Melancholia

   As a term used in medicine since the ancient Greeks, "melancholia" had two core elements of meaning, neither specifically referring to sad forms of depression: (1) All mental affections in which mood, drive, and intellectual function were somehow down ("mania" meant the opposite); (2) Melancholia as a synonym for madness, in the sense of fixed delusional ideas (mania involved false perceptions, or hallucinations). For example, in 1809 John Haslam (1764–1844), the "apothecary" of Bethlem Hospital ("Bedlam") in London, wrote, "As the terms Mania and Melancholia are in general use, and serve to distinguish the forms under which insanity is exhibited, there can be no objection to retain them; but I would strongly oppose their being considered as opposite diseases. In both there is an equal derangement" (Observations on Madness and Melancholy, 2nd ed., pp. 36–37). Breaking with centuries of humoral theory, in which melancholia was linked to an excess of "black bile," in his First Lines of the Practice of Physic (1777), William Cullen, professor of the institutes of medicine at Edinburgh University, attempted to rearrange the classification of diseases on a more modern basis. He was not the first to break with the past on this, but he was the most important. He identified the "Vesaniae," or disorders of intellectual function, and among the Vesaniae he singled out melancholia, by which he meant "partial insanity," and mania, which meant "universal insanity." Cullen’s system, of great influence upon his successors, thus paid little attention to mood disorders as such (though he did mention "despondence" and "weariness of life," and considered "depressed spirits" elsewhere in the volume, among the "adynamiae"). Many pre-1850 accounts of melancholia make clear that depression of mood was often at the core, though the authors highlight other features of "madness." Timothy Bright (1551–1615), a physician to St. Bartholomew’s Hospital in London, wrote in his 1586 book, A Treatise of Melancholie, that one kind of melancholia—"natural" he called it—results from "the mind’s apprehension" (later, reactive depression), the other "unnatural" kind being a more somatic illness of the humors of the body (later, endogenous depression). Bright is discussing here not undifferentiated madness but more what we would recognize as depression.

   In his great work on melancholia, The Anatomy of Melancholy (1621), Oxford cleric Robert Burton (1577–1640) said, "I think I may truly conclude that they are not always sad and fearful, but usually so. . . . Some are afraid that heaven will fall on their heads; some afraid they are damned, or shall be" (p. 328). Melancholic patients, Burton continued, are "most part sad: pleasant thoughts depart soon, sorrow sticks by them still continually, gnawing as the vulture did Tityus’ bowels, and they cannot avoid it. [After terrible dreams] their heavy hearts begin to sigh: they are still fretting, chafing, sighing, grieving, complaining, finding faults, repining, grudging, weeping . . . Aretaeus well calls it a vexation of the mind, a perpetual agony" (p. 331). In fact, Burton seems to have been describing a mixture of depression and anxiety, which is more common in community psychiatry than either pure depression or pure anxiety. Burton was himself a sufferer. In 1801, Philippe Pinel in his book, Medical-Philosophical Treatise on Mental Alienation (Traité médico-philosophique sur l’aliénation mentale), contrasted "the gay and expansive passions that may lead reason astray" with "a melancholic constitution, frequent cause of the most extreme estrangements and the most exaggerated ideas" (from the second ed., 1809, pp. 34, 59). Thus, even though traditionally "melancholia" did serve as a kind of catch-all for insanity, there always has been an understanding that at its core lay what we would call "depression."

   Starting late in the nineteenth century, the diagnosis depression began to displace melancholia, and the term went out of style in the understanding of mood disorders. Then in 1957, in his Classification of Endogenous Psychoses (Die Aufteilung der endogenen Psychosen), German psychiatrist Karl Leonhard (1904–1988), who had only just moved from the University of Erfurt to the Charité teaching hospital in Berlin, began the rehabilitation of melancholia with his notion of "pure melancholia" as one of the "phasic" (bipolar) psychoses. (See Wernicke–Kleist–Leonhard Pathway.) Melancholia entered the DSM system in the second edition in 1968 in the form of "involutional melancholia" (a Kraepelinian diagnosis that Kraepelin had later abandoned). (See Depression: Emergence: involutional melancholia [1896].) The third edition in 1980 made melancholia a subtype of "major depression," and speci-fied as operational criteria a loss of pleasure in life; a lack of reactivity to pleasurable things; and at least three of a list of six symptoms, including feeling worse in the morning than the afternoon, marked motor retardation or agitation, and inappropriate guilt feelings. DSM-III-R in 1987 changed this hierarchy of symptoms a bit by simply calling for five out of a list of nine potentially melancholic symptoms. DSM-IV returned to the style of the 1980 by insisting that the patient have loss of pleasure or lack of reactivity in addition to three out of a list of six other symptoms. (Readers will understand the impatience of many observers at the failure of DSM-style psychiatry to isolate homogeneous, treatment-responsive subgroups.)

   For other developments in the melancholia diagnosis, see Depression: Emergence and Depression: Recent Concepts: psychotic depression.