A man whose face exemplifies the melancholy temperament

Melancholia or melancholy (from ',Burton, Bk. I, p. 147 meaning black bile) is a concept found throughout

ancient Ancient history is a time period from the beginning of writing and recorded human history through late antiquity. The span of recorded history is roughly 5,000 years, beginning with the development of Sumerian cuneiform script. Ancient h ...

medieval In the history of Europe, the Middle Ages or medieval period lasted approximately from the 5th to the late 15th centuries, similarly to the post-classical period of World history (field), global history. It began with the fall of the West ...

, and premodern medicine in Europe that describes a condition characterized by markedly depressed mood, bodily complaints, and sometimes

hallucination A hallucination is a perception in the absence of an external stimulus that has the compelling sense of reality. They are distinguishable from several related phenomena, such as dreaming ( REM sleep), which does not involve wakefulness; pse ...

s and

delusion A delusion is a fixed belief that is not amenable to change in light of conflicting evidence. As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, hallucination, or some other m ...

s. Melancholy was regarded as one of the

four temperaments The four temperament theory is a proto-psychological theory which suggests that there are four fundamental personality types: sanguine, choleric, melancholic, and phlegmatic. Most formulations include the possibility of mixtures among the types ...

matching the

four humours Humorism, the humoral theory, or humoralism, was a system of medicine detailing a supposed makeup and workings of the human body, adopted by Ancient Greek and Roman physicians and philosophers. Humorism began to fall out of favor in the 17th ce ...

. Until the 18th century, doctors and other scholars classified melancholic conditions as such by their perceived common causean excess of a notional fluid known as "black bile", which was commonly linked to the spleen.

Hippocrates Hippocrates of Kos (; ; ), also known as Hippocrates II, was a Greek physician and philosopher of the Classical Greece, classical period who is considered one of the most outstanding figures in the history of medicine. He is traditionally referr ...

and other ancient physicians described melancholia as a distinct disease with mental and physical symptoms, including persistent fears and despondencies, poor appetite,

abulia In neurology, abulia, or aboulia (from , meaning "will"),Bailly, A. (2000). Dictionnaire Grec Français, Éditions Hachette. refers to a lack of will or initiative and can be seen as a disorder of diminished motivation. Abulia falls in the midd ...

, sleeplessness, irritability, and agitation. Later, fixed

s were added by

Galen Aelius Galenus or Claudius Galenus (; September 129 – AD), often Anglicization, anglicized as Galen () or Galen of Pergamon, was a Ancient Rome, Roman and Greeks, Greek physician, surgeon, and Philosophy, philosopher. Considered to be one o ...

and other physicians to the list of symptoms. In the

Middle Ages In the history of Europe, the Middle Ages or medieval period lasted approximately from the 5th to the late 15th centuries, similarly to the post-classical period of global history. It began with the fall of the Western Roman Empire and ...

, the understanding of melancholia shifted to a religious perspective, with sadness seen as a vice and

demonic possession Spirit Possession is an altered state of consciousness and associated behaviors which are purportedly caused by the control of a human body and its functions by Supernatural#Spirit, spirits, ghosts, demons, angels, or Deity, gods. The concept ...

, rather than somatic causes, as a potential cause of the disease. During the late 16th and early 17th centuries, a cultural and literary cult of melancholia emerged in England, linked to

Neoplatonist Neoplatonism is a version of Platonic philosophy that emerged in the 3rd century AD against the background of Hellenistic philosophy and religion. The term does not encapsulate a set of ideas as much as a series of thinkers. Among the common id ...

and

humanist Humanism is a philosophical stance that emphasizes the individual and social potential, and agency of human beings, whom it considers the starting point for serious moral and philosophical inquiry. The meaning of the term "humanism" ha ...

Marsilio Ficino Marsilio Ficino (; Latin name: ; 19 October 1433 – 1 October 1499) was an Italian scholar and Catholic priest who was one of the most influential humanist philosophers of the early Italian Renaissance. He was an astrologer, a reviver of Neo ...

's transformation of melancholia from a sign of vice into a mark of genius. This fashionable melancholy became a prominent theme in literature, art, and music of the era. Between the late 18th and late 19th centuries, ''melancholia'' was a common medical diagnosis. In this period, the focus was on the abnormal beliefs associated with the disorder, rather than depression and affective symptoms. In the 19th century, melancholia was considered to be rooted in subjective 'passions' that seemingly caused disordered mood (in contrast to modern biomedical explanations for mood disorders). In Victorian Britain, the notion of melancholia as a disease evolved as it became increasingly classifiable and diagnosable with a set list of symptoms that contributed to a biomedical model for the understanding mental disease. However, in the 20th century, the focus again shifted, and the term became used essentially as a synonym for depression. Indeed, modern concepts of depression as a

mood disorder A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood. The classification is in the ''Diagnostic ...

eventually arose from this historical context. Today, the term "melancholia" and "melancholic" are still used in medical diagnostic classification, such as in

ICD-11 The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World H ...

and

DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiat ...

, to specify certain features that may be present in major depression. Related terms used in historical medicine include lugubriousness (from

Latin Latin ( or ) is a classical language belonging to the Italic languages, Italic branch of the Indo-European languages. Latin was originally spoken by the Latins (Italic tribe), Latins in Latium (now known as Lazio), the lower Tiber area aroun ...

'' lugere'': "to mourn"), moroseness (from Latin '' morosus'': "self-will or fastidious habit"), wistfulness (from a blend of "wishful" and the obsolete English '' wistly'', meaning "intently"), and saturnineness (from Latin '' Saturninus'': "of the planet Saturn).

Early history

The name "melancholia" comes from the old medical belief of the four

humours Humorism, the humoral theory, or humoralism, was a system of medicine detailing a supposed makeup and workings of the human body, adopted by Ancient Greek and Roman physicians and philosophers. Humorism began to fall out of favor in the 17th ce ...

: disease or ailment being caused by an imbalance in one or more of the four basic bodily liquids, or humours. Personality types were similarly determined by the dominant humor in a particular person. According to

and subsequent tradition, melancholia was caused by an excess of black bile, hence the name, which means "black bile", from

Ancient Greek Ancient Greek (, ; ) includes the forms of the Greek language used in ancient Greece and the classical antiquity, ancient world from around 1500 BC to 300 BC. It is often roughly divided into the following periods: Mycenaean Greek (), Greek ...

μέλας (), "dark, black", and χολή (), "bile"; a person whose constitution tended to have a preponderance of black bile had a ''melancholic'' disposition. In the complex elaboration of humorist theory, it was associated with the earth from the

Four Elements The classical elements typically refer to earth, water, air, fire, and (later) aether which were proposed to explain the nature and complexity of all matter in terms of simpler substances. Ancient cultures in Greece, Angola, Tibet, India, a ...

, the season of autumn, the

spleen The spleen (, from Ancient Greek '' σπλήν'', splḗn) is an organ (biology), organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The spleen plays important roles in reg ...

as the originating organ and cold and dry as related qualities. In

astrology Astrology is a range of Divination, divinatory practices, recognized as pseudoscientific since the 18th century, that propose that information about human affairs and terrestrial events may be discerned by studying the apparent positions ...

it showed the influence of

Saturn Saturn is the sixth planet from the Sun and the second largest in the Solar System, after Jupiter. It is a gas giant, with an average radius of about 9 times that of Earth. It has an eighth the average density of Earth, but is over 95 tim ...

, hence the related adjective ''saturnine''. Melancholia was described as a distinct

disease A disease is a particular abnormal condition that adversely affects the structure or function (biology), function of all or part of an organism and is not immediately due to any external injury. Diseases are often known to be medical condi ...

with particular mental and physical symptoms in the 5th and 4th centuries BC. Hippocrates, in his ''

Aphorisms An aphorism (from Greek ἀφορισμός: ''aphorismos'', denoting 'delimitation', 'distinction', and 'definition') is a concise, terse, laconic, or memorable expression of a general truth or principle. Aphorisms are often handed down by tra ...

'', characterized all "fears and despondencies, if they last a long time" as being symptomatic of melancholia.Hippocrates, ''Aphorisms'', Section 6.23 Other symptoms mentioned by Hippocrates include: poor appetite,

, sleeplessness, irritability, agitation.Epidemics, III, 16 cases, case II The Hippocratic clinical description of melancholia shows significant overlaps with contemporary nosography of depressive syndromes (6 symptoms out of the 9 included in DSM diagnostic criteria for a Major Depressive). In

ancient Rome In modern historiography, ancient Rome is the Roman people, Roman civilisation from the founding of Rome, founding of the Italian city of Rome in the 8th century BC to the Fall of the Western Roman Empire, collapse of the Western Roman Em ...

added "fixed delusions" to the set of symptoms listed by Hippocrates. Galen also believed that melancholia caused cancer.

Aretaeus of Cappadocia Aretaeus () is one of the most celebrated of the ancient Greek physicians. Little is known of his life. He was ethnically Greek, born in the Roman province of Cappadocia, Asia Minor (modern day Turkey), and most likely lived in the second half o ...

, in turn, believed that melancholia involved both a state of anguish, and a delusion. In the 10th century

Persian Persian may refer to: * People and things from Iran, historically called ''Persia'' in the English language ** Persians, the majority ethnic group in Iran, not to be conflated with the Iranic peoples ** Persian language, an Iranian language of the ...

physician Al-Akhawayni Bokhari described melancholia as a chronic illness caused by the impact of black bile on the brain. He described melancholia's initial clinical manifestations as "suffering from an unexplained fear, inability to answer questions or providing false answers, self-laughing and self-crying and speaking meaninglessly, yet with no fever." In Middle-Ages Europe, the humoral, somatic paradigm for understanding sustained sadness lost primacy in front of the prevailing religious perspective.Azzone P. (2013) pp. 23ff.Azzone P (2012) Sin of Sadness: Acedia vel Tristitia Between Sociocultural Conditioning and Psychological Dynamics of Negative Emotions. Journal of Psychology and Christianity, 31: 50–64. Sadness came to be a vice (λύπη in the Greek vice list by Evagrius Ponticus, tristitia vel acidia in the 7 vice list by

Pope Gregory I Pope Gregory I (; ; – 12 March 604), commonly known as Saint Gregory the Great (; ), was the 64th Bishop of Rome from 3 September 590 until his death on 12 March 604. He is known for instituting the first recorded large-scale mission from Ro ...

). When a patient could not be cured of the disease it was thought that the melancholia was a result of

. In his study of French and Burgundian courtly culture,

Johan Huizinga Johan Huizinga (; 7 December 1872 – 1 February 1945) was a Dutch historian and one of the founders of modern cultural history. Life Born in Groningen as the son of Dirk Huizinga, a professor of physiology, and Jacoba Tonkens, who died two ...

noted that "at the close of the Middle Ages, a sombre melancholy weighs on people's souls." In chronicles, poems, sermons, even in legal documents, an immense sadness, a note of despair and a fashionable sense of suffering and deliquescence at the approaching end of times, suffuses court poets and chroniclers alike: Huizinga quotes instances in the ballads of

Eustache Deschamps Eustache Deschamps (13461406 or 1407) was a French poet, byname Morel, in French "Nightshade". Life and career Deschamps was born in Vertus. He received lessons in versification from Guillaume de Machaut and later studied law at Orleans Universi ...

, "monotonous and gloomy variations of the same dismal theme", and in

Georges Chastellain Georges Chastellain (c. 1405 or c. 1415 – 20 March 1475), Burgundian chronicler and poet, was a native of Aalst in Flanders. Chastellain's historical works are valuable for the accurate information they contain. As a poet he was famous am ...

's prologue to his Burgundian chronicle, and in the late 15th-century poetry of Jean Meschinot. Ideas of reflection and the workings of imagination are blended in the term ''merencolie'', embodying for contemporaries "a tendency", observes Huizinga, "to identify all serious occupation of the mind with sadness". Painters were considered by

Vasari Giorgio Vasari (30 July 1511 – 27 June 1574) was an Italian Renaissance painter, architect, art historian, and biographer who is best known for his work '' Lives of the Most Excellent Painters, Sculptors, and Architects'', considered the ide ...

and other writers to be especially prone to melancholy by the nature of their work, sometimes with good effects for their art in increased sensitivity and use of fantasy. Among those of his contemporaries so characterised by Vasari were

Pontormo Jacopo Carucci or Carrucci (; May 24, 1494 – January 2, 1557), usually known as Jacopo (da) Pontormo or simply Pontormo (), was an Italian Mannerist painter and portraitist from the Florentine School. His work represents a profound stylisti ...

and

Parmigianino Girolamo Francesco Maria Mazzola (11 January 150324 August 1540), also known as Francesco Mazzola or, more commonly, as Parmigianino (, , ; "the little one from Parma"), was an Italian Mannerist painter and printmaker active in Florence, Rome, ...

, but he does not use the term of

Michelangelo Michelangelo di Lodovico Buonarroti Simoni (6March 147518February 1564), known mononymously as Michelangelo, was an Italian sculptor, painter, architect, and poet of the High Renaissance. Born in the Republic of Florence, his work was inspir ...

, who used it, perhaps not very seriously, of himself. A famous

allegorical As a literary device or artistic form, an allegory is a narrative or visual representation in which a character, place, or event can be interpreted to represent a meaning with moral or political significance. Authors have used allegory throughou ...

engraving Engraving is the practice of incising a design on a hard, usually flat surface by cutting grooves into it with a Burin (engraving), burin. The result may be a decorated object in itself, as when silver, gold, steel, or Glass engraving, glass ar ...

Albrecht Dürer Albrecht Dürer ( , ;; 21 May 1471 – 6 April 1528),Müller, Peter O. (1993) ''Substantiv-Derivation in Den Schriften Albrecht Dürers'', Walter de Gruyter. . sometimes spelled in English as Durer or Duerer, was a German painter, Old master prin ...

is entitled ''

Melencolia I ''Melencolia I'' is a large 1514 engraving by the German Renaissance artist Albrecht Dürer. Its central subject is an enigmatic and gloomy winged female figure thought to be a personification of melancholia – melancholy. Holding her head in ...

''. This engraving has been interpreted as portraying melancholia as the state of waiting for inspiration to strike, and not necessarily as a depressive affliction. Amongst other allegorical symbols, the picture includes a

magic square In mathematics, especially History of mathematics, historical and recreational mathematics, a square array of numbers, usually positive integers, is called a magic square if the sums of the numbers in each row, each column, and both main diago ...

and a truncated

rhombohedron In geometry, a rhombohedron (also called a rhombic hexahedron or, inaccurately, a rhomboid) is a special case of a parallelepiped in which all six faces are congruent rhombi. It can be used to define the rhombohedral lattice system, a honeycomb w ...

. The image in turn inspired a passage in ''

The City of Dreadful Night ''The City of Dreadful Night'' is a long poem by the Scottish poet James "B.V." Thomson, written between 1870 and 1873, and published in the ''National Reformer'' in 1874, then, in 1880, in a book entitled ''The City of Dreadful Night and Othe ...

'' by James Thomson (B.V.), and, a few years later, a sonnet by

Edward Dowden Edward Dowden (; 3 May 18434 April 1913) was an Irish critic, professor, and poet. Biography He was the son of John Wheeler Dowden, a merchant and landowner, and was born at Cork, three years after his brother John, who became Bishop of Edi ...

. The most extended treatment of melancholia comes from Robert Burton, whose ''

The Anatomy of Melancholy ''The Anatomy of Melancholy'' (full title: ''The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it. In Three Maine Partitions with their several Sections, Members, and Subsections. Ph ...

'' (1621) treats the subject from both a literary and a medical perspective. His concept of melancholia includes all mental illness, which he divides into different types. Burton wrote in the 17th century that music and dance were critical in treating mental illness. In the

Encyclopédie , better known as ''Encyclopédie'' (), was a general encyclopedia published in France between 1751 and 1772, with later supplements, revised editions, and translations. It had many writers, known as the Encyclopédistes. It was edited by Denis ...

Diderot Denis Diderot (; ; 5 October 171331 July 1784) was a French philosopher, art critic, and writer, best known for serving as co-founder, chief editor, and contributor to the along with Jean le Rond d'Alembert. He was a prominent figure during t ...

and

d'Alembert Jean-Baptiste le Rond d'Alembert ( ; ; 16 November 1717 – 29 October 1783) was a French mathematician, mechanics, mechanician, physicist, philosopher, and music theorist. Until 1759 he was, together with Denis Diderot, a co-editor of the ''E ...

, the causes of melancholia are stated to be similar to those that cause

Mania Mania, also known as manic syndrome, is a Psychiatry, psychiatric Abnormality (behavior), behavioral syndrome defined as a state of Abnormality (behavior), abnormally elevated arousal, affect (psychology), affect, and energy level. During a mani ...

: "grief, pains of the spirit, passions, as well as all the love and sexual appetites that go unsatisfied."

English cultural movement

During the later 16th and early 17th centuries, a curious cultural and literary cult of melancholia arose in England. In an influential 1964 essay in

Apollo Apollo is one of the Twelve Olympians, Olympian deities in Ancient Greek religion, ancient Greek and Ancient Roman religion, Roman religion and Greek mythology, Greek and Roman mythology. Apollo has been recognized as a god of archery, mu ...

, art historian

Roy Strong Sir Roy Colin Strong, (born 23 August 1935) is an English art historian, museum curator, writer, broadcaster and landscape designer. He has served as director of both the National Portrait Gallery and the Victoria and Albert Museum in London. ...

traced the origins of this fashionable melancholy to the thought of the popular

and

(1433–1499), who replaced the medieval notion of melancholia with something new: ''

'' (''The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it... Philosophically, Medicinally, Historically, Opened and Cut Up'') by Burton, was first published in 1621 and remains a defining literary monument to the fashion. Another major English author who made extensive expression upon being of an melancholic disposition is Sir

Thomas Browne Sir Thomas Browne ( "brown"; 19 October 160519 October 1682) was an English polymath and author of varied works which reveal his wide learning in diverse fields including science and medicine, religion and the esoteric. His writings display a d ...

in his ''

Religio Medici ''Religio Medici'' (''The Religion of a Doctor'') by Sir Thomas Browne is a spiritual testament and early psychological self-portrait. Browne mulls over the relation between his medical profession and his Christian faith. Published in 1643 afte ...

'' (1643). ''

Night-Thoughts ''The Complaint: or, Night-Thoughts on Life, Death, & Immortality'', better known simply as ''Night-Thoughts'', is a long poem by Edward Young published in nine parts (or "nights") between 1742 and 1745. It was illustrated with notable engr ...

'' (''The Complaint: or, Night-Thoughts on Life, Death, & Immortality''), a long poem in blank verse by

Edward Young Edward Young ( – 5 April 1765) was an English poet, best remembered for ''Night-Thoughts'', a series of philosophical writings in blank verse, reflecting his state of mind following several bereavements. It was one of the most popular poem ...

was published in nine parts (or "nights") between 1742 and 1745, and hugely popular in several languages. It had a considerable influence on early

Romantics Romanticism (also known as the Romantic movement or Romantic era) was an artistic and intellectual movement that originated in Europe towards the end of the 18th century. The purpose of the movement was to advocate for the importance of subjec ...

in England, France and Germany.

William Blake William Blake (28 November 1757 – 12 August 1827) was an English poet, painter, and printmaker. Largely unrecognised during his life, Blake has become a seminal figure in the history of the Romantic poetry, poetry and visual art of the Roma ...

was commissioned to illustrate a later edition. In the visual arts, this fashionable intellectual melancholy occurs frequently in portraiture of the era, with sitters posed in the form of "the lover, with his crossed arms and floppy hat over his eyes, and the scholar, sitting with his head resting on his hand"descriptions drawn from the frontispiece to the 1638 edition of Burton's ''Anatomy'', which shows just such by-then stock characters. These portraits were often set out of doors where Nature provides "the most suitable background for spiritual contemplation" or in a gloomy interior. In music, the post-Elizabethan cult of melancholia is associated with

John Dowland John Dowland ( – buried 20 February 1626) was an English Renaissance composer, lutenist, and singer. He is best known today for his melancholy songs such as "Come, heavy sleep", " Come again", " Flow my tears", " I saw my Lady weepe", " N ...

, whose motto was ''Semper Dowland, semper dolens'' ("Always Dowland, always mourning"). The melancholy man, known to contemporaries as a "malcontent", is epitomized by Shakespeare's

Prince Hamlet Prince Hamlet is the title character and protagonist of William Shakespeare's tragedy ''Hamlet'' (1599–1601). He is the Prince of Denmark, nephew of the usurping King Claudius, Claudius, and son of King Hamlet, the previous King of Denmark. At ...

, the "Melancholy Dane". A similar phenomenon, though not under the same name, occurred during the German ''

Sturm und Drang (, ; usually translated as "storm and stress") was a proto-Romanticism, Romantic movement in German literature and Music of Germany, music that occurred between the late 1760s and early 1780s. Within the movement, individual subjectivity an ...

'' movement, with such works as ''

The Sorrows of Young Werther ''The Sorrows of Young Werther'' (; ), or simply ''Werther'', is a 1774 epistolary novel by Johann Wolfgang von Goethe, Johann Wolfgang Goethe, which appeared as a revised edition in 1787. It was one of the main novels in the ''Sturm und Drang'' ...

'' by

Goethe Johann Wolfgang (von) Goethe (28 August 1749 – 22 March 1832) was a German polymath who is widely regarded as the most influential writer in the German language. His work has had a wide-ranging influence on Western literature, literary, Polit ...

or in

Romanticism Romanticism (also known as the Romantic movement or Romantic era) was an artistic and intellectual movement that originated in Europe towards the end of the 18th century. The purpose of the movement was to advocate for the importance of subjec ...

with works such as '' Ode on Melancholy'' by

John Keats John Keats (31 October 1795 – 23 February 1821) was an English poet of the second generation of Romantic poets, along with Lord Byron and Percy Bysshe Shelley. His poems had been in publication for less than four years when he died of tub ...

or in

Symbolism Symbolism or symbolist may refer to: *Symbol, any object or sign that represents an idea Arts *Artistic symbol, an element of a literary, visual, or other work of art that represents an idea ** Color symbolism, the use of colors within various c ...

with works such as '' Isle of the Dead'' by

Arnold Böcklin Arnold Böcklin (16 October 182716 January 1901) was a Swiss Symbolism (arts), Symbolist Painting, painter. His five versions of the ''Isle of the Dead (painting), Isle of the Dead'' inspired works by several late-Romantic composers. Biography ...

. In the 20th century, much of the counterculture of

modernism Modernism was an early 20th-century movement in literature, visual arts, and music that emphasized experimentation, abstraction, and Subjectivity and objectivity (philosophy), subjective experience. Philosophy, politics, architecture, and soc ...

was fueled by comparable alienation and a sense of purposelessness called "

anomie In sociology, anomie or anomy () is a social condition defined by an uprooting or breakdown of any moral values, standards or guidance for individuals to follow. Anomie is believed to possibly evolve from conflict of belief systems and causes b ...

"; earlier artistic preoccupation with death has gone under the rubric of

memento mori (Latin for "remember (that you have) to die")

. The medieval condition of

acedia Acedia (; also accidie or accedie , from Latin , and this from Greek , "negligence", "lack of" "care") has been variously defined as a state of listlessness or torpor, of not caring or not being concerned with one's position or condition in th ...

(''acedie'' in English) and the Romantic

Weltschmerz (; literally "world-pain") is a literary concept describing the feeling experienced by an individual who believes that reality can never satisfy the expectations of the mind, resulting in "a mood of weariness or sadness about life arising from ...

were similar concepts, most likely to affect the intellectual.

Modern connotations

Until the 18th century, writings on melancholia were mainly concerned with beliefs that were considered abnormal, rather than affective symptoms. Melancholia was a category that "the well-to-do, the sedentary, and the studious were even more liable to be placed in the eighteenth century than they had been in preceding centuries." In the 20th century, "melancholia" lost its attachment to abnormal beliefs, and in common usage became entirely a synonym for depression. Sigmund Freud published a paper on Mourning and Melancholia in 1918. In 1907, the German psychiatrist

Emil Kraepelin Emil Wilhelm Georg Magnus Kraepelin (; ; 15 February 1856 – 7 October 1926) was a German psychiatrist. H. J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, psychopharmacology and psychiatric ...

influentially proposed the existence of a condition he called ' involutional melancholia', which he thought could help explain the more frequent occurrence of depression among elderly people. He surmised that in the elderly "the processes of involution in the body are suited to engender mournful or anxious moodiness", though by 1913 he had returned to his earlier view (first expounded in 1899) that age-related depression could be understood in terms of

manic-depressive illness Bipolar disorder (BD), previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks, and in some cases months. If the elevated m ...

. In 1996, Gordon Parker and Dusan Hadzi-Pavlovic described "melancholia" as a specific disorder of movement and mood. They attached the term to the concept of "endogenous depression" (claimed to be caused by internal forces rather than environmental influences). In 2006, Michael Alan Taylor and Max Fink also defined melancholia as a systemic disorder that could be identified by depressive mood rating scales, verified by the presence of abnormal

cortisol Cortisol is a steroid hormone in the glucocorticoid class of hormones and a stress hormone. When used as medication, it is known as hydrocortisone. Cortisol is produced in many animals, mainly by the ''zona fasciculata'' of the adrenal corte ...

metabolism. They considered it to be characterized by depressed mood, abnormal motor functions, and abnormal vegetative signs, and they described several forms, including retarded depression,

psychotic depression Psychotic depression, also known as depressive psychosis, is a major depressive episode that is accompanied by psychotic symptoms.Hales E and Yudofsky JA, eds, The American Psychiatric Press Textbook of Psychiatry, Washington, DC: American Psych ...

and

postpartum depression Postpartum depression (PPD), also called perinatal depression, is a mood disorder which may be experienced by pregnant or postpartum women. Symptoms include extreme sadness, low energy, anxiety, crying episodes, irritability, and extreme cha ...

Melancholic depression

For the purposes of medical diagnostic classification, the terms "melancholia" and "melancholic" are still in use (for example, in

and

) to specify certain features that may be present in

major depression Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Intro ...

, referred to as depression with melancholic features such as:World Health Organization, "6A80.3 Current depressive episode with melancholia", International Statistical Classification of Diseases and Related Health Problems, 11th rev. (September 2020). * severely depressed mood, wherein the person often feels despondent, forlorn, disconsolate, or empty * pervasive anhedonia – loss of interest or pleasure in most activities that are normally enjoyable * lack of emotional responsiveness (mood does not brighten, even briefly) to normally pleasurable stimuli (such as food or entertainment) or situations (such as warm, affectionate interactions with friends or family) * terminal insomnia – unwanted early morning awakening (two or more hours earlier than normal) * marked psychomotor retardation or agitation * marked loss of appetite or weight loss A specifier essentially is a subcategory of a disease, explaining specific features or symptoms that are added to the main diagnosis. According to the

DSM-IV The ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM''; latest edition: ''DSM-5-TR'', published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a com ...

, the "melancholic features" specifier may be applied to the following only: #

Major depressive episode A major depressive episode (MDE) is a period characterized by symptoms of major depressive disorder. Those affected primarily exhibit a depressive mood for at least two weeks or more, and a loss of interest or pleasure in everyday activities. Oth ...

, single episode #

, recurrent episode #

Bipolar I disorder Bipolar I disorder (BD-I; pronounced "type one bipolar disorder") is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other ti ...

, most recent episode depressed #

Bipolar II disorder Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienc ...

, most recent episode depressed It is important to note, however, that people who suffer from melancholic depression do not need to have melancholic features in every depressive episode.

Signs and symptoms

Melancholic depression requires at least one of the following symptoms during the last depressive episode: *

Anhedonia Anhedonia is a diverse array of deficits in hedonic function, including reduced motivation or ability to experience pleasure. While earlier definitions emphasized the inability to experience pleasure, anhedonia is currently used by researcher ...

(the inability to find pleasure in positive things) * Lack of mood reactivity (i.e. mood does not improve in response to positive/desired events; failure to feel better) And at least three of the following: * Depressed mood that is subjectively different from grief or loss (marked by despair, gloominess, and "empty-mood") * Severe weight loss or loss of appetite * Psychomotor agitation or retardation (i.e. increased or decreased movement, speech, and cognitive function) * Early morning awakening (i.e. waking up at least 2 hours before the normal wake up time of the patient) * Guilt that is excessive * Worse depressed mood in the morning Melancholic features apply to an episode of depression that occurs as part of either

major depressive disorder Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive depression (mood), low mood, low self-esteem, and anhedonia, loss of interest or pleasure in normally ...

, persistent depressive disorder (dysthymia), or

bipolar disorder Bipolar disorder (BD), previously known as manic depression, is a mental disorder characterized by periods of Depression (mood), depression and periods of abnormally elevated Mood (psychology), mood that each last from days to weeks, and in ...

I or II. They are more likely to occur in patients who suffer from depression with psychotic features. People with melancholic depression also tend to have more physically visible symptoms such as slower movement or speech.

Causes

The causes of melancholic

depressive disorder A mood disorder, also known as an affective disorder, is any of a group of conditions of mental disorder, mental and Abnormal behavior, behavioral Disorder (medicine), disorder where the main underlying characteristic is a disturbance in the per ...

are believed to be mostly biological factors that can be hereditary. Biological origins of the condition include problems with the

HPA axis The pascal (symbol: Pa) is the unit of pressure in the International System of Units (SI). It is also used to quantify internal pressure, stress, Young's modulus, and ultimate tensile strength. The unit, named after Blaise Pascal, is an SI ...

and sleep structure of patients. MRI studies have indicated that melancholic depressed patients have issues with the connections between different regions of the brain, specifically the insula and fronto-parietal cortex. Some studies have found that there are biological marker differences between patients with melancholic depression and other subtypes of depression. The research regarding melancholic depression consistently finds that men are more likely to receive a melancholic depression diagnosis.

Treatment

Melancholic depression, due to some fundamental differences with standard clinical depression or other subtypes of depression, has specific types of treatments that work, and the success rates for different treatments can vary. Treatment can involve

antidepressants Antidepressants are a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction. Common side effects of antidepressants include dry mouth, weight gain, dizziness, headaches, akathisia, sexu ...

and empirically supported treatments such as

cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD, and anxiety disorders. Cognitive behavioral therapy focuses on challenging and chang ...

and

interpersonal therapy Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and achieving symptomatic recovery. IPT is an empirically supported treatment (EST) that follows a highly structured and ...

for depression. Melancholic depression is often considered to be a biologically based and particularly severe form of depression. Therefore, the treatments for this specifier of depression are more biomedical and less psychosocial (which would include talk therapy and social support). The general initial or "ideal" treatment for melancholic depression is antidepressant medication, and psychotherapy is added later on as support if at all. The scientific support for medication as the best treatment is that patients with melancholic depression are less likely to improve with placebos, unlike other depression patients. This indicates the improvements observed after medication actually come from the biological basis of the condition and the treatment. There are several types of antidepressants that can be prescribed including

SSRIs Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs primarily work by blo ...

, SNRIs,

tricyclic antidepressant Tricyclic antidepressants (TCAs) are a class of medications that are used primarily as antidepressants. TCAs were discovered in the early 1950s and were marketed later in the decade. They are named after their chemical structure, which contains ...

s, and MAOIs; the antidepressants tend to vary on how they work and what specific chemical messengers in the brain they target. SNRIs are generally more effective than SSRIs because they target more than one chemical messenger (

serotonin Serotonin (), also known as 5-hydroxytryptamine (5-HT), is a monoamine neurotransmitter with a wide range of functions in both the central nervous system (CNS) and also peripheral tissues. It is involved in mood, cognition, reward, learning, ...

and

norepinephrine Norepinephrine (NE), also called noradrenaline (NA) or noradrenalin, is an organic compound, organic chemical in the catecholamine family that functions in the brain and human body, body as a hormone, neurotransmitter and neuromodulator. The ...

). Although

psychotherapy Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of Psychology, psychological methods, particularly when based on regular Conversation, personal interaction, to help a person change behavior, increase hap ...

treatments can be used such as talk therapy and cognitive behavioral therapy (CBT), they have shown to be less effective than medication. In a

randomized clinical trial A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical t ...

, it was shown that CBT was less effective than medication in treating symptoms of melancholic depression after 12 weeks.

Electroconvulsive therapy Electroconvulsive therapy (ECT) is a psychiatry, psychiatric treatment that causes a generalized seizure by passing electrical current through the brain. ECT is often used as an intervention for mental disorders when other treatments are inadequ ...

(ECT) was previously believed to be an effective treatment for melancholic depression. ECT has been more commonly used for patients with melancholic depression due to the severity. In 2010, a study found that 60% of depression patients treated with ECT had melancholic symptoms. However, studies since the 2000s have failed to demonstrate positive treatment results from ECT, although studies also indicate a more positive response to ECT in melancholic patients than other depressed patients. It has been observed in studies that patients with melancholic depression tend to recover less often than other types of depression.

Frequency

The prevalence of having the melancholic depression specifier among patients diagnosed with clinical depression is estimated to be about 25% to 30%. The incidence of melancholic depression has been found to increase when the temperature and/or sunlight are low.

Citations

External links

Grunwald Center website: Durer's ''Melencolia'' and clinical depression, iconography and printmaking techniques

on the Berlin exhibition "Melancholy: Genius and Madness in Art"
Diderot's historic writing on Melancholy

"The Four Humours" on "In Our Time"

"An Anatomy of Melancholy" on "In Our Time"

At the Roots of Melancholy
{{Authority control Obsolete terms for mental disorders Humorism Mood disorders Emotions