Resurrecting melancholia.

OBJECTIVE

To define melancholia as a distinct mood disorder, identified by unremitting depressed mood, vegetative dysfunction, and psychomotor disturbances, verifiable by neuroendocrine tests, and treatable by electroconvulsive therapy and tricyclic antidepressants.

METHOD: A review of the literature of two centuries finds descriptions of severe mood disorders, either depression or mania or circular, defined as 'melancholia.' In the 1980 diagnostic revision (DSM-III), melancholia was relegated to a features specifier only.

RESULTS

DSM classification criteria develop heterogeneous patient samples that are neither guides to prognosis nor to treatment response, and confound studies of pathophysiology. Within the large population of mood disorders, a syndrome of melancholia is identifiable by specific behaviors, vegetative signs, and validated by neuroendocrine abnormalities (cortisolemia). Populations so identified are clinically homogeneous and have improved treatment responses. Patients meeting criteria for melancholia are now identified as psychotic depressed, geriatric depressed, postpartum psychosis, and pharmacotherapy resistant.

CONCLUSION

The review supports the establishment of melancholia by empirically derived criteria rather than by a checklist is an alternative to the major depression choice and offers an improved model for psychiatric classification.