As you are starting to see, Major Depression has many flavors, none more pleasant than the next, and each comes with important treatment implications. Perhaps the darkest character in the line-up is Melancholic Features. Unfortunately, patients can experience more than one specifier at a time during their MDD episodes. Melancholic depression with mood congruent Psychotic Features is the ultimate depressive damnation.

The prevalence of Melancholic Features is not well-documented. In 2017, ?ojko & Rybakowski noted approximately 25-30% of MDD sufferers seem to meet criteria. The condition often goes unrecognized in evaluations according to Melancholia experts Parker et al. (2010). It is feasible this could lead to the patient being labeled as having “untreatable depression.” This is because Melancholic requires a particular intervention.

The term Melancholia, or “black bile,” as noted in the first postin this series, 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, researchers seem to agree that those with Melancholic Features exhibit significant problems with their endocrine system during depressive spells, particularly in relation to the stress hormone, cortisol (Fink & Taylor, 2007; Parker, et al., 2010), making an even stronger case for biological underpinnings. Some researchers have advocated Melancholic depression is unique enough to be its own stand-alone depression syndrome instead of an MDD specifier.

The presentation:

Melancholic features is usually marked by recurrent or even chronic (at least 2 years’ duration) Major Depressive episodes filled with despondency, serious disruption in sleep and appetite (to the point of anorexic appearance), along with psychomotor abnormalities often in the form of agitation. To witness such a patient, it sometimes seems “With 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 like it was contagious, and wanted to hold up his hands to shield himself. 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-20’s, 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 6AM, 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 the past couple of weeks, Bobby remained cold to her pursuit. Usually an avid photographer, he hasn’t picked up a camera in the past month. Not only this, Bobby usually loved to eat, but lately, he mostly pushed his food around the plate. In the morning Bobby 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 acute. Dr. H, recognizing the Melancholia presentation, explained to Bobby that he’d be happy to help see him through this. However, the nature of Bobby’s depression warranted an emergency medication appointment with a psychiatrist first.

In the Diagnostic and Statistical manual of Mental Editions, 5th Edition (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 their mood doesn’t brighten much 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

*Researchers Parker et al. (2010) note that while Psychotic Features aren’t currently a diagnostic criterion, they are not unusual in Melancholia, especially involving themes of guilt, sin, and ruination. They also note profound concentration difficulty in many examples.

Can you identify Bobby’s symptoms that led to his meeting criteria for Melancholic Features? Feel free to share in Comments!

Treatment implications:

This form of MDD has extremely 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 helpful given the global havoc is may wreak.

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). This makes sense, as these medications often increase appetite and sedation and also help with anxiety/restlessness. Severe cases of Melancholia may require other biological interventions, namely electroconvulsive therapy(ECT) or transcranial magnetic stimulation (TMS). It was noted in Kaplan (2010) that about 60% of depressed patients referred for ECT have melancholic features.

As noted in the post on With Anxious Distress, anxious agitation adds a significant risk factor for suicide. Now, if you can imagine the trio of severe despondency and insomnia, along with relentless agitation and psychosis, the gravity of the situation is easy to understand. Patients in such condition almost always require hospitalization. Carefully evaluating depressed patients for Melancholic Features could quite literally be a lifesaver.

It may sound strange, but not everyone with MDD is shrouded in a constant bad mood. Stay tuned for tomorrow’s post on Atypical Features.


Bodkin, J.A., Goren, J.L. (2007, September). Psychiatric Times. Not obsolete: continuing roles for tca’s and maoi’s.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

Fink M., Taylor M.A. (2007) Resurrecting melancholia. Acta Psychiatr Scand. 115, (Suppl. 433), 14-20.;sequence=1

Kaplan, A. (2010). Whither melancholia? Psychiatric Times. Retrieved from

?ojko, D., & Rybakowski, J. K. (2017). Atypical depression: current perspectives.Neuropsychiatric disease and treatment,13, 24472456.

Parker G., Fink M., Shorter E., et al. Issues for DSM-5: whither melancholia? The case for its classification as a distinct mood disorder. American Journal of Psychiatry,2010;167(7):745-747. doi:10.1176/appi.ajp.2010.09101525

Perry P.J.(1996) Pharmacotherapy for major depression with melancholic features: relative efficacy of tricyclic versus selective serotonin reuptake inhibitor antidepressants. Journal of Affective Disorders (39), 1-6.