Generality
Melancholia (or melancholic depression) is a psychiatric disorder characterized by a very strong lowering of mood and an inability to find pleasure in positive events (anhedonia).
Treatment involves the administration of antidepressant drugs in combination with other approaches (such as cognitive-behavioral therapy and interpersonal psychotherapy), normally implemented for major depressive disorder.
What's this
Melancholia is a particularly severe form of depression characterized by a distinctive clinical profile:
- Deep and groundless lowering of mood;
- Anedonia (loss of interest or inability to take pleasure in performing activities that are usually rewarding);
- Marked slowing of all psychic activities and motor initiative.
Causes
Melancholia is caused by the interaction of biological, genetic and psychosocial factors.
- Biological factors : depression with melancholic features seems to have a biological root. These causes have not yet been fully clarified, but the dysfunction of some neurotransmitters, or substances that allow the normal transmission of nerve impulses, could be implicated. In fact, these play an important role in the mechanisms that regulate mood, the ability to react to situations and the relationship with the outside world. People with psychotic, hospitalized or elderly disorders are considered more susceptible to the development of melancholia.
- Genetic factors : in some cases, a predisposition to melancholia may be present among 1st grade family members.
- Psychosocial factors : often, melancholic episodes occur without an apparent reason; only in a few cases can they be associated with a negative triggering event (stressful situations, disappointments, sudden grief etc.).
Melancholia is frequent in older people and often goes unnoticed, as some doctors interpret the symptoms as manifestations of senile dementia.
Involuntary melancholy
Involutive melancholia is a form of depression that occurs for the first time in the involutionary period of life, that is, indicatively from the age of 40-55 years in females and 50-65 years in males.
The set of symptoms with which it manifests itself is characteristic and consists of:
- State of agitation and depression;
- Delusion of guilt or deprivation;
- Death obsession;
- Delusional fixation on gastrointestinal functioning.
In some patients, paranoid delusions of persecution also occur.
Symptoms, signs and complications
Melancholia manifests itself with:
- Persistent and extreme sadness;
- Loss of interest in performing routine activities or inability to experience;
- Early morning awakenings (at least two hours earlier than the norm);
- Agitation or, on the contrary, psychomotor slowing;
- Severe anorexia with weight loss;
- Intensification of symptoms in the morning;
- Excessive or inappropriate feelings of guilt.
The beginning of these episodes is not usually caused by a specific event; even when something positive and rewarding happens, the mood of the individual does not improve, not even for a short time.
Melancholia can be associated with somatic and organic signs, such as headaches, lack of energy, myalgia, adynamia and reduced facial expression. Sometimes other psychic symptoms coexist (eg anxiety disorders, panic attacks, paranoid delusions, etc.).
Diagnosis
The diagnosis of depression with melancholic characteristics is based on clinical evaluation (DSM criteria) and requires the presence of at least one of the following symptoms:
- Anedonia (loss of interest or inability to take pleasure in performing activities that are usually rewarding);
- Lack of mood reactivity with respect to positive events;
and at least three of the following:
- Depression that has no understandable motivation;
- Severe anorexia with weight loss;
- Significant agitation or psychomotor slowing;
- Early morning awakening;
- Excessive or inappropriate feelings of guilt;
- Intensification of symptoms in the morning.
According to the DSM-IV, the melancholic characteristics apply to an episode of depression that occurs in the context of:
- Major depressive disorder (single or recurrent episode);
- Type I bipolar disorder (recent depressive episode);
- Type II bipolar disorder (recent depressive episode);
Therapy
Depression with melancholic characteristics almost always requires a pharmacological treatment (also considering the biological basis of the disease). Given that melancholia is not triggered by external circumstances, but depends on the onset of neurobiological dysfunctions, it is necessary to establish a therapeutic protocol that acts in this sense.
As for antidepressants, they are essentially used:
- Selective serotonin reuptake inhibitors (SSRIs): ex. fluoxetine, paroxetine, sertraline and escitalopram;
- Serotonin-norepinephrine reuptake inhibitors (SNRIs): ex. duloxetine and venlafaxine;
- Norepinephrine and dopamine reuptake inhibitors (NDRI): eg bupropion.
Other medicines used are:
- Mood stabilizers (eg mirtazapine, trazodone, vortioxetine and vilazodone);
- Tricyclic antidepressants (eg imipramine, nortriptyline and amitriptyline);
- Monoamine oxidase inhibitors (eg tranylcypromine, phenelzine and isocarboxazide).
Drugs are associated with other treatments, such as cognitive-behavioral psychotherapy, in order to resolve or reduce the symptoms of the disease.
