From the Guidelines
Melancholy syndrome, a severe subtype of major depressive disorder, should be treated with a combination of antidepressant medication and psychotherapy, prioritizing selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) as first-line treatments, as they have similar efficacy and are viable choices for initial treatment, according to the most recent and highest quality study 1.
Treatment Options
- Antidepressant medication: SSRIs like sertraline (50-200mg daily) or escitalopram (10-20mg daily) are often first-line medications, though tricyclic antidepressants such as amitriptyline (75-150mg daily) or serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine (75-225mg daily) may be more effective for melancholic features.
- Psychotherapy: CBT sessions (typically 12-16 weekly sessions) complement medication by addressing negative thought patterns.
Key Considerations
- Treatment should continue for at least 6-12 months after symptom resolution to prevent relapse.
- Physical symptoms like early morning awakening, significant weight loss, and psychomotor retardation are hallmarks of this condition.
- The biological basis involves dysregulation of the hypothalamic-pituitary-adrenal axis and neurotransmitter imbalances, particularly affecting serotonin, norepinephrine, and dopamine systems.
Importance of Prompt Evaluation and Treatment
- Due to the severity of symptoms and increased suicide risk, prompt professional evaluation and consistent treatment adherence are essential.
- The American College of Physicians recommends considering patient preferences and MDD severity when choosing initial treatment, and the Canadian Network for Mood and Anxiety Treatments suggests CAM interventions as an additional option for MDD of mild to moderate severity 1.
From the FDA Drug Label
The efficacy of Venlafaxine Hydrochloride Tablets in the treatment of major depressive disorder was established in 6-week controlled trials of adult outpatients whose diagnoses corresponded most closely to the DSM-III or DSM-III-R category of major depression and in a 4-week controlled trial of inpatients meeting diagnostic criteria for major depression with melancholia A major depressive episode implies a prominent and relatively persistent depressed or dysphoric mood that usually interferes with daily functioning (nearly every day for at least 2 weeks); it should include at least 4 of the following 8 symptoms: change in appetite, change in sleep, psychomotor agitation or retardation, loss of interest in usual activities or decrease in sexual drive, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, and a suicide attempt or suicidal ideation. The fifth was a 4-week study of adult inpatients meeting DSM-III-R criteria for major depression with melancholia whose venlafaxine HCl doses were titrated in a range of 150 to 375 mg/day (t.i. d. schedule).
Venlafaxine is indicated for the treatment of major depressive disorder, including melancholia. The efficacy of venlafaxine in treating melancholia was established in a 4-week controlled trial of inpatients meeting diagnostic criteria for major depression with melancholia 2.
- Key symptoms of major depressive episode include:
- Change in appetite
- Change in sleep
- Psychomotor agitation or retardation
- Loss of interest in usual activities or decrease in sexual drive
- Increased fatigue
- Feelings of guilt or worthlessness
- Slowed thinking or impaired concentration
- Suicide attempt or suicidal ideation The recommended dose for treating major depression with melancholia was titrated in a range of 150 to 375 mg/day 2.
From the Research
Definition and Characteristics of Melancholy Syndrome
- Melancholy syndrome is a condition characterized by a distinct quality of mood that cannot be interpreted as severe depression 3
- It has a history that reaches back to Hippocratic times, and its modern meaning was established based on Kraepelin's manic-depressive illness 3
- Melancholia differs from depression in terms of origin, psychopathology, and therapy 3
Prevalence and Clinical Features of Melancholy Syndrome
- A European multicenter study found a prevalence rate of 60.71% for melancholic features in major depressive disorder (MDD) patients 4
- Melancholic MDD patients were characterized by a significantly higher likelihood of higher weight, unemployment, psychotic features, suicide risk, inpatient treatment, severe depressive symptoms, and receiving add-on medication strategies 4
- They were also less likely to be prescribed selective serotonin reuptake inhibitors (SSRIs) 4
Treatment of Melancholy Syndrome
- There is no evidence to support a specific treatment strategy for melancholic MDD patients, but their prescribed medication strategies were different from those for patients without melancholia 4
- A study found that the combination of fluoxetine with cognitive-behavioral therapy (CBT) was superior to fluoxetine alone, CBT alone, and placebo in treating adolescents with major depressive disorder 5
- Another study found that continuing SSRIs for 1 year reduces the risk of major depressive disorder and relapse, and that the combination of SSRIs and CBT may effectively reduce relapse 6
Comparison with Depression
- Depression and melancholia are two distinct conditions that were combined into a single category in DSM-III 3
- Depression is a deepened or prolonged sadness in everyday life, while melancholia has a distinct quality of mood that cannot be interpreted as severe depression 3
- The treatment of depression and melancholia differs, with depression being treated with a diverse range of methods, including rest, talk therapy, and medication, while melancholia has primarily been treated with somatic therapy, such as electroconvulsive therapy, and tricyclic antidepressants 3