Melancholia: A Distinct Entity?

As the debates about the future shape of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, continue, a review of one of the liveliest arguments, about melancholia as a diagnostic category in its own right, appears timely.In A Case for Reprising and Redefining Melancholia, Dr Gordon Parker1 argues persuasively for melancholia being positioned as a separate, independent subtype of depression. He points out that the diagnosis of melancholic can be delineated with relative precision, and that it has important clinical consequences in favouring biological therapy (drug and electroconvulsive) above psychotherapy, and broad-spectrum antidepressants (ADs) over narrow-action selective serotonin reuptake inhibitors. Conversely, and disconcertingly, the current accretion of varied depressive syndromes under only one diagnostic umbrella precludes both targeted treatments and more productive research of the different entities.When Dr Parker1 reminds us of the limitations to current, unitary, severity-based grouping of depressions, it is hard not to agree with his argument for a separate melancholic category. The DSM symptom-based diagnoses have a century-old, historical foundation and have served satisfactorily for shorthand communication among mental health professionals and for administrative purposes. However, for what is now really needed and missing, both in practice and in research advancement, the current classification has fundamental limitations. As Dr Parker points out, when we now ask for a diagnosis helpful in selecting effective treatment, informing about prognosis and advancing research of the underpinnings, we leave empty-handed.To be fair, DSM-1II was a step forward, compared with its predecessors, which were based largely on speculative theories. Nevertheless, stressing reproducibility without accompanying validity of mood disorder diagnoses created entities that are inadequately demarcated and highly heterogeneous. The current mood disorder categories neither serve the clinical need for guidance in treatment nor inform psychobiological research.Dr Parker's metaphor of major breathlessness standing for major depression1· p m is indeed instructive: it shows how in other areas of medicine these nonspecific entities would not stand as acceptable or valid constructs of disease. One can think of many similar examples from medicine where a seemingly reproducible but abundantly heterogeneous and invalid diagnostic construct would not survive.Of course, a dispute about the classification of depressions is not new. Dr Parker revives another question that raged a few decades ago: Is there 1 large unitary or 2 distinctly binary depressions (for example, endogenous depression and reactive and (or) neurotic depression1· p 286). Amusingly, he points out that the binary model of low mood was already mentioned by St Paul in the Bible. Dr Parker spent a long time searching for the right answer2·5 and discovered that the solution depends on methodology: eliminating nonspecific symptoms leads unavoidably to 2 types of depression; 2 distinct categories that had been employed in clinical practice for decades. Despite this evidence, a unitarian view was introduced in DSM-III and the International Classification of Diseases, 10th Revision, with clinical varying merely dimensionally. This approach has been consolidated during the past 3 decades - long outlasting its expiry date.While dissatisfied, Dr Parker1 does not favour a return to the old binary categories; he proposes a new revision delineating melancholia from a group of other, nonmelancholic depressions. And he supports his argument by the utility and validity of his revision and recommends concentrated studies to improve melancholia's clinical distinction. It may be worth mentioning that similar arguments about the limitations of DSM approach can be made not only about depressive disorders but also about the bipolar spectrum. …

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