An Overview of Melancholic Depression

Older man with depression
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Melancholic depression is a form of major depressive disorder (MDD) that is characterized by a profound presentation of severe depression. With this form of depression, there is a complete loss of pleasure in all or almost everything. In the DSM-5, melancholia is a specifier for MDD, so a person would be diagnosed as having major depressive disorder with melancholic features. 

While melancholic depression is no longer considered a separate diagnosis, some researchers suggest that it should be considered a distinct syndrome in order to improve treatments and outcomes.

The term 'melancholia' is one of the oldest terms used in psychology. It has been around since Hippocrates introduced it in the fifth century B.C., and it means "black bile" in Greek. This is fitting because Hippocrates believed that an excess of black bile, one of what he labeled "The Four ​Humours," caused melancholia. The symptoms he categorized under melancholia are nearly identical to the symptoms we use today, including fear, not wanting to eat, insomnia, restlessness, agitation, and sadness. 


Symptoms of melancholic depression include:

  • A distinct quality of depressed mood characterized by profound despondency, despair, or emptiness: You're not simply sad or down due to a life event, such as the death of a loved one. What you're feeling is greater than that.
  • Depression is consistently worse in the morning
  • Early morning waking of at least two hours earlier than normal
  • Psychomotor disturbances of either retardation, the slowing of normal movement, or agitation, increased and/or irregular movement
  • Anorexia or weight loss
  • Excessive or inappropriate guilt

To clarify the type of mental health disorder you have, your doctor may use specifiers. For instance, if you have severe depression with symptoms of melancholia, you may be diagnosed as having major depressive disorder (the broader illness) with melancholic features (the specific symptoms).


The start of these episodes is usually not caused by a specific event. Even when something good happens, the individual's mood does not improve, not even for a short time. 

Older people, inpatients, and those who exhibit psychotic features are at greater risk for melancholic depression.

The exact causes of depression are not clear, but genetics, family history, past trauma, brain chemistry, and hormones may all play a role. Melancholic depression, however, is believed to have strong biological origins.

One neuroimaging study found that a key "signature" marker was only seen in participants with melancholic depression but was not observed in those with non-melancholic depression or in those without depression.


Your doctor will start with an evaluation to assess the nature, severity, and duration of your symptoms. Some of the questions your doctor may ask include:

  • Has your daily routine changed?
  • Do you still enjoy the things you used to like doing?
  • Do you have trouble getting out of bed in the morning?
  • How do you sleep?
  • Are your symptoms worse in the morning?
  • Is it difficult for you to concentrate?
  • Is there anything that helps improve your mood?

Your doctor will also evaluate your physical health and may perform some tests or blood work to check that your symptoms are not related to some type of underlying medical condition.

In order to be diagnosed with melancholic depression, an individual must exhibit symptoms of major depressive disorder such as:

  • Feelings of persistent sadness
  • Loss of interest and pleasure
  • Low energy or fatigue
  • Irritability
  • Appetite changes
  • Sleep difficulties
  • Changes in activity levels
  • Difficulty concentrating
  • Thoughts of dying or suicide

To be diagnosed with melancholic features, you must have at least three of these symptoms:

  • Depression that is different from grief
  • Weight loss or loss of appetite
  • Slowed activity or restlessness
  • Excessive guilt
  • Waking much earlier than normal
  • More severe depressive symptoms in the morning

Your doctor will also rule out other conditions. Other issues that may be considered include:

  • Bipolar disorder
  • Cyclothymic disorder
  • Persistent depressive disorder
  • Disruptive mood dysregulation disorder
  • Premenstrual dysphoric disorder
  • Depression that's caused by illicit drugs, prescribed medications or some physical illness


For melancholic depression, medication is almost always a must because it seems to have a biological root. In other words, since it is usually not triggered by outside circumstances, the causes appear to be mainly due to genetic makeup and brain function, necessitating a medication that works on biological causes like brain function.

Types of antidepressants that may be used for melancholic depression include:

  • Selective serotonin reuptake inhibitors (SSRIs): These medications work by changing the way the neurotransmitter serotonin works in the brain, improving mood. Typical kinds include Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), and Lexapro (escitalopram).
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs affect the way both serotonin and norepinephrine work in the brain. Common kinds are Cymbalta (duloxetine) and Effexor (venlafaxine).
  • Norepinephrine and dopamine reuptake inhibitors (NDRIs): Wellbutrin (bupropion) is the only medication in this class that affects norepinephrine and dopamine.
  • Atypical antidepressants: These medications affect brain chemicals which seem to improve mood. Examples of medicines in this category are Remeron (mirtazapine), Oleptro (trazodone), Brintellix (vortioxetine), and Viibryd (vilazodone).
  • Tricyclic antidepressants (TCAs): These are first-generation of antidepressants and may have more side effects than newer versions. This class includes Tofranil (imipramine), Pamelor (nortriptyline), and amitriptyline.
  • Monoamine oxidase inhibitors (MAOIs): This is another older class of antidepressants that can have serious side effects but may be a good option for certain people. The main medications in this class are Parnate (tranylcypromine), Nardil (phenelzine), and Marplan (isocarboxazid).

Research suggests that melancholic depression responds better to tricyclic antidepressants than to SSRIs, psychotherapy, or social interventions. 


Because melancholic depression is characterized by such profound feelings of sadness, loss of pleasure, and lack of interest in daily activities, it can create major disruptions in how a person is able to function in many areas of life.

If you suspect that you have melancholic symptoms, you should talk to your doctor. Antidepressants are the first-line of treatment for this condition and can be very effective. There are, however, some things that you can do to help manage your symptoms and complement your medication-based treatments.

Lifestyle modifications that may help improve your mood include:

  • Getting regular exercise
  • Spending time with friends and loved ones
  • Eating a healthy diet
  • Meditation
  • Following a consistent sleep schedule

It is important to remember, however, that the symptoms of melancholic depression can make all of these things very difficult. Once your medications begin to take effect, you may find it easier to start incorporating these into your daily routine.

Online resources and support groups may also be helpful for managing your symptoms of melancholic depression. Talk to your doctor to decide if this is a good option to complement your other treatments.

If your depressive symptoms seem to be worsening or if you are experiencing suicidal thoughts, you should talk to your doctor immediately. You can also reach out to the National Suicide Prevention Lifeline at 1-800-273-8255.

A Word From Verywell

Melancholic depression can have a serious impact on your work, school, social, and home life. Fortunately, there are effective treatments that can help. If you have symptoms of depression, talk to your doctor who can rule out other causes and recommend treatment options that can help you get back to your regular self.

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