A mixed state core for melancholia: an exploration in history, art and clinical science

Authors

  • H. S. Akiskal,

    1. University of California at San Diego, La Jolla
    2. International Mood Center, La Jolla, CA, USA Dr. H.S. Akiskal is on the speaker's bureau of Abbott, Astra Zeneca, Bristol-Myers-Squibb, Eli Lilly & Co and GSK. He is also on the U.S. Bipolor advisory board for GSK K.K. Akiskal declares no conflicts of interests
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  • K. K. Akiskal

    1. International Mood Center, La Jolla, CA, USA Dr. H.S. Akiskal is on the speaker's bureau of Abbott, Astra Zeneca, Bristol-Myers-Squibb, Eli Lilly & Co and GSK. He is also on the U.S. Bipolor advisory board for GSK K.K. Akiskal declares no conflicts of interests
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  • Presented at the Conference: ‘Melancholia: Beyond DSM, Beyond Neurotransmitters’, May 2–4, 2006, Copenhagen, Denmark.

Hagop S Akiskal, Psychiatry Service 116A, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
E-mail: hakiskal@ucsd.edu

Abstract

Objective:  We argue for a mixed state core for melancholia comparing concepts of melancholia across centuries using examples from art, history and scientific literature.

Method:  Literature reviews focusing on studies from Kraepelin onward, DSM-IV classification and view-points from clinical experience highlighting phenomenologic and biologic features as predictors of bipolar outcome in prospective studies of depression.

Results:  Despite the implied chemical pathology in the term endogenous/melancholic depression, frequently reported glucocortical and sleep neurophysiologic abnormalities, there is little evidence that melancholia is inherited independently from more broadly defined depressions. Prospective follow-up of ‘neurotic’ depressions have shown melancholic outcomes in as many as a third; hypomania has also been observed in such follow-up.

Conclusion:  These findings and considerations overall do suggest that melancholia as defined today is more closely aligned with the depressive and/or mixed phase of bipolar disorder. Given the high suicidality from many of these patients the practice of treating them with antidepressant monotherapy needs re-evaluation.

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