Diagnosis Depression: Major Depressive Disorder (MDD) with Melancholic Features

I wanted to finish the discussion on the various specifiers for major depressive disorder. In this post I will discuss melancholic features. 

The most distinct feature in MDD with melancholic features is profound loss of interest (anhedonia) in all or almost all activities. This is a common feature in MDD as well, but the loss of pleasure in activities is far more severe. There is also a complete lack of reactivity to anything that would usually be considered by the person as pleasurable. 

In addition, at least three of the following are required: 

1. Depressed mood that is experienced as qualitatively different from the feeling experienced after a loss. 
2. Depression that is worse in the morning. 
3. Awakening at least two hours prior to the usual wake time 
4. Marked psychomotor retardation (slow movement) or agitation 
5. Significant anorexia or weight loss 
6. Excessive or inappropriate guilt 

I think of this specifier as a more profound form of MDD. 

One thing we try to do with modern pharmacology is treat specific symptoms with classes of medication that match the neurotransmitter profile. The medication selection or augmentation strategy may change depending on the symptoms we want to target. For example, fatigue and concentration are largely regulated by norepinephrine and dopamine, so we may choose a medication that targets these neurotransmitters. In this example of melancholic depression sleep and appetite may be the primary issues, we may select a more sedating medication like mirtazapine. I will provide more details on the symptom-based selection of medication for depression in future posts.