Feature Article

Making sense of the complex depressed patient. Part 3: melancholic and psychotic depression

Kay Wilhelm

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Abstract

Melancholic depression can occur in patients of any age but is more likely to have first onset in patients aged over 60 years. Patients with earlier onset melancholic depression are more at risk of developing bipolar disorder.

Key Points

  • Melancholic depression and psychotic depression (melancholic depression with associated psychotic features) are associated with significant morbidity and high suicide risk.
  • Melancholic depression is more commonly late onset (patients over the age of 60 years) and related to microvascular disease or other neurodegenerative and illness-related factors – structural melancholia.
  • Early-onset melancholic depression (often before the age of 30 years) has a genetic predisposition – functional melancholia. These patients have an increased risk of developing bipolar disorder.
  • Diagnosis relies on symptoms (anhedonia, non-reactivity, diurnal mood variation and early morning wakening) and observable features of psychomotor disturbance involving retardation and/or agitation with impaired cognitive processing (poor concentration and inattention).
  • Red flags for melancholic depression include sudden and significant change in behaviour, poor sleep, sudden unexplained appetite loss, sudden inability to work effectively and complaints about being unable to think, unusual ruminations and/or preoccupations, and talk of hopelessness.
  • Dual-action antidepressants are the treatment of choice for melancholic depression; the serotonin and noradrenaline reuptake inhibitors (SNRIs) are first line, followed by tricyclic antidepressants. Psychotic depression is treated with antidepressants and antipsychotics.

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