Melancholy - not just a ‘state of mind’ but maybe a mental illness

By Dr. Ananya Mandal, MDMar 19 2010

Dr. Ananya Mandal, MD

Melancholia was first identified by the Greek physician Hippocrates, who described sufferers as being plagued with ''fears and despondencies''. But due to lack of exact biochemical and clinical features this condition has been struck off the Diagnostic and Statistical Manual of Mental Disorders used worldwide to diagnose mental illnesses.

Gordon Parker, a professor of psychiatry at the University of NSW and director of the Black Dog Institute, is heading a team of 17 international psychiatrists who want the 2500-year-old condition, melancholia, listed as an illness in its own right in the next edition of the Diagnostic and Statistical Manual of Mental Disorders, due in 2013.

In the current edition, the DSM-IV-TR, psychiatrists must choose between diagnosing major or minor depression for patients with the usual treatments including antidepressants, and psychotherapy or counseling.

Impact

Australia alone is estimated to have over 600,000 melancholic patients. Treating melancholic patients with counseling has been found to be ineffective leading to a rise in suicides in this population of patients.

''I see about three people a week who have had meandering psychotherapy for years with no real outcome,'' said Dr. Parker.

''Major depression seems to have gravitas and meaning but the treatment is very open-ended. If you see a psychiatrist, you will get drugs and cognitive behavioural therapy. If you see a counselor, you will get counseling. But if you see someone in a kaftan, you will get crystal therapy … That's why I'm against it being used as a diagnosis,'' Professor Parker said.

Clinical features

Professor Parker says melancholy is a very physical state, with many sufferers at risk of suicide. "The person's signs of concentration [are] quite distinct and impaired, so that they can't read something or concentrate on it," he said. "Secondly they can have what we called retardation. "Where they feel very slowed down, a lack of energy. It's almost impossible to get out of bed and have a bath or shower. "They find their mood is lacking in any pleasure. They can't be cheered up, they can't look forward to anything."

Opposition

However there are eminent psychiatrists still opposing the inclusion of this condition as a separate illness. Ian Hickie, the executive director of the Brain and Mind Research Institute, said there was no new evidence to include melancholia in the manual and no evidence people with varying forms of depression responded to particular medications.

''The approach being championed by [Professor Parker] reached its zenith in the '80s but it hasn't delivered,'' Professor Hickie said. ''There is little interest elsewhere in the world in this because it cannot be supported by biochemistry.''

Way forward in therapy for Melancholia

The Black Dog Institute is about to embark on a study of three treatments that will take three years. "At the moment we feel that many treatments are just being given in a universal, non-specific way," Professor Parker said. "We need a more rational model. What that will actually do to the sales of anti-depressants is, I think, predictable, but not likely to be an expansion."