Melancholic depression is a type of major depressive disorder, usually characterized by overwhelming feelings of hopelessness, excessive guilt, and loss of interest in usual activities. A person with melancholic depression may have impaired functioning at work, school, or in relationships. Treatment usually includes a combination of medication and therapy.
Depression Is Treatable with Therapy
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What Is Depression?
Depression is a common but serious mental health condition in which someone can experience a variety of symptoms. Some symptoms include changes in their sleep, eating habits, and social availability. Often times, those with depression withdraw from loved ones and social situations and are more at risk for suicidal ideation. Depression can impact anyone of any age, and people often feel a very low mood and have no interest in their hobbies.
Types of Depression
There are many types of depression, including:
- Major depressive disorder
- Persistent depressive disorder
- Melancholic depression
- Seasonal affective disorder
- Bipolar depression
- Atypical depression
- Postpartum depression
- Premenstrual dysphoric disorder
- Situational depression
What Is Melancholic Depression?
Melancholic depression is a type of severe depression that has the characteristics of major depressive disorder as well as features unique to melancholia. Melancholia was previously considered to be a distinct disorder but is now seen as a specifier of depressive disorders, according to the American Psychiatric Association (APA).2
Unique features of melancholic depression include:1
- The lack of a positive reaction to good news
- Loss of enjoyment of most daily activities
- Changes in sleep
- Difficulty concentrating
- Feelings of deep despair
Who Is at Risk For Developing Melancholic Depression?
Melancholic depression is more likely to occur in middle-aged and older adults vs. young adults or children. Changes in movement such as restlessness or lethargy are also more common in melancholic depression.1
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Signs of Melancholic Depression
Signs and symptoms of melancholic depression include low mood and sleep difficulties, are typically more severe than depression symptoms, and have a higher risk of suicide and suicidal ideation.
Typical signs of melancholic depression include:3
- Difficulty getting out of bed and getting started with the morning routine
- Lower mood in the morning hours
- Waking up hours earlier than usual
- Change in performance during work hours, in school, in relationships, or completing tasks at home
- Lack of enthusiasm when hearing of good news
- Lack of enjoyment from activities that were previously enjoyed
- Statements of despair that are not related to grief or loss
- Either physical restlessness or slowed movement
- Weight loss related to loss of appetite
- Statements of feeling excessive guilt or inappropriate guilt
How Is Melancholic Depression Diagnosed?
There are three categories of symptoms that characterize melancholic depression. The first category is major depression symptoms. The second category has two symptoms; one of these must be present for the diagnosis of melancholia to apply. The third category includes the additional symptoms of melancholic depression. Three out of six of these symptoms must be present for depression to be diagnosed as melancholic.
Categories for Diagnosing Melancholic Depression
Here are symptoms in three categories that must be present for a diagnosis of melancholic depression:
1. Major depression symptoms, including (any five of the following):
- Feelings of persistent sadness
- Loss of interest or enjoyment
- Low energy or fatigue
- Irritability
- Increase or decrease in appetite
- Difficulties with sleep
- Difficulty with concentration
- Feelings of worthlessness
- Recurrent thoughts of death or suicidal thoughts
2. Melancholic depression must include either lack of pleasure in almost all activities or lack of positive response to good news or other positive stimuli.
3. In addition, there must be at least three of the following symptoms:
- Sadness that is not related to the loss of a loved one
- Waking up two hours earlier than usual
- Observable changes in movement, either slowed down or agitated depression
- Significant weight loss or anorexia
- Excessive or inappropriate guilt
Depression Is Treatable with Therapy
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Causes of Melancholic Depression
As with other forms of depression, various contributing factors include a genetic predisposition for depression, hormonal imbalances, brain function, and traumatic events. It has been observed that melancholic depression is much more common among those who have family members with serious mood disorders. It is less common for episodes of melancholic depression to be associated with negative life events or life stressors.
Common causes and triggers of melancholic depression include:
Biological Causes
Family history studies have shown that individuals with melancholic depression were much more likely to have close relatives with severe forms of depression when compared to individuals who had non-melancholic forms of depression.4
Hormone Levels
Research has shown an association between elevated cortisol levels in the bloodstream and the melancholic form of depression. These differences in cortisol levels are believed to be due to changes in the hypothalamus, pituitary gland, or adrenal glands, and the interaction of these three parts of the endocrine system.5
Brain Structure & Function
Some evidence indicates that people with melancholic depression have less effective connections between specific parts of the brain related to attention and concentration. This evidence is consistent with the impaired concentration, which is one symptom of melancholic depression.6
Traumatic Events
Trauma may trigger an episode of melancholic depression. Although trauma is not believed to be a cause of melancholic depression, it may trigger this form of depression in someone who already has a biological tendency for it.7
Seasonal Changes
Environmental factors like falling temperatures and lack of sunlight have been shown to trigger episodes of melancholic depression, although they are not believed to be causes.8
Melancholic Depression Treatment
Depression treatment often involves both medication and psychotherapy. Since biological factors are seen as primary causes for melancholic depression, medication is often an important part of treatment. Psychotherapy might be directed at changing unhealthy beliefs or habits, and finding better ways to cope with the problems that trigger episodes of depression. There are additional treatments for those who don’t respond to medications or psychotherapy.
Medication
Medication for depression may be prescribed by a primary physician or a psychiatrist.
Depression medication can fall into six categories:9
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
- Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)
- Newer antidepressants
- Older antidepressants (tricyclics)
- Monoamine oxidase inhibitors (MAOIs)
It may be necessary to try several different medications before finding one that is effective and has manageable side-effects. Some research indicates that tricyclic antidepressants are more effective than SSRIs or psychotherapy for melancholic depression.10
Therapy
Depression therapy is generally considered to be an effective treatment option. It can help with adjustment to current problems, regardless of the causes of those problems. It can also identify issues that are contributing to the depression so that changes can be made. Realistic short-term and long-term goals might be set, resulting in a greater sense of control over circumstances.
Some studies conclude that there’s no compelling evidence to show that persons with melancholia respond to psychotherapy as well as they do to medications.11 Others have evaluated CBT for depression and determined some specific benefits.11 The focus of CBT is to identify the thoughts, feelings, and behaviors that affect your daily well-being. New ways of thinking about current circumstances and new behavioral responses lead to an improved mood.
Other Treatment Options
Additional forms of treatment are available when a depression is so severe that antidepressant medications and psychotherapy are not providing enough relief of symptoms (often called treatment-resistant depression). These other options include residential treatment programs and brain stimulation therapies.13
Residential Treatment
Residential treatment may involve full hospitalization or partial hospitalization. Full hospitalization is recommended when the depressed person is unable to care for themself or is in danger of harming themself. The risk of suicidal ideation and acts is relatively high for melancholic depression due to the severity of the low mood and other symptoms. Full hospitalization is intended to keep the person safe until their mood improves.
Partial Hospitalization
Partial hospitalization programs, also called day treatment programs, are helpful when the depressed person needs more frequent support than what outpatient psychotherapy can provide. These programs typically include both individual and group sessions, as well as medical oversight of the effectiveness of medications.
Electroconvulsive Therapy (ECT)
Electroconvulsive therapy involves passing electrical impulses through the brain to trigger small brief seizures. ECT is usually administered in a series of 6-12 treatments over a period of a few weeks. This well established procedure often results in the rapid relief of symptoms for those with severe depression.
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How to Get Help For Melancholic Depression
Getting help for melancholic depression usually starts with contacting a primary care physician. After doing an evaluation, the physician will either prescribe antidepressant medications or refer to a psychiatrist for medication evaluation. The next step in treating melancholic depression is to begin working with a psychotherapist to learn ways to cope with symptoms.
Knowing how to choose a therapist can feel daunting. Begin by contacting the health insurance company and getting a list of providers in that geographic area. Next, contact a few of these providers to determine the best fit in terms of their specialty and availability, as well as your costs and any other personal preferences. If uninsured, contact the local community mental health clinic and ask about available services.
You can also use an online therapist directory, where you can sort by location, insurance coverage, and specialty.
How to Get Help For a Loved One
How to get help for a friend or loved one involves similar steps, while keeping in mind that any personal health information for another adult will be protected by law. You may be able to offer help and reminders but they must accept the need for professional help for themselves.
Here’s how to get help for a loved one with melancholic depression:
- Offer to help them find a provider who is in network or affordable
- Offer to remind them of their appointment
- Remind them of the importance of following the recommended treatment plan
- Remind them to participate in psychotherapy as a part of their treatment
- Express hopefulness and confidence that they’ll receive effective help
What to Do When There’s a Risk of Suicide
If your loved one appears to be in danger of harming themself, you should act quickly. Don’t be afraid to jump in to find your loved one the help they need. If you are concerned about suicide risk, call the National Suicide Prevention Lifeline at 1-800-273-8255. If your loved one is in immediate danger, call 9-1-1.
6 Ways to Cope With Melancholic Depression
It can be very difficult to cope or get help when you’re feeling sad, low energy, or a lack of motivation. However, coping strategies like goal-setting and education may provide some temporary relief of symptoms in addition to medication and therapy.
Six coping strategies to cope with melancholic depression include:13
1. Set Reasonable Goals For Yourself
This often means cutting back on obligations when possible. Giving yourself permission to do less on your worst days may relieve the feelings of excessive guilt which are common in melancholic depression.
2. Educate Yourself
Learn about the causes and treatments for melancholic depression. Being aware of the causes of this form of depression might help to stop self-blaming and lessen feelings of worthlessness. Knowing that there are effective treatments may be helpful in maintaining hope and also in sticking to the treatment plan.
3. Take Care of Your Body
Consider whether you’re eating a healthy diet, getting enough exercise, and getting good sleep. Of these lifestyle factors, sleep can be a particular challenge for those with melancholic depression. Early morning awakening is a common symptom of this form of depression, often leading to a sleep deficit over time. Mental health professionals can provide strategies to improve sleep.
4. Try New Ways to Manage Stress
Many stress management techniques can be self-taught, such as meditation, mindfulness, journaling, or progressive muscle relaxation. Any of these can be effective in relieving stress, irritable mood, and low energy.
5. Avoid Mind-Altering Substances
Avoid the use of alcohol and other recreational drugs, which may be worsening your depression and making it more difficult to treat. If you have tried to stop already without success, talk to your physician or therapist. There are treatment programs and support groups to help you limit or stop use of these substances.
6. Reach Out to Online Support Groups
Organizations like The National Alliance on Mental Illness (NAMI) offer education, counseling, and support groups. It can be very helpful to share experiences and tips for coping with other individuals who have had similar symptoms.
Final Thoughts On Melancholic Depression
When you’re dealing with melancholic depression, it can feel like things will never get better. However, reaching out to a trusted loved one and finding appropriate care can really make a positive difference in how you feel.
Additional Resources
To help our readers take the next step in their mental health journey, Choosing Therapy has partnered with leaders in mental health and wellness. Choosing Therapy is compensated for marketing by the companies included below.
Online Therapy
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Melancholic Depression Infographics
