Book Review

Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness

N Engl J Med 2007; 356:646-647February 8, 2007

Article

Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness
By Michael Alan Taylor and Max Fink. 544 pp. New York, Cambridge University Press, 2006. $150. ISBN: 978-0-521-84151-1

Depression is hardly a neglected subject. Not only is it recognized by the World Health Organization as the leading cause of disability worldwide, but library shelves groan with books on the subject. What distinguishes this book is its emphasis on an extreme form of depression, for which the authors, Michael Alan Taylor and Max Fink, use the old-fashioned term “melancholia.” They believe that patients with melancholia are not receiving optimal treatment because the field has shifted its attention to milder mood disorders. Their aim is to put melancholia back on the map.

They begin by reconsidering the classification of mood disorders in psychiatry's diagnostic guide, The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which, in the absence of sufficient knowledge about cause or pathophysiology, classifies most mental disorders as patterns of behavior. The category called mood disorders has a number of entries, such as major depressive disorder, dysthymic disorder, and bipolar disorder, each with a menu of characteristic symptoms as well as a series of “specifiers.” For major depression, the specifiers include severity (mild, moderate, or severe), the presence or absence of psychotic features (such as the delusion of deserving punishment), and “melancholic features” (such as loss of pleasure in all activities, anorexia, early-morning awakening, and psychomotor retardation or agitation).

Taylor and Fink propose a different way of slicing up the pie. Their objection to the official diagnostic scheme is that it fails to recognize melancholia as a “unique stage” of depression that “represents a qualitative change in underlying pathophysiology,” usually accompanied by impaired feedback regulation of the adrenal cortex. Because they believe that melancholia is a qualitatively different type of depression, they argue that the critical diagnostic distinction between various mood disorders should be that between melancholia and nonmelancholia.

Should a diagnosis of melancholia be made, the authors provide several therapeutic recommendations. The first is to consider initial treatment with a tricyclic antidepressant such as nortriptyline or desipramine, which the authors find more effective for melancholia than the selective serotonin-reuptake inhibitors (SSRIs) that are used widely for milder depression. Taylor and Fink are particularly skeptical of the practice of putting patients through lengthy trials with a series of ineffective SSRIs, thereby condemning the patients to months of excruciating mental distress. And they deplore the reluctance to use electroconvulsive therapy, which can quickly relieve melancholia in the vast majority of cases and which they think should be considered a first-line treatment for patients with melancholia accompanied by prominent psychotic symptoms.

For psychiatrists who specialize in the treatment of people with severe depression, there is not a lot that is new in this book. But Taylor and Fink are right to call attention to the current neglect of melancholic depression. For example, the elaborate and expensive study of treatments for major depression, Sequenced Treatment Alternatives to Relieve Depression (STAR*D),1,2 specifically excluded patients with depression with psychotic features, and many of these patients would probably meet Taylor and Fink's criteria for melancholia. The study also omitted electroconvulsive therapy as a treatment alternative for patients who did not respond to multiple drug trials, even though about 20% of the STAR*D patients had depression with melancholic features, as observed by Khan and colleagues.3

In considering the reasons why patients with melancholy no longer occupy center stage, Taylor and Fink speculate that “intrusive actions of the pharmaceutical industry encouraged a weakening of criteria to justify the use of antidepressant drugs in the largest number of persons.” Whereas the expansion of diagnostic criteria for depressive disorders, whatever its causes, has also had benefits, the authors' emphasis on the special nature of melancholia serves as a welcome reminder that we should pay more attention to this blackest form of mood disorder.

Samuel H. Barondes, M.D.
University of California, San Francisco, San Francisco, CA 94143-0984
barondes@cgl.ucsf.edu

References

References

1. 1

   Rush AJ, Trivedi MH, Wisniewski SR, et al. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. N Engl J Med 2006;354:1231-1242
   Full Text | Web of Science | Medline

2. 2

   Trivedi MH, Fava M, Wisniewski SR, et al. Medication augmentation after the failure of SSRIs for depression. N Engl J Med 2006;354:1243-1252
   Full Text | Web of Science | Medline

3. 3

   Khan AY, Carrithers J, Preskorn SH, et al. Clinical and demographic factors associated with DSM-IV melancholic depression. Ann Clin Psychiatry 2006;18:91-98
   CrossRef | Medline