Melancholia

Melancholia is a state of severe depression which is marked by melancholic features. It can be traced to Greek word Melan which means black or dark and Chole which means bile. According to ancient and medieval medical practitioners there were four humors or body fluids namely black bile, yellow bile, phlegm and blood. These humors have to be in balanced proportion with respect to amount and strength of each humor for the body and mind to be in healthy state. Any imbalance in these humors was believed to result into various disorders of mind and body. Melancholia used to occur if a person has excess of black bile which was believed to be secreted by spleen and kidneys. Such a person was found to become sullen, sad, unsociable and prone to anger. Nowadays medical science no longer attributes the physical or mental disorders to the imbalance in these humors or bodily fluids but the word melancholia which is a general term for despondency is still used in psychiatry.

Melancholic depression is a subtype of Major Depressive Disorder (MDD) in the Diagnostic and Statistical Manual of Mental Disorders. It refers to extreme and persistent feelings of sadness and hopelessness. This disorder affects almost all areas of life be it work, school or relationships. Such people tend to lose interest in activities they once enjoyed and may even find their life not worth living.

Causes of Melancholic Depression

The cause of melancholic depression is not completely understood yet. But it is believed to be mainly due to biological factors while others may have inherited it from their parents. Many times a stressful situation can trigger melancholic depression but this is just a contributing factor and not sufficient to cause depression. Impairment in the ability to pay attention and concentrate are distinctly found in melancholic depression which diminish the ability to shift focus away from internal dysphoric states. A neuroimaging study has found signature marker or disrupted neural connection that may be responsible for this inability to disengage effectively from the interoceptive signals only in people with melancholic depression and not in those with non melancholic depression or in those without depression.

Also it is seen that people with psychotic symptoms are more likely to develop melancholic depression. Melancholic depression is frequently found in old age. In such elderly it is often left undiagnosed as the symptoms are perceived to be a part of dementia. Melancholic depression is a separate condition that can be comorbid with dementia in the old age. Also the incidence of melancholic depression has been found to be more when the temperature or sunlight is low.

Sign and Symptoms

The severity and presentation of melancholic depression vary greatly from patient to patient. They are more likely to occur in people who frequently suffer from Major Depressive Disorder, particularly the ones who have MDD with psychotic features. According to DSM-V diagnosis of melancholic depression requires at least one of the following symptoms-

• Anhedonia i.e. inability to find pleasure in positive things.
• Lack of mood reactivity i.e. mood does not improve in response to positive events.

And at least three of the following:

• Depression that is subjectively different from grief or loss.
• Severe weight loss or loss of appetite
• Psychomotor agitation or retardation.
• Guilt that is excessive.
• Worse mood in the morning.

Thus in order to be diagnosed with melancholic depression a person must have symptoms of Major Depressive Disorder such as feelings of persistent sadness, loss of interest and pleasure, low energy and fatigue, irritability, appetite changes, sleep difficulties, changes in activity levels, difficulty concentrating, thoughts of dying or suicide along with at least three symptoms of melancholia that can be depression that is different from grief, weight loss or loss of appetite, slowed activity or restlessness, excessive guilt, waking much earlier than normal and more depressive symptoms in the morning.

Management of Melancholic Depression

Melancholic depression causes major disruption in almost all areas of life be it work, school or relationships. If one is going through feelings of profound sadness, or loss of pleasure or lack of interest in daily activities one should consult a doctor for medications. Along with medi cations there are some coping strategies that are found to be very effective while dealing with melancholic depression. This mainly involves lifestyle modification that can help improve mood and includes:

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

At times online resources and support groups can be helpful in coping with melancholic depression although one must talk to a doctor to decide if this is a good option in any individual case.

It is seen that in the beginning it is very difficult to follow the above coping strategies due to the very symptoms of melancholic depression. However once medications begin to show effect things get relatively easier with time.

If ones depressive symptoms are getting worse or if someone experiences suicidal thoughts one must talk to the doctor immediately.

Treatment of Melancholic Depression

As melancholic depression is found to have biological and genetic causes thus use of medications that can work at biological level like brain function is necessary.

In addition to medications talk therapy has been found to be very effective in dealing with depression. Talk therapy involves visiting a therapist on regular basis and discussing the symptoms and related problems. In this way talk therapy helps a person to adjust to the stressful condition, replace negative attitude with positive and healthy beliefs, improve communication skills, cope with challenges, solve problems, increase self esteem and thus gain a sense of control and satisfaction in life. Group therapy also helps in similar way by giving one an opportunity to share feelings with those who can relate.
In severe cases electroconvulsive therapy ECT can be performed to relieve the symptoms. It is considered now to be a safe and effective treatment for mental illnesses like Major Depressive Disorder with melancholic features.

Homoeopathy has a great role to play in treating melancholic depression. Unlike allopathic treatment, homoeopathic medicine does not cause any side effects or drug dependency. However in severe cases where there is a risk of suicide, allopathic medicines can be used along with homoeopathic treatment till the patient gets stable.

The best homoeopathic medicine for depression is the one most similar to the disease manifestation. For this the homoeopathic doctor takes a detailed case history of each patient. He tries to find out the cause and characteristic effects of depression in every case. As instructed by Master Hahnemann in his Organon of Medicine, any mental illness is one sided chronic disease and affects the person as a whole. According to him mental illnesses are psychosomatic in nature and involve both i.e the psychic and the physical sphere of the patient. Therefore in order to treat mental illness the homoeopathic physician tries to explore the physical generalities like appetite, desire and aversion in food, thirst and various other bodily tendencies for the purpose of individualization. As melancholic depression is having strong genetic root, miasmatic background is also carefully explored. For this the homoeopathic physician thoroughly elicits the family history and past history of the patient.

Commonly indicated homoeopathic medicines for melancholic depression are as follows:

Aurum metallicum– It has a strong feeling of self-condemnation and worthlessness. Aurum Metallicum personality has a thorough disgust of life and talk of committing suicide. General symptoms like nightly aggravation, caries of bones, offensive discharges, high blood pressure further helps in confirmation of aurum as the remedy.

Ignatia amara– In this the depression arises from loss of a loved one or disappointments. Ignatia as a person is hysterical as shown in the frequent mood swings they suffer. They brood silently and consolation aggravates them. They tend to sigh and sob as they tend to bottle things up. They are oversensitive and even a well meaning advice is taken as criticism. Poor sleep and sensation of something stuck in throat is common.

Natrum muriaticum– Symptoms arise after a shock or loss and when they have been unable to cry or grieve properly for their loss. They tend to bottle things up and are averse to sympathy yet are very empathetic. They appear cold and distant as they tend to build up an emotional barrier. They cannot cry easily but events like coughing, yawning or laughing or music brings tears in the eyes easily. They tend to hold grudges and have resentment. They tend to lose weight due to psychic cause despite eating well. Desire to lick salt and headache from exposure to the sun are common general symptoms.

Sepia – It is especially suited to females who always tend to feel lacking in energy, making them indifferent even to their own family members. They tend to cry easily and become very irritable. They have a desire to keep themselves busy especially in water-related activities like dishwashing and laundry without any incentive to do so. They tend to lose interest in coition. General symptoms like chilliness, emptiness in the stomach particularly in morning or nausea at the smell of food indicates Sepia.