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Depressed mood most of the day, nearly every day, as indicated by either subjective report [e.g., feels sad or empty] or observation made by others [e.g., appears tearful]. [In children and adolescents, this may be characterized as an irritable mood.]
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Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
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Significant weight loss when not dieting or weight gain [e.g., a change of more than 5 of body weight in a month], or decrease or increase in appetite nearly every day.
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Insomnia or hypersomnia nearly every day
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Psychomotor agitation or retardation nearly every day
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Fatigue or loss of energy nearly every day
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Feelings of worthlessness or excessive or inappropriate guilt nearly every day
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Diminished ability to think or concentrate, or indecisiveness, nearly every day
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Recurrent thoughts of death [not just fear of dying], recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
My reason for mentioning him has to do with the DSM-5 Revision process. This man has Manic-Depressive Illness, the same kind Kraepelin wrote about a long time ago. It’s in his history – substance abuse, family history of substance abuse. It’s in his course – recurrent episodes, hypomania at the end of a depressive episode, etc. But it was somewhere else too – in his clinical presentation. I thought about it the first and only time I saw him as a patient based on how he described his symptoms and his thinking. The way he was. It was more than "Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others."
His "depression" won’t fit into a sentence. It’s a paragraph. He doesn’t appear "sad." He looks worried, brooding. He’s driven to talk about how he feels or doesn’t feel but has trouble putting it into words. He’s self flagellating, including about his symptoms. He seems to have no memory that he ever felt differently from how he feels right now and has no concept of "better." He doesn’t want to "do" anything or go anywhere. While there are several things that might explain his symptoms – moving, his marriage, etc, none of them seem related and are quickly incorporated into his self attacking. I’ve spent my days talking to unhappy people and am fairly good at it, but talking to this man isn’t getting anywhere. His mind returns to talking about how he feels [or doesn’t feel] as soon as there’s a lull in the conversation like it’s affixed with a rubber band. Words like "sad" or "guilty" don’t capture what he is experiencing. "Bad" is closer, as a noun, an adjective, and an adverb. And, speaking of nouns, he’s not "depressed" – he is "depression."
I mention him for two reasons. First, this is not the kind of person treated in those clinical trials we keep talking about – maybe a few, but certainly not the majority. I see those people in the clinics frequently, the ones described by the criteria above. This is something else, a different entity not described by a "dimension" or an add-on. Saying he has MDD "with melancholia" or "with psychotic features" implies a continuity with other patients that doesn’t exist. He was not "psychotic," so the differential diagnosis was Melancholia or a Depressive Episode in the context of Manic Depressive Illness [if we still used Reserpine to treat high blood pressure, Reserpine induced Depression would be on the list too]. The diagnostic system we have now doesn’t have the depth to separate him out from other depressed people. We need that back in the DSM – and not just as a "dimension." Dimensions are fine for other things, I guess. But not this.
My other reason for mentioning him is the difficulty getting him treated. These days, I rarely see a depressed person who doesn’t say, "I’ve been told that I might have bipolar" or "I’m on Depakote for the bipolar." I hear it so often I want to scream. It’s widely over-diagnosed and unnecessarily medicated. It’s so common that it’s lost its valence – just another bipolar. Manic Depressive Illness is not that common, and it’s a big deal that has a powerful effect on the course of life and the person’s family. The episode itself needs treating. The treatment is biologic – medication, and sometimes ECT. He may need hospitalization for treatment as well as his own protection. And I haven’t been able to get that for him. This particular patient needs to be followed and tried on long term preventive treatment instead of driving 100+ miles to see a retired acquaintance in his front yard. Patients with this illness may endure their episodes, but are also vulnerable to suicide when they feel another one coming on ["I just can’t do it again"], at its depths ["this is too bad and I’m worth nothing anyway"], and when they are are improving ["it was too much"]. He’s also a set-up for a substance abuse "relapse" during an episode. The last time I referred him, he got "lost in the crowd" and wasn’t followed. This time, I sent a mega-explicit-letter to his new psychiatrist, but I worry he’ll be just another "med eval" case on "the panel."
Your patient fits the classic picture of melancholic depression. Your description of his altered mood is the tipoff. This is the distinct quality of depressed mood that many nosologists have emphasized and, as you say, these cases are not the rule in today’s antidepressant drug registration trials. They are not the rule either in the mass marketing of antidepressant drugs. Yet we would do well to recall that these were the patients in whom antidepressant drug efficacy was first recognized, in the 1950s. In 1921, Kraepelin described the distinctive mood of melancholia as a uniquely aversive, anguished or uncomfortable experience – he used terms like painful tension and torment. His contemporary British colleague Gillespie in 1926 referred to it as “…something formless… vague and very unpleasant in tone. From this arose the difficulty that these patients have in expressing their condition to the physician.†William Styron in Darkness Visible said it “verge(d) close to being beyond description.†William James in 1902 described it as ‘a positive and active anguish… wholly unknown to healthy life.’ These accounts are very different from the pallid characterization in DSM-III-IV of the distinct quality as different from grief. Defining it by what it isn’t does not come close to an adequate description.
The essential strategic blunder of DSM-III, which was continued in DSM-IV, was the decision to walk away from hard won clinical insights concerning melancholic and nonmelancholic depression (each with several virtual synonyms). This problem was compounded by two more blunders: the characterization of generic major depression as melancholia lite, and the lack of syndromal depth in the DSM-III-IV definitions of generic major depression as well as the melancholia specifier. Syndromal depth is the texture one gets when salient information like your patient’s past episodes and family history are considered in addition to the list of allowable symptoms.
As best I can tell, DSM-5 will continue with the crippling heterogeneity of generic major depression.