Melancholic depression is a type of major depressive disorder (MDD) that has a dire effect on virtually all areas of life including work, school, and relationships. This severe form of clinical depression causes a near total loss of any sense of pleasure in almost every aspect of daily life. 

Though it’s no longer considered its own diagnosis per the DSM-5, some doctors and researchers still believe it should be so that treatment options can be improved. 

What is melancholic depression? What are some of the major melancholic depression symptoms and signs? What causes it, how is it diagnosed, do you need to take a depression test, and what treatments are available? Read on to learn everything there is to know about melancholic depression. 

What is Melancholic Depression?

Melancholic depression is a subtype, or specifier, for major depressive disorder (MDD). Melancholia is a term that’s been used in psychology since the 5th century B.C. First introduced by Hippocrates, the term is still fitting, as the original symptoms categorized under this melancholic subtype are virtually the exact same as what we use today. Fear, insomnia, lack of appetite or not wanting to eat, restlessness, sadness, and extreme agitation are all symptoms of melancholic depression.

“If things that you once enjoyed doing now feel just a bit empty or emotionless, that could be a sign to look out for as it relates to possible melancholic depression. There is hope, and there is treatment out there, you deserve it.”

Talkspace therapist Kate Rosenblatt, MA, LPC, LMHC

Signs & Symptoms of Melancholic Depression

There are many melancholic depression symptoms to be aware of if you’re concerned that you or someone you love might be living with this form of depression. Melancholic symptoms are more likely to be seen in people who have very severe major depressive disorder symptoms or who experience MDD with psychotic features.

If you’re thinking to yourself, “my depression is getting worse,” here is a list of symptoms similar to MDD:

  • Despair, profound and extreme despondency, emptiness
  • Depressive symptoms that are worse in the morning
  • Loss of interest in once-enjoyed activities
  • Weight loss
  • Anorexia
  • Waking at least two hours before your normal time in the mornings
  • Inappropriate or excessive guilt
  • Agitation 
  • Psychomotor disturbances such as slow normal movement or irregular or increased movement
  • Sleep disruptions
  • Inability to react appropriately to good news
  • Difficulty concentrating
  • Thinking about and/or talking about death
  • Thinking about suicide
  • Attempting suicide

“It’s helpful to know your own mental health ‘baseline’ around depression symptoms, meaning, what does a usual day feel like for you, or how do you usually respond to certain stressors? Knowing our own baselines can be helpful, especially when we’re not feeling like our usual selves. So if you’re noticing feelings of more hopelessness, or guilt, or an emptiness, or any changes in your appetite or sleep, it would be helpful to speak with a trusted mental healthcare provider to discuss what’s been going on and to get some support.”

Talkspace therapist Kate Rosenblatt, MA, LPC, LMHC

What Causes Melancholic Depression?

Unlike some other forms of depression, melancholic depression typically isn’t the result of a single triggering event. Specific to melancholic depression is the fact that even when good things happen in your life, the result won’t be an improved mood. While the exact cause of depression isn’t totally understood, a few things come in to play that can increase risk, including:

  • Family history
  • Genetics
  • Brain chemistry
  • Trauma experienced in your past
  • Hormones

Melancholic depression is widely accepted to have a strong biological origin. One study shows a signature marker that’s been found only in people with melancholic depression (but not in people with other forms of depression or in people who don’t have any form of depression at all). 

Diagnosing Melancholic Depression

Since melancholic depression isn’t recognized by the American Psychiatric Association (APA), making a diagnosis can be a little bit different. Now the APA considers melancholic depression a type of depression. If you have symptoms of melancholy with your depression, your diagnosis would likely be major depressive disorder with melancholic features.

There are a few common questions that doctors will most likely ask during an assessment. Some of them may include:

  • Does anything improve your mood?
  • Is it difficult for you to get out of bed in the morning?
  • Do you struggle getting your morning started?
  • Have you noticed that your daily routine has changed recently?
  • Do you find that your symptoms are worse in the morning or in the evening time?
  • Do you feel like you sleep well most nights?
  • Have you recently noticed a significant change in your sleep habits?
  • Can you describe what a normal day looks like?
  • Do you enjoy things like you always have, or have you noticed a difference in what brings you pleasure?
  • How is your concentration — do you feel like you have trouble concentrating?

Wondering if you have a form of depression like melancholic depression? Check out our depression test.  

In addition to an evaluation that’s used to assess how severe your symptoms are, it’s not uncommon for your physical health to also be evaluated. This might include bloodwork and additional medical testing to rule out the possibility that some of your symptoms might be related to an underlying medical condition not related to depression.

For a melancholic depression diagnosis to be made, you must show symptoms of melancholic MDD including:

  • A loss of interest and pleasure in activities
  • Persistent feelings of sadness
  • Irritability
  • Low energy
  • Difficulty with sleep habits
  • Changes in appetite
  • Altered activity levels
  • Increased difficulty with concentration
  • Thoughts of dying
  • Thoughts of suicide

Additional symptoms can also include “can’t get out of bed depression.” 

At least three of the following symptoms must be present for a melancholic diagnosis to be made:

  • Weight loss or a loss of appetite
  • Depression not related to grief
  • Excessive guilt
  • Slowed activity or feeling restless
  • Waking earlier than normal
  • Increased depressive symptoms in the morning hours

Finally, several other conditions will need to be ruled out before a melancholic diagnosis can be made. Some of these issues can include:

  • Cyclothymic disorder
  • Bipolar disorder
  • Persistent depressive disorder
  • Premenstrual dysphoric disorder
  • Disruptive mood dysregulation disorder
  • Depression that’s the result of prescription medication, illicit drugs, or a variety of physical ailments

Types of Treatment for Melancholic Depression

Melancholic depression is widely accepted to be the result of a biological route, not something that’s triggered by outside circumstances. Because of this, medication is most often a big part of a treatment plan. Melancholic depression seems to be largely due to brain function and genetic makeup. This means the medication prescribed needs to be effective at addressing biological causes such as brain function.

Some antidepressant treatments that might be prescribed to treat melancholic depression include:

  • Selective serotonin reuptake inhibitors (SSRIs) — SSRIs change how neurotransmitter serotonin affects the brain, which is how they can help improve your depressed mood. MDD is often treated with SSRIs, but people who have MDD with melancholic features might actually have a better response to first line antidepressant treatment. 
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) — SNRIs can change how norepinephrine and serotonin work in the brain. 
  • Norepinephrine and dopamine reuptake inhibitors (NDRIs) — The only NDRI that works on norepinephrine and dopamine is a medication known as Wellbutrin.
  • Atypical antidepressants — By having an impact on brain chemicals that improve your depressed mood, atypical antidepressants might be prescribed to treat melancholic depression.
  • Tricyclic antidepressants (TCAs) – TCAs are known as the first generation antidepressant treatment. One drawback to using TCAs in general is they tend to have more potential side effects than newer medications might.
  • Monoamine oxidase inhibitors (MAOIs) – MAOIs are also older medications. They have the potential to cause severe side effects, but for a specific type of person, they can still sometimes be a good option.

Medication isn’t the only way to treat melancholic depression. Psychotherapy, also commonly known as talk therapy, is an effective form of treatment, especially when it’s combined with medication. For most people, combining these two treatment options can be an effective way to manage melancholic depression.

Therapy for melancholic depression can be done in person or through online therapy sessions. Therapy can show you how to effectively:

  • Deal with stress in your life
  • Adjust after experiencing a major crisis
  • Identify and then replace negative beliefs or behaviors with positive ones
  • Enhance your communication skills
  • Increase your self-esteem
  • Help you learn how to cope with challenges in your life
  • Teach you how to identify and solve problems
  • Help you create a sense of control in your life

Individual one-on-one therapy is not the only option for someone looking to treat melancholic depression. Group therapy has been found effective as well.

Very extreme and severe cases might benefit from electroconvulsive therapy (ECT). By attaching electrodes that send electrical impulses to the brain, a mild seizure is triggered. Even though ECT has been proven safe and effective, there’s still a pretty negative stigma attached to the idea of using it to treat mental health conditions and mood disorders. For this reason alone, it’s generally not the first line of treatment for melancholic depression. That said, combining therapy, medication, and ECT may be an effective treatment option for melancholic depression symptoms if medication and therapy combined aren’t sufficient.

Therapy through Talkspace can be an affordable, effective, and accessible way for you to treat your melancholic depression. If you’re living with MDD with major depressive disorder with melancholic features, it might be time to consider getting the help you need.