Melancholia

What is Melancholia?

First described by Hippocrates, melancholia is a form of major depressive disorder (MDD), also called melancholic depression, a severe condition that strikes people suddenly.

Melancholia was referred to as endogenous depression, meaning “coming from within,” and considered different from depression that stems from external conditions, such as stress. This name is due to the fact that melancholia typically arises from biological causes rather than psychological factors.

Today, melancholia is not recognized as its own separate illness but a type of severe depression characterized by ongoing feelings of hopelessness and sadness. For people with melancholia, just getting through the day can be difficult. What separates melancholia from other types of MDD is severity of symptoms and length of time symptoms last. Other symptoms more specific to melancholia include improving energy and mood as the day goes on, waking early in the morning due to sleep pattern disruptions, and the fact that symptoms usually appear suddenly.

Most people who suffer from melancholia aren’t people you see every day that may be dealing with depression but are usually those hospitalized for major depressive disorder.

Melancholia is one of five different subtypes of depression that affect a majority of people suffering from the condition. Other subtypes of depression include atypical depression, anxious depression, vascular depression, and psychotic depression. These distinctions arose from different responses to various treatments. While melancholia is categorized as one of the more severe types of depression, there is hope. There are several treatments that have been shown to be effective, particularly in the pharmacological field.

Knowing what causes melancholia is very important to help identify and treat this form of depression.

Symptoms of Melancholia

While different types of major depressive disorder share symptoms with melancholia, this type of depression is typically a more severe type of MDD. The more depressive episodes people experience, the more likely their depression will take on a life of its own.

There are many symptoms that present with melancholia, including:

  • Intense and persistent feelings of sadness
  • Loss of interest in activities the person once enjoyed
  • Feeling anxious or stressed
  • Difficulty remembering things and making decisions
  • Not enough or too much sleep
  • Not eating enough or overeating – irregular diet
  • Lack of energy or feeling tired much of the time
  • Slow movements
  • Changes in body movement (i.e. nervous fidgeting)
  • Feelings of worthlessness and low self esteem
  • Feelings of misplaced guilt
  • Lack of desire to be social
  • Depression is usually worse in the morning hours
  • Negative thoughts appear repeatedly
  • Feelings and thoughts of suicide

Symptoms of melancholy typically occur in people who frequently suffer from depressive episodes and are seen more often with those who have psychotic symptoms along with MDD.

Everyone has passing sadness or “melancholy” at times, but for most people it’s short term with little to no consequence. However, if any of these symptoms are present and last for a long time, it’s a good idea to seek help.

There are plenty of treatments for melancholia that are effective for those suffering from this condition. Medication is typically the first line of defense for treatment options.

Causes of Melancholia

One of the main causes of melancholia is its strong ties to genetics, which is a more likely cause than other psychological or social factors. Evidence suggests that genetic factors contribute to melancholia not by one particular gene, but by a combination of genes, which indicates it is an inheritable condition. If a parent has been clinically diagnosed with depression, there’s a 40% chance of the same condition developing in their children. However, it is unlikely to occur in the absence of stressful life circumstances. When stress does present itself, children of those diagnosed with melancholia are likely to suffer from depression resulting from the stressor.

While not a lot is known about depression and brain chemistry, it is thought that neurotransmitter function is disrupted in instances of depression. Neurotransmitters carry signals from one part of the brain to another. Three neurotransmitters that impact a person’s mood are dopamine, serotonin, and noradrenaline. These particular transmitters do not function normally in the brain of a person who is suffering from depression.

Other physical factors also include Dementia in elderly people and physical illness.

While gender does not seem to play a role in cases of melancholia (about the same amount of men and women suffer from it), women tend to suffer from general depression more so than men.

While less likely than physical factors, melancholia can be triggered by existing psychological issues, such as:

  • Depression due to drug use
  • Depression due to bipolar disorder
  • Depression due to persistent depressive disorder

There are certain personality traits, such as anxiety, shyness, low self-worth, and high interpersonal sensitivity that are also known to cause depression, however, these causes are more likely for non-melancholia types of depression.

Typically, there is no one single cause for depression. While melancholia is typical of biological factors, there can be multiple causes, but it is important to identify symptoms and seek treatment early. Knowing the symptoms is the first step to identifying the condition.

Treatment of Melancholia

Treatment of melancholia begins with determining if someone is suffering from the condition. Since melancholia is not identified by professionals as its own separate psychological disorder, it may be characterized as MDD with melancholic features.

To find out if a person is suffering from melancholia a doctor may ask the patient a series of questions, such as:

  • Do you have trouble concentrating?
  • Has there been a change in your daily routine?
  • Have your sleep patterns changed recently? Do you sleep well?
  • Do you enjoy activities you once enjoyed?
  • Do you have difficulty getting out of bed in the morning?
  • Are symptoms worse in the morning or at night?
  • Does anything improve your mood?

The two most effective and often used treatments for MDD with melancholia are medication and psychological therapy, however, it’s been found that drug treatment prior to therapy tends to work best for this depressive condition. Therapy on its own shows a lower positive response rate. Melancholia does also respond to electroconvulsive therapy (ECT), although ECT is not often required as a treatment.

In clinical tests, melancholia doesn’t typically respond to placebos where other forms of depression typically respond at a rate of over 40%.

Medication is the first line of treatment and drugs that block the reuptake of norepinephrine and serotonin tend to be most effective. Drugs like Venlafaxine and Mirtazapine may be effective in treating more of the symptoms associated with melancholia.

The classes of anti-depressants typically used in treating melancholia include:

Monoamine Oxidase Inhibitors (MAOIs)

The first antidepressants to be developed, MAOIs elevate levels of serotonin, dopamine, and norepinephrine in the brain. They are typically given to those suffering from anxiety or unusual depression, however, because of their interactions with food and other medications they are not often prescribed. These drugs also have the dangerous side effect of causing suicidal tendencies in younger people. Some MAOIs include isocarboxazid, phenelzine sulfate, and tranylcypromine sulfate.

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

While SNRIs are typically prescribed for nerve pain, they also work for some people who are suffering from depression. SNRIs work by increasing activity of the brain chemicals serotonin and norepinephrine. Some SNRIs include duloxetine, milnacipran, desvenlafaxine, and venlafaxine.

Tricyclic Antidepressants (TCAs)

TCAs work by elevating activity of norepinephrine and serotonin, which are brain chemicals that regulate mood. These drugs aren’t often prescribed due to the possibility of causing heart problems. They are typically prescribed to people with bipolar disorder, which is a trigger for melancholia. Some TCAs include amitriptyline, norpramin, pamelor, and tofranil.

Norepinephrine and dopamine reuptake inhibitors (NDRIs)

NDRIs are a form of reuptake inhibitor. This drug impacts the reuptake of norepinephrine and dopamine in the brain. The only NDRI is bupropion, which can also be considered an atypical antidepressant.

Atypical antidepressants

Atypical antidepressants are so named because they don’t fit into other classes of antidepressants and each are unique from one another. They work by impacting changes in chemistry of the brain and brain nerve cell circuitry communication which regulates mood and helps to alleviate depressive symptoms. These drugs are classified as second-generation antidepressants. Some of the atypical antidepressants include mirtzazpine, nefazodone, trazodone, vortioxetine, and bupropion.

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are one of the most common types of antidepressants and are often prescribed for those diagnosed with MDD. However, there is some discussion as to whether this is an effective treatment for melancholia and is unlikely to be used in most cases. SSRIs work by producing serotonin available to the brain by blocking the reuptake process. Some SSRIs include citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline.

Pharmacological therapy

Melancholia typically responds best to pharmacological therapy and is usually the first line of treatment. Patients suffering from melancholia tend to respond better to some of the older antidepressant therapy drugs such as serotonin-norepinephrine reuptake inhibitors and monoamine oxidase inhibitors. Some certain atypical antipsychotics may be used with antidepressants to aid in their effectiveness.

When antidepressants are taken regularly and as prescribed, they improve symptoms of depression between 80% and 90% of the time. While treatment is essential to relieve the symptoms of depression, there may be some measures that can be taken to help prevent melancholia.

Prevention of Melancholia

Early prevention of melancholia may prevent people from suffering an episode of the condition at some point in their lives, particularly people who are biologically predisposed.

Some preventative measures that can be taken are:

  • Helping a child in an abusive situation
  • Good prenatal care and good sleep hygiene for newborns
  • Getting children help for sleep disorders
  • Helping children and young adults with alcohol and drug abuse who are at risk for depression
  • Identifying and getting treatment for signs of early depression
  • Keeping blood pressure under control

These measures do not guarantee that a person will not suffer from melancholia, however, any preventative measures taken will surely help. Considering this condition is believed to be more biological that psychological in nature, perhaps it would be more effective to focus efforts towards preventing relapse through monitoring once the person has been treated through medication and counseling.

Prevention of relapse for melancholia includes:

  • Continued treatment with medication
  • Reducing stress at home and work
  • Detection of relapse and subsequent treatment efforts as soon as possible
  • Compliance with treatment by the patient
  • Close monitoring by a medical professional

It’s important to deal with depression in an appropriate way and try to pinpoint causes to enable treatment as soon as possible to pave the way to a happier life.

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Last Reviewed:
September 18, 2017
Last Updated:
September 18, 2017
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