide attempts occurred with greatest frequency in individuals with melancholic depression. Goldney, Adam, O'Brien, and Termansen (1981) studied 100 female suicide attempters in four Australian inpatient wards and assessed for melancholia. One-third of

Somatic treatment of melancholic depression

There is disagreement about whether melancholic and non-melancholic depressed individuals respond differently to pharmacotherapy and pill placebos. Because of the large number of studies with conflicting data, two papers with alternate viewpoints are cited here. Feinberg (1992) suggested that accurate diagnosis and subtyping of depression is crucial in determining response to treatment. He cited studies demonstrating that melancholic depressed individuals responded to imipramine but not

Psychosocial treatment for melancholic depression

The widespread clinical belief that melancholia should be treated pharmacologically has not been challenged until recently. This notion originally stemmed from older conceptualizations of melancholia as an endogenous disorder. In comparison to the extensive research base on somatic treatments, few studies have examined the efficacy of psychotherapy for melancholic depression. Prusoff, Weissman, Klerman, and Rounsville (1980) were the first to evaluate psychosocial treatments in melancholia.

Summary and conclusions

The proportion of cases with melancholia in an outpatient setting is much lower than non-melancholic forms of depression (Thase & Friedman, 1999). Although it is an uncommon problem, practitioners should be aware that individuals with melancholic symptomatology may require separate assessment tools and the consideration of different treatment options. Unfortunately, there is still debate over what features define melancholia. The DSM-IV specifier “with melancholic features” and RDC of “definite

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