Melancholic and Psychotic Depression – Review of Diagnosis and Management

Posted on:July 26, 2020
Last Updated: October 30, 2022
Time to read: 20–24 minutes

Melancholic and psychotic depressions are severe forms of depression associated with high morbidity and suicide risk. [Wilhelm K., 2009]

The initial description of melancholia was during the time of Hippocrates in the 5th century BC. There were two schools of thought – the psychological vs the biological. [Kotsopoulos, S. 2018]

The psychological perspective:

Melancholia was caused by a “fault of the heart”, that is to say by a repressed wickedness: such was the opinion of Socrates, of Plato (to some extent) and of the stoic philosophers posidonius, Zenon and Cicero.

The biological perspective:

A mental disease resulting from a cerebral dismetabolism with a lowering of the tone the brain, which became “dry and cold” through the action of the black bile. The symptoms of melancholia were caused by an “intemperies cerebri”, which was a repercussion of the pathogenic action of an inhibitory humour such as the black bile.

Aretaeus the Cappadocian (c. 50 A.D.), Soranus of Ephesus (c 78-117 A.D.), and Rufus of Ephesus considered mania and melancholia to be different expressions of the same disease which today would be considered to encompass the manic-depressive spectrum.

Soranus of Ephesus described melancholia as:

Individuals exhibiting mental anguish and distress, dejection, silence, animosity towards members of their household, sometimes a desire to live, and at other times a longing for death; suspicion that a plot is being hatched against him, weeping without reason, meaningless muttering and occasional joviality. [Wilhelm K., 2009]

Rufus drug therapy was quite elaborate. His idea was cleansing the body of accumulated noxious substances such as black bile with vomiting (epithymum, aloe) bowel movements (black hellebore), sweating, urination. Special caution ought to be given to the drug administration lest it might cause harm. Under certain circumstances, phlebotomy might be required. Intervals in the treatment and travelling were recommended. It was of interest that Rufus recommended the use of wine in moderation and sexual intercourse as being helpful against melancholia. Similar opinion was expressed by Galen and by Paulus on the beneficial effects of sexual activity [έξ αφροδισίων ωφέλειαι – of aphrodisiac benefits] on melancholia. [Kotsopoulos, S. 2018]