Melancholic depression is a very distressing condition. It may have a unipolar or bipolar course.
Symptoms of Melancholic Depression
- Anhedonia (distinct loss of pleasure in usual interests and activities)
- Non-reactive mood
- Mood and energy worse in the morning (Usually worse in the mornings: Signs tend to fluctuate during the course of the day. This is best observed first hand by the general practitioner. Family and friends may report change in behaviour, but not be aware of the significance of this feature).
- Profound and uncharacteristic inanition – ‘emptiness and inactivity’ (eg. unable to ‘fire-up’ and get out of bed and have a shower).
- Observable psychomotor disturbance is a very important and specific diagnostic feature of melancholic depression. It includes cognitive processing problems (poor concentration, inattention) and motor signs: retardation and agitation affecting the face, speech and body
The CORE Rating Scale
The CORE rating scale can be used to assess psychomotor retardation (observable psychomotor disturbance), which is a very important and specific diagnostic feature of melancholic depression.
See the CORE rating scale [PDF, 904KB]
Mechanisms and Age of Onset
Melancholic depression is a biologically based condition, but mechanism is different in different age groups. Disruption of circuits linking basal ganglia and pre-frontal cortex leads to a triad of: depression; cognitive impairment; and psychomotor disturbance
Functional Melancholia
- Younger onset (eg <60 years), ? genetic predisposition
- Often strong family history of depression
- Structural abnormalities rare on imaging
- Good response to broad spectrum antidepressants, ECT
- Mechanism: Functional shut-down of circuits linking basal ganglia and pre-frontal cortex
Structural Melancholia
- Older onset (eg > 60 years), ? vascular predisposition
- Family history of depression less common, but cerebrovascular disease more common
- Structural abnormalities on imaging
- Poorer response to antidepressants & ECT, risk of delirium
- Mechanism: Structural disruption of circuits linking basal ganglia and pre-frontal circuits, preceding full dementia in months or years.
Observational Assessment
When assessing a patient, it is important to consider:
- Individuals with good social skills or psychosis may underplay inner distress and despair
- Consider factors such as voice tone, whether the ‘light in their eyes’ is lost
- Individuals may fluctuate over the day, usually worst in the mornings. It is best for the GP to see them during the part of the day when they report being slower, more hopeless. This is usually in the morning.
Some useful questions which can help to determine if a patient is suffering from melancholic depression include:
- Do you still read the newspaper… watch TV?
- What do you do all day – what would you normally do?
- What do you still enjoy - hobbies…children/grandchildren…sunrise?
- Do you feel worse in the morning or the evening?
- How do you sleep? Do you wake early in the morning?
- Can you be cheered up? What lifts your mood?
Response to Treatment
ECT is highly effective. Broader spectrum antidepressants are more effective than ’narrow spectrum’; TCAs, MAOIs are better than > SNRIs (venlafaxine, mirtazapine, duloxetine) > SSRI and other single-action drugs. The superiority of TCA over SSRI antidepressants increases with age.
If antidepressant alone fails, brief augmentation of antipsychotic may ‘kick-start’ response.
