uestion: Is the patient's depression melancholic? (I realize I may have asked this once already.)


    
    
    
    
    
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Help: The patient has had two to four sequential
      antidepressants, in adequate doses, and has not responded, and is now
      considered to have a treatment-resistant depression.  As noted, a complete
      reassessment of diagnosis, including the medical differential, is
      indicated before proceeding. 

    
    
Following this, the patients may be dichotomized again into those that
      meet criteria for melancholia, which we presume to be a type of depression
      that more frequently has a biological basis,¹ reflects greater
      genetic vulnerability to mood disorder,² and a higher likelihood of
      susceptibility to alteration by somatic treatments,³ than those that
      are non-melancholic where the prognosis for such treatments is (at this
      point in the algorithm) perceptably more guarded. Subsequent questions
      will subdivide things further on the basis of possible treatment choice
      and prognosis for a favorable outcome.

    
    
¹Maes M, Schotte C, D'Hondt P, et al. Biological
      heterogeneity of melancholia: results of pattern recognition methods. J
      Psychiat Res 1991;25:95-108.

    
    
²Kendler KS. The diagnostic validity of melancholic major
      depression in a population-based sample of female twins. Arch Gen
      Psychiatry 1997;54:299-304.

    
    
³Rush AJ, Weissenburger JE. Melancholic symptom features and
      DSM-IV. Am J Psychiatry 1994;151:489-498.


















    
    

    
    
Comment: 

    
    
For a treatment resistant depression that meets criteria for
      melancholia, we think the prognosis for eventual response to somatic
      therapy is relatively good. Experience suggests that few patients with
      melancholia remain that way chonically and that eventually they at least
      improve enough to have "only" major depression or dysthymia.
      Hence, we advocate continued sequential pharmacotherapy trials
      (medical/substance abuse/diagnostic errors having been ruled out or
      treated). 

    
    
The choice of what to try next may at this point be influenced by
      significant comorbid problems. The presence of these comorbid psychiatric
      and/or medical problems may improve or worsen the prognosis for the
      depression. Occasionally, a treatment selection directed toward a comorbid
      disorder with relatively good prognosis for treatment may result in a
      better overall outcome for this depressed patient. Click on the next link
      to review possible comorbid conditions. 

    
    
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