Am J Psychiatry 1994; 151:489-498
Copyright © 1994 by American Psychiatric Association
Melancholic symptom features and DSM-IV
AJ Rush and JE Weissenburger
Mental Health Clinical Research Center, University of Texas Southwestern Medical Center, Dallas.
OBJECTIVE: The purpose of this article is to provide an overview of
existing systems for the diagnosis of the endogenous (melancholic) subtype
of major depression. METHOD: The authors review the critical empirical
research examining this subtype and discuss its implications for DSM-IV.
They examine the relationship of endogenous/melancholic symptoms to other
clinical features, treatment response, selected laboratory tests,
consistency across episodes, family history, and particular courses of
illness. RESULTS: Melancholic symptom features are predictive of a positive
response to ECT and to tricyclic antidepressants in the severely ill. Key
features include psychomotor retardation, unreactive mood, pervasive
anhedonia, and distinct quality of mood. Melancholic features are
associated with shorter REM latency and/or nonsuppression of cortisol
during the dexamethasone suppression test. Depressive episodes that are not
melancholic may take on melancholic features with repetition and passage of
time in some individuals. Once melancholic features are present, it is
unclear whether they repeat across subsequent episodes. Melancholic
features are not uniquely associated with a positive family history of
depression per se, but they may be especially associated with a family
history of severe depression. CONCLUSIONS: The available evidence suggests
some clinical utility and some (albeit not entirely consistent) validity
for the concept of melancholic features. Consequently, DSM-IV will retain
the designation "with melancholic features," return to the shorter DSM-III
feature listing, and broaden the designation by requiring either unreactive
mood or pervasive anhedonia but not both. Further research on this subgroup
is indicated.
