Melancholia must be understood as distinct from depression

In Western nations – or nations whose ethos is philosophically Western – this is a relevant discussion. Economically, politically – on a global scale – we are diminished. Mostly by the incompetence of our own leaders. Yes, that is not limited to our political leaders.

First described by Hippocrates, “melancholia” or melancholic depression was considered a specific condition that commonly struck people out of the blue – and put them into the black. In modern times, it came to be described as “endogenous depression” (coming from within) in contrast to depression stemming in response to external stressors.

In 1980, the third edition of the Diagnostic and Statistical Manual (DSM-III), the official classificatory system of the American Psychiatric Association, re-modelled depressive disorders. The new classification operated largely on degrees of severity, comprising “major” depression and several minor depressions.

This is how depression came to be modelled as a single entity, varying only by severity (this is known as the dimensional model). And over the last decade, this model has been extended to include “sub-clinical depressions”, which is basically when someone is sad or down but not diagnosable by formal mental illness criteria.

The changes generated concern about the extension of “clinical depression” to include and “pathologise” sadness. While everyone feels down or sad sometimes, normally these moods pass, with little if any long-term consequences.

The boundary between this everyday kind of feeling down and clinical depression is imprecise. But the latter is associated with a greater severity of symptoms, such as losing sleep or thinking life isn’t worth living, lasts for longer and is much more likely to require treatment.

The dimensional model is intrinsically limited; “major depression” is no more informative a diagnosis than “major breathlessness”. It ignores the differing – biological, psychological and social – causes that may bring about a particular depressive condition and which inform the most appropriate therapeutic approach (be it an antidepressant drug, psychotherapy or social intervention)…

My research team is trying to establish melancholia’s categorical status and detection, and so improve its management. Here’s what we know – or think we know – about the distinctness of melancholia.

First, it shows a relatively clear pattern of symptoms and signs. The individual experiences profound bleakness and has no desire to socialise, for instance, finding it hard to obtain any pleasure in life or to be cheered up…

Episodes commonly emerge “out of the blue”. Even if it follows a stressor, it’s disproportionately more severe than might be expected and lasts longer than the stressor…

Melancholia has a strong genetic contribution, with sufferers likely to report a family history of “depression”, bipolar disorder or suicide. It’s largely biologically underpinned rather than caused by social factors (stressors) or psychological factors, such as personality style.

The illness is also unlikely to respond to placebo, whereas major depression has a placebo response rate in excess of 40%. But melancholia shows greater response to physical treatments, such as antidepressant drugs (especially those that work on a broader number of neurotransmitters), and to ECT (electroconvulsive therapy). ECT is rarely required, however, if appropriate medications are prescribed.

Phew!

Melancholia shows a lower response to psychotherapy, counselling and psychosocial interventions – these treatments are more salient and effective for non-melancholic depression.

Melancholia shows similar “treatment specificity”, with medication being the treatment of choice.

When is it anything else?

Clearly, melancholia needs to be recognised as a distinct psychiatric condition – not simply as a more severe expression of depression. This recognition could lead to improved clinical and community awareness, which is important because managing melancholia requires a specific treatment approach.

Though no mention is made of societal context, economics, socio-political realities, I presume to hope that treatment providers have the sophistication to peer around more broadly than suggested here. The feeling that Life Sucks sometimes is a direct reflection of the fact that Life Sucks. Not only for an individual; but, a whole class of people. That class defined in economic, ethnic, caste or gender terms.

When you live in a nation where the predominant political rulers, liberal or conservative, seem bent upon ruling the world through military and economic might – and their diminishing returns seem more and more likely to end in destruction of our species and a good deal of the world as well – melancholia rooted in political ineffectuality seems a logical choice.

Sometimes.

Photos of a war crime in progress


Click to enlarge — Ezz Al-Zanoun/Getty Images

A boy stands at a funeral ceremony held for Palestinian Abu Jamei, who died after an Israeli aircraft hit his house in Khan Yunis, Gaza

“You can’t have occupation and human rights.”

That’s what public intellectual and essayist Christopher Hitchens had to say about Israel’s occupation of Palestinian territories, one of the most contentious components of the decades-long Israeli-Palestinian conflict.

This conflict came to a head once again last summer, when Israel launched a seven-week military campaign in the Gaza Strip region of Palestine that resulted in about 2,200 deaths — 1,500 of them civilian.

This campaign is just the latest in a long line of fighting in Gaza — and beyond, so much so that the United Nations just reported that within five years, Gaza could be uninhabitable.

Click this link to see more of the story, more photos.