Melancholic Depression: Symptoms and Treatment

Medically Reviewed by Jabeen Begum, MD on March 04, 2024
Written by Frances Gatta, Susan Bernstein, Amy Gopal
8 min read

Melancholic depression , also called melancholia, is a serious type of depression. Researchers think this type of depression mainly affects your central nervous system. About 25%-30% of people living with depression have this type.

Melancholic depression can be more challenging to treat, as it doesn’t respond as well to non-melancholic depression treatment such as selective serotonin reuptake inhibitors (SSRIs), talk therapy, and hospitalization. However, two effective treatment options for melancholic depression include: 

  • Electroconvulsive therapy (ECT), which involves sending small electric currents through your brain
  • Tricyclic antidepressants, the earliest introduced medicines for major depressive disorder

Although melancholic depression may have more severe symptoms and may be harder to treat than other types of depression , you can learn to manage your symptoms with the help of a mental health professional.

Melancholic depression is more likely to cause physical symptoms, not just feeling blue or tearful. You may have no energy and feel empty. You may be unable to feel happiness, and your mood won’t change even when something good happens to you. Your movements and thoughts may slow down.

The two main symptoms are:

  • You stop enjoying activities in your life.
  • You can’t respond to pleasure in a positive way.

Melancholic depression is also characterized by:

  • Sleep problems, such as being unable to fall and stay asleep or waking up too early
  • Loss of appetite or weight loss
  • Trouble with concentration or memory
  • Feeling empty or unresponsive
  • Excessive guilt
  • Feelings of hopelessness
  • Thoughts of suicide

Psychomotor signs

If you have melancholic depression, your behaviors may change. Examples include:

  • Speech changes, or talking at different volumes or pausing when you speak
  • Eye movements (like a fixed gaze or not making eye contact when you talk with people)
  • Slowed movement of your head, limbs, or torso
  • Slouched posture
  • Touching your face or body often

Body aches

Some research shows that about 70% of people with melancholic depression can also have musculoskeletal pain.

Changes in your brain and hormonal pathways can contribute to melancholic depression. The hypothalamus, pituitary gland, adrenal glands, and other brain areas tied to memory, thinking, and emotion regulation may not be working correctly. This pathway is called the hypothalamic-pituitary-adrenal (HPA) axis. These glands release chemicals that regulate stress and appetite.

With melancholic depression, you may have high levels of cortisol, a steroid hormone that your adrenal glands make when you’re under stress. Your HPA axis regulates this process and can affect many functions of your body, including your appetite, metabolism, and memory.

You may also have changes in brain signals called neurons. These signals affect how you respond to your surroundings.

The following can be risk factors for melancholic depression:

  • Age. Melancholic depression symptoms usually happen later in life.
  • Genetics. This type of depression tends to run in families. People in your family tree may have had mood problems or even died by suicide.
  • Time of year. Melancholic depression symptoms may be worse at times of the year when there is less sunlight, when the days are shorter, or when it’s cold outside.
  • Postpartum changes. People who have postpartum depression, or depression soon after giving birth, may also experience melancholic symptoms.

Your doctor or a mental health professional will diagnose your depression based on your signs and symptoms.

You must have one or both of the two main symptoms of melancholic depression: loss of the ability to enjoy life or inability to respond to pleasurable activities in life.

You must also have at least three of these symptoms:

  • Despair not due to grief or loss of a loved one
  • Loss of appetite or significant weight loss
  • Psychomotor changes
  • Depressed mood that’s worse in the morning than at night
  • Waking up at least 2 hours earlier than you want
  • Strong feelings of guilt

Melancholic depression treatments may include a combination of medications and therapy.

Antidepressants

Doctors often prescribe tricyclic antidepressants (TCAs) for melancholic depression, although they may also use other antidepressants and medications. TCAs include these medications:

Electroconvulsive therapy

If your other treatments don’t work, your doctor may suggest electroconvulsive therapy (ECT) to ease your symptoms. While you’re under general anesthesia, a technician sends electrical signals to your brain, causing you to have brief seizures. ECT may change your brain's chemical balance to ease depression symptoms.

Psychotherapy

Psychotherapy, or talk therapy, involves talking with a psychiatrist, psychologist, or other mental health professional about your emotions, thoughts, and behavior. You can use this treatment to learn how to respond to life’s challenges in a healthy way. However, talk therapy isn’t always as helpful for treating melancholic depression as other types of depression. Even after treatment, your symptoms may come back again, but it’s possible to manage your depression with the help of your doctor and mental health professionals.

Having untreated melancholic depression may lead to other physical and mental health problems. It may also affect your relationship with yourself and the people around you. Here are some complications that melancholic depression can cause:

  • Weight loss
  • Pain
  • Falling sick often
  • Decreased physical activity and increased risk of cardiovascular problems
  • Alcohol use disorder or being unable to control how often you drink
  • Anxiety
  • Staying alone or by yourself 
  • Self-harm
  • Thinking about suicide, attempting suicide, or dying by suicide
  • Frequent and unexpected panic attacks
  • Problems at work or school
  • Relationship problems

Your doctor will work with you to create a treatment plan that works best for you, which may include antidepressant medicines, talk therapy, and ECT. These treatments may improve your symptoms and quality of life. You may also be able to live more meaningfully and actively with melancholic depression by making changes to your everyday routine. You can:

  • Take your medication as prescribed, and talk to your doctor about any new over-the-counter medications or supplements you plan to take.
  • Engage in exercise and activities that let you move around, such as dancing, taking walks, swimming, cooking, yoga, and gardening.
  • Prioritize your sleep by following a regular sleep schedule.
  • Do mind-body exercises such as journaling, deep breathing, yoga, and tai chi.
  • Eat a healthy and well-balanced diet.
  • Avoid smoking and drinking alcohol.
  • Do activities that make you think creatively, such as drawing, singing, playing an instrument, taking pictures, and knitting and crocheting.
  • Spend more time outdoors.
  • Spend more time with people you love.
  • Meet and interact with new people. For example, you could join a dance class or a gym, or try volunteering in your community.

Caregiving for someone with melancholic depression may involve:

  • Encouraging them to follow through with their treatment.
  • Doing their chores and running errands for them.
  • Helping them feel empowered so that they can live fully despite their mental condition.
  • Taking them to their doctor’s appointments and attending these appointments with them.
  • Planning treatments with them and their doctor.
  • Providing emotional support whenever they show melancholic depression symptoms.
  • Helping them with their money or legal decisions.

Caregiving can come with stress, overwhelming feelings and loneliness, and even mental health problems such as anxiety, sleep problems, and depression. The strain of caregiving for someone with melancholic depression may also cause you to see changes in your body. These may include having body aches, stomach problems, tense muscles, or headaches more often and falling sick more easily. It may also contribute to long-term health problems including heart disease, diabetes, and cancer.

You can reduce the burden of caregiving by:

  • Joining support groups, where you can talk with, learn more, and share experiences with other caregivers of people with melancholic depression.
  • Prioritizing your rest by creating “me-time” for yourself every day.
  • Staying in touch with your loved ones and asking for and accepting help.
  • Speaking with a doctor when the stress of being a caregiver feels out of your control.
  • Following healthy habits such as sleeping, eating, exercising, and going for health checkups regularly.
  • Staying on top of tasks by making to-do lists and following routines.

Here’s a list of mental health resources to support caregivers in managing their daily challenges, sourced from the Anxiety & Depression Association of America (ADAA):

Melancholic depression is a serious type of depression that may cause you to lose interest in doing anything, feel very sad for no apparent reason, be indifferent when positive things happen to you, eat differently, lose weight, and sleep less. If you have any of these symptoms, see a doctor, and they can give you an appropriate diagnosis and talk with you about your treatment. You can manage your symptoms and improve your overall well-being if you follow your treatment plan and care for yourself by engaging in healthy activities.

What triggers melancholy?

Unlike other types of depression, experts say a negative or distressing event doesn’t trigger melancholy. Instead, it’s thought to happen due to biological causes such as genetics.

What is melancholic temperament depression?

Before modern medicine, there was a theory of four temperaments to describe people: sanguine, choleric, melancholic, and phlegmatic. Each was tied to a “humor,” or fluid in the body. Melancholia was linked to an excess amount of black bile, causing a depressive temperament. Today, melancholic depression is classified as a subtype of major depression according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the handbook used by mental health professionals to diagnose mental disorders. Melancholic depression is mainly marked by a loss of the ability to enjoy life or to respond to pleasurable activities in life.

What is melancholic sadness?

People may describe melancholic sadness, or melancholy, as intense and overwhelming feelings of sadness.

How do you help someone with melancholic depression?

You can help someone with melancholic depression by being there for them as much as you can. You can go to their doctor’s appointment with them, listen to them with empathy and compassion whenever they talk to you about their problems, and encourage them to participate in treatment and activities that improve their well-being.