Melancholic Depression: Symptoms and Treatment Options

Depression is a common mental illness that affects tens of millions of people per year. Although many people think of depression as a single mental illness, there are several distinct types and subtypes of depression, each with distinct symptoms. 

Melancholic depression, or major depressive disorder with melancholic features, is a subtype of depression. 

If you have melancholic depression or are experiencing a melancholic depressive episode, you may experience an almost complete loss of pleasure in your life, as well as noticeable feelings of hopelessness, despair and emptiness. 

These feelings can be persistent, and it’s far from uncommon for them to interfere with your day-to-day life.

Like other types of depression, melancholic depression can be treated with medication, therapy and lifestyle changes.

Below, we’ve explained what melancholic depression is, as well as the symptoms you may start to experience if you have this form of depression. 

We’ve also discussed the factors that can contribute to melancholic depression, as well as your options for seeking treatment and improving your quality of life. 

Melancholic depression, or melancholia, is a subtype of major depressive disorder. It’s defined by several unique symptoms, including intense, persistent feelings of hopelessness, guilt and a lack of pleasure from life. 

Previously, melancholic depression was viewed as a separate disorder from depression. Today, it’s generally viewed as a subtype or specifier of major depressive disorder. 

Between 25 and 30 percent of people with depression have melancholic symptoms.

Within the mental health community, there has been ongoing debate about whether melancholia should be seen as a subtype of depression or as its own distinct syndrome.

The term “melancholia” is several millennia old and stems from the ancient theory that diseases were caused by an imbalance in the four humors, or internal bodily liquids. 

Thousands of years before the modern germ theory of disease originated, physicians believed that many medical conditions were caused by imbalances in the body’s levels of blood, yellow bile, phlegm and black bile.

Large amounts of black bile, or melancholia (which is derived from the Greek word for black bile), were thought to contribute to depressive thoughts in people.

Although modern medicine shows us that this isn’t true, the term melancholia has stuck around and remains used to describe this type of depressive illness.

Some of the symptoms of melancholic depression are similar to those of depression, or major depressive disorder. However, melancholic depression also involves some symptoms that can be uniquely severe or pronounced. These include: 

• A pervasive lack of pleasure from activities and hobbies. A common symptom of melancholic depression is anhedonia — an inability to feel pleasure during activities or occasions that would otherwise make you feel happy and satisfied.If you have melancholic depression, you might find it difficult to find anything enjoyable, even if it was previously one of your favorite hobbies or activities.

• Feelings of hopelessness, guilt or ruin. It’s common for depressed patients to experience a depressed mood if they have melancholic depression. You may feel hopeless, guilty or as if you’re stuck in a desperate situation.

• Reduced emotional responses. A common symptom of melancholic depression is a nonreactive mood. You may find it difficult to care about or react to anything, even if it would normally provoke a positive or negative response from you. 

• Cognitive impairment. Several forms of depression can affect your cognitive function, including melancholic depression. When you’re depressed, you may find it more difficult to focus on specific tasks or remember information. 

• Slowed movements and speech. Melancholic depression often involves psychomotor disturbances — slowness in your movement and thought. You may notice that you move slower than usual, or that your speech patterns are slightly different.

• Spontaneous agitation. Psychomotor disturbances can also result in sudden physical agitation and movement, such as motor restlessness — an irresistible urge to move your limbs.

• Difficulty falling asleep or staying asleep. Many forms of depression can affect your sleep, including melancholic depression. You may experience insomnia, or wake up in the night due to interruptions in your sleep cycle.Research suggests that melancholic depression can affect the architecture of your sleep, causing you to spend less time in deep sleep during the night.

• Loss of appetite and/or weight. Depression commonly involves changes in your eating habits and appetite. If you have melancholic depression, you may lose the desire to eat and experience weight loss.

• More severe symptoms in the morning. Melancholic depression often involves diurnal variation — fluctuations in the severity of your symptoms throughout the day, and with melancholic depression you are likely to feel worse in the morning.

The symptoms of melancholic depression are often severe. Depressed patients with melancholic depression have an elevated risk of experiencing suicidal thoughts and/or behavior.

Melancholic depression may develop later in life than non-melancholic depression. Some of the symptoms of melancholic depression, such as psychomotor disturbances (notable appearance of slowing or increased physical motor activity, changes in discrete body movements, and speech characteristics during a depressed state, sometimes also referred to as psychomotor retardation or psychomotor agitation), may be more distinct in older people.

Not everyone with melancholic depression experiences all of these symptoms. You may develop certain symptoms of melancholic depression, along with other, more general symptoms of major depression or other forms of depressive illness. 

Numerous factors are believed to cause depression, including genetics, traumatic and stressful life events, physical illnesses and even certain types of medication.

Experts believe that melancholic depression in depressed patients is caused by biological factors rather than social or psychological ones. There may be a strong genetic component to melancholic depression.

Some research has found that melancholic depressed patients have physical differences in brain composition and function, such as decreased connectivity between parts of the brain that control sensation and memory.

If you think you might have melancholic depression, it’s important to contact a licensed mental health provider for help.

You can do this by talking to your primary care provider and asking for a mental health referral, by contacting a psychiatrist in your city, or from home using our psychiatry service to talk with a licensed psychiatry provider online.

As part of the evaluation process, your provider may ask you about the type of symptoms you’re  currently experiencing, their severity and how long they’ve lasted.

You might also be asked about specific aspects of your depressive symptoms, such as how you sleep, whether or not you experience enjoyment from certain activities, or if you have symptoms that become more severe at certain times of day.

Like with other forms of depression, your mental health provider might ask you to complete one or several assessments in order to provide an accurate diagnosis. 

Make sure to answer honestly and in full so that your provider has all the information they need to treat you. 

If you have melancholic depression, your healthcare provider will likely diagnose you with major depressive disorder with melancholic features. 

While melancholic depression is treatable, it often requires a different treatment approach from major depressive disorder. Remission is less common, and many of the approaches that work for clinical depression may not be fully effective for melancholic depression.

Medication

Like other forms of depression, melancholic depression is often treated using medications called antidepressants.

Antidepressants work by changing  the levels of certain neurotransmitters in your brain, such as serotonin. They can take several weeks to start working, but are often effective for people with depression or other forms of mental illness. 

Several different types of antidepressants are prescribed to treat depression, including selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs) and older medications, such as monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs).

Your healthcare provider might prescribe an antidepressant to treat your melancholic depression symptoms and help you recover.

Research suggests that older antidepressants, such as tricyclic antidepressants, are often more effective at treating melancholic depression than newer medications, but other research has refuted this, suggesting that SSRIs may be just as effective as older medications for this type of depression.

You might need to try several antidepressants before finding the medication that’s best suited to your symptoms and personal needs. 

Therapy

Depression is often treated with psychotherapy, or talk therapy. Psychotherapy involves talking to a mental health provider, such as a psychiatrist, psychologist or therapist, to learn strategies for identifying and changing their thoughts and behavior.

There are many types of therapy, one form of therapy that’s often used to manage depression is cognitive behavioral therapy, or CBT. This type of therapy involves identifying the unhelpful ways of thinking that contribute to depression, then implementing techniques to cope with them and relieve symptoms. 

While therapy is effective for major depressive disorder, it isn’t always as effective for melancholic depression. 

In fact, research suggests that people affected by melancholic depression often fail to respond to talk therapy or social interventions.

To improve your results, your mental health provider may combine talk therapy with other forms of treatment for depression. 

Electroconvulsive Therapy

Melancholic depression is sometimes treated with electroconvulsive therapy (ECT), a treatment that involves stimulating the brain using electricity.

ECT is typically used to treat people with severe forms of depression that don’t respond to other treatments. Your mental health provider may suggest ECT if you have melancholic depression that doesn’t improve with antidepressants or therapy alone.

Melancholic depression is a serious mental illness that can affect every aspect of your life, from your moods and feelings to your ability to maintain your career and relationships.

If you think you may have melancholic depression, it’s important to talk to an expert. 

You can do this by scheduling an appointment with a licensed mental health provider in your city, or by using our online mental health services to talk to a licensed provider from your home. 

Worried about depression? Our guide to the signs of clinical depression explains what you might experience if you’re depressed, as well as the steps that you can take to get help and make real progress towards recovery.