from SG:"I would be grateful if you would consider a thorough posting on what you’ve seen as melancholia. I think I’ve followed your postings faithfully and you’ve made me aware that not all MDD is the same but I’d really like your opinion on what I believe you term melancholia."
The term, Melancholia [literally black bile] comes from antiquity and describes a state of painful dejection, famously portrayed in Albrecht Dürer’s wood-cut shown on the leftt. In a variety of incarnations, the term has been used over the years to describe a particular kind of depressed state, often dichotomized with all other forms of depression. Most people trained in psychiatry in my era and before were taught [and accepted] that there were two forms of depression – the terms were endogenous depression and exogenous depression, but there have plenty of other synonyms for each. The controversy is that the DSM-III and all of its later iterations did not separate the depressions into two groups, or in fact, into groups at all. All depressions were included under the term Major Depressive Disorder. Reasons? The usual suspects – lack of evidence-based or measurement-based this and that. Who really knows?
Depression is a communicative emotion. When you meet a person who is depressed, you can usually see it and are drawn to comment on it, "You look really down." It’s quickly the topic of the encounter, and one is drawn to think and ask about "why?" – why is this person depressed? Some patients know the answer, or have an idea about it. Even those who don’t know, at least understand the question. Patients with Melancholic Depression may or may not have something to say in response, but it doesn’t seem relevant. There’s not a why, at least not one that makes any sense. What they say isn’t really an explanation of the depression, it’s a part of it. In Melancholia, there’s a timeless quality – the patient doesn’t so much connect with a before and a during. The patient I mentioned earlier [as precisely as possible…] kept saying things like "I think I’ve always been…" or "I never been …" He was a person I’ve seen in the community a number of times when he was perfectly fine, but even in the presence of someone who’d been around him when he was obviously happy and enjoying himself, he couldn’t relate to ever having felt anything other than his Melancholy.
Melancholic Depression isn’t only pervasive in time, it’s pervasive in all dimensions. There’s a saying "there’s a black dog over there" meaning that there’s no escape from the feeling, and the interviewer quickly feels that because everything the patient says simply reiterates the state of depression. The interview goes nowhere, because there’s no place other than the depression to go. Likewise, the Melancholic person doesn’t relate to the words that we usually use to describe depression like sadness. I used the word "blue" in talking to this man, and he said "not blue – more like black." Later he said "not really sad" and "it’s not like grieving." The way such statements are usually understood is that Melancholic patients are describing a feeling unlike anything that occurs naturally in life. We all know what sadness feels like and can be empathic with depression of the usual variety, but there’s not a similar connection with Melancholy. The Melancholic is not describing something we’ve personally ever felt [and knows it].
Self-attacking, self-flagellating, guilt, shame, low self esteem are all phrases used to describe the negative perception of the depressed person. In Melancholia, it seems to also have a different quality, though this is more how these patients seem to me than something I’ve read. They think the are bad, like a noun. But it’s not bad as in evil, it’s bad like "that pear has gone bad" eg rotten. And it’s often that they are bad because they are Melancholic – not because of things done or not done before. In the case in point, he said that he was bad because he didn’t want to work, get out of bed, be with his daughter, be any fun, etc. Something like being a rotten apple that would spoil the other apples in the barrel.
There’s more. The physical symptoms [sleep, appetite, diurnal variations, etc.] are prominent [see below]. There’s often a family history [Depressions, Manic Depressive Illness, Alcoholism, Suicides]. The patient may have had previous episodes of depression or comorbid alcoholism or alcohol problems. This is the clinical presentation of the Depressive Episodes in Manic Depressive Illness. Melancholic Depressives respond to Antidepressants regularly and are particularly responsive to ECT. Almost anyone who has talked about Melancholia over the ages has presumed Melancholia to be a biological disease. At the time I was in training, this was called Endogenous Depression, contrasted with Exogenous Depression – depressions related to life and personality. Like many other psychiatrists, I still essentially believe that schema, knowing full well that it hasn’t been proven.
The part that I least understood at the time was mentioned in the last post – the syndrome we were calling "endogenous depression." It was a classic, and the DSM-III even acknowledges it as such as Melancholia with its classic symptoms:
C. At least three of the following:
[a] distinct quality of depressed mood, i.e. the depressed mood is perceived as distinctly different from the kind of feeling experience following the death of a loved one[b] the depression is regularly worse in the morning[c] early morning awakening [at least two hours before usual time of awakening][d] marked psychomotor retardation or agitation[e] significant anorexia or weight loss[f] excessive or inappropriate guiltIn a footnote, they say of Melancholia:
A term from the past, in this manual used to indicate a typically severe form of depression that is particularly responsive to somatic therapy. The clinical features that characterize this syndrome have been referred to as "endogenous." Since the term "endogenous" implies, to many, the absence of precipitating stress, a characteristic not always associated with this syndrome, the term "endogenous" in not used in DSM-III.
The agenda of the DSM-III was to remove ideology from diagnosis [Adolf Meyers’ Depressive Reaction or the Freudian Depressive Neurosis]. That is understandable. But the patients didn’t change. My guess is that they were afraid to have a dichotomous depressive diagnosis because those "theories" might have lived on. There’s a simple fact that remains. The Melancholic Depressions are way in the minority. The other depressed patients would have disappeared from psychiatry altogether had they been in a category that implied "non-biologic" causes since Psychiatry was medicalizing and becoming biological, even though it was declaring itself "descriptive." My friends assure me that neither the drug companies nor the biological psychiatrists had anything to do with that decision – the rapid explosion of psychopharmacology that followed the DSM-III revision being opportunistism or serendipity. I have nothing more to say on that point.
This is a very clear and informative look at depression types. The Wikipedia entry on sickness behavior is helpful in understanding possible biological mechanisms for the behavioral manifestations.
There are many non-pharmacologic interventions that can be brought to bear on the inflammatory processes. They would include promoting circadian rhythms via sleep and rest, getting sufficient direct sunlight on a routine daily basis, participating in enjoyable aerobic and strength exercise on a daily basis, maintaining a whole foods-based anti-inflammatory diet, and having daily meaningful social interactions.
In essence, this is the fundamental basis of non-psychiatric nursing care: promotion and support of health behaviors toward achieving and maintaining the patient’s optimum function.
However, in order to achieve the activities listed, many essentials need to be in place: reliable safe shelter/housing, reliable and accessible sources of fresh potable water and wholesome food, reliable and safe transportation, the means to access daily meaningful social interactions, the ability to access safe outdoor areas for sun exposure, exercise and exposure to nature. All social, none psychiatry/medical-based.
In inpatient psychiatric settings, if there is any outdoor exposure at all (most hospital units have no outside access for patients in any form), it’s akin to cages: walls and roof prison fencing. There is nothing green, fresh, sun-filled or relaxing. There are no nature sounds. There are few, if any, meaningful social interactions on inpatient units. Outside the daily patient interrogations by the rotating cast of characters on the treatment team, patients are instructed to socialize with other patients, dubbed their “peers”. Nowhere else in healthcare are patients instructed to do that in order to “get better”. Oncology, cardiac, kidney failure, pedicatric, gerontologic patients, etc. aren’t forced to comingle. Indeed, this would be seen as coercive and a breach of patient confidentiality. As it should be in patients with diagnosed mental illnesses. The environment of inpatient psychiatric care is highly toxic, and it’s based on – what, exactly?
From my review of the psychiatric nursing and hospital administration literature, the environment was built largely on the principles and practices of prison control and management. Slap on some medical and nursing traidtions and left over Freud, and you are left with the misery that is inpatient psychiatric hospitalization. If one is profoundly depressed, is it logical to conclude that such an environment is actually iatrogenic instead of therapeutic?
Hospital food is highly processed, nutrient poor, inexpensive ingredient laden fare. If nutrients are offered, they are done so casually in pill form via vitamins and supplements, and not in whole and unadulterated food. Vitamin D is withheld from patients when they are denied outside time in direct sunlight.
The environment is sickness inducing.
Instead of patients being partnered with staff to participate in these activities on a continuum of dependence to independence, replete with customized treatment/ wellness management plans that are actionable, the overarching goal is hospital discharge. That’s actually a hospital target which has no bearing in and of itself to the patient’s health and wellbeing.
If psychiatry were to “take back” care for patients with melancholic depression, medication would only be one tool in the armamentarium.
As it stands, there is no “team leader” on the farcical treatment team.
Thank you very much, Mickey. Much for me to ponder. Appreciate AEG’s comments as well. Having had a child hospitalized five years ago (mercifully for a brief period of time), I share the bafflement that we think people are going to get better under florescent lights with no exposure to the outdoors, cruddy food, no exercise, etc., etc. As a point of interest, to my surprise, the staff psychiatrist recommended a therapeutic wilderness program at discharge, which did in fact happen. While no panacea, at least there is fresh air, exercise, healthy food, group support and encouragement, mastery of new skills (such as busting a fire), elimination of constant exposure to media and electronics, etc. Seems to make more sense than today’s psychiatric institutions.
Just wondering if we know from Irving Kirsch’s analysis of clinical trial data if he found any evidence of more efficacy from SSRIs if the depression was more “endogenous” or “melancholic” in nature? Or since the DSM III lumped all depression together, is there no way to separate that out in clinical trials? When you say Melancholic Depressives respond to antidepressants regularly and are particularly responsive to ECT, is that based on your observations in your clinical practice? On a different note, I do find the notion that depression caused by a clear precipitant (such as grief or loss of a job) is somehow going to be helped by a psychotropic drug makes no sense to me. And this is the case where I think Whitaker’s notion of an iatrogenic effect to be most plausible…when we muck with the chemistry of a brain, while the mind and soul of that human is trying to cope with tragedy, seems like we may just be making things worse.
From what you wrote, this section stands out: “Why not make it a disorder of its own and call it Melancholia. That would have allowed etiologic and therapeutic research to proceed.” Yes, this is the saddest part…while we’ve been assuming SSRIs and their ilk “work”, the suicide rates are the highest in a decade, Nemeroff is on the board of AFSP, and Nemeroff is leading Out of the Darkness Walks. Great plan.
When I was labeled with this diagnosis (endogenous depression)–many years ago–it was more ‘acceptable’ to me than a label of ‘mental illness’ or ‘melancholia.’ Identified as a mere ‘chemical imbalance’ enables me to more willingly comply with treatment recommendations. Tricyclics and the Prozac were helpful anesthetics that allowed me to cope . . . to push the black dog away for awhile . . . to kick the can down the road. I had a question, Mickey, based on an anecdotal observation. Have patients you treated for this disorder ever described as a symptom an overburdening sense of cold–a ‘chill’ that cuts to the bone and cannot be remedied by merely putting on a jacket. Some of my deepest holes were accompanied by an internal sensation of cold that surpassed harsh midwestern-winter outdoor exposure. I’ve never had occasion to visit with others who understood/acknowledged the difference between ‘melancholia’ and ‘depression’ (and yes! I believe there IS a difference). So, I had no way to compare observations regarding the accompanying symptom of indescribale bone-chilling, shivering cold.
Melody
Melody,
I’m certainly not the expert on Melancholic symptoms, having seen a only a finite number of cases myself. But I would not doubt your report for a second. The essence of melancholia is that it an experience that defies language because we don’t have a word or words for it, so those afflicted are forced to use metaphors. What I have seen in melancholia is a drive to convey the feeling to another person that is often frustrating because no matter how sympathetic the listener, one can see that they don’t know the feeling from the inside. There are other examples – the internal experience of traumatized people [“broken,” “not safe,” like a shattered widshield,” etc.] and incipient psychosis [emotional ataxia, “uncanny” emotions] come to mind. I think it’s why Styron’s book “Darkness Visible” is so widely quoted because he works so hard to describe the “indescribable.” I would add “…an overburdening sense of cold – a ‘chill’ that cuts to the bone and cannot be remedied by merely putting on a jacket” to the unique descriptions of experience that I have heard. They say – this is something like no other. I’ll bet if you were talking among people who had been through an episode – you would see nods of recognition on their faces, even if they had not described it in the same way.