Melancholia ormelancholy (fromGreek:µέλαινα χολήmelaina chole,[1] meaningblack bile)[2] is a concept found throughoutancient,medieval, andpremodern medicine in Europe that describes a condition characterized by markedlydepressed mood, bodily complaints, and sometimeshallucinations anddelusions.
Melancholy was regarded as one of thefour temperaments matching thefour humours.[3] Until the 18th century, doctors and other scholars classified melancholic conditions as such by their perceived common cause – an excess of a notional fluid known as "black bile", which was commonlylinked to the spleen.Hippocrates and other ancient physicians described melancholia as a distinct disease with mental and physical symptoms, including persistent fears and despondencies, poor appetite,abulia, sleeplessness, irritability, and agitation.[4][5] Later, fixeddelusions were added byGalen and other physicians to the list of symptoms.[6][7] In theMiddle Ages, the understanding of melancholia shifted to a religious perspective,[8][9] with sadness seen as a vice anddemonic possession, rather than somatic causes, as a potential cause of the disease.[10]
During the late 16th and early 17th centuries, a cultural and literary cult of melancholia emerged in England, linked toNeoplatonist andhumanistMarsilio Ficino's transformation of melancholia from a sign of vice into a mark of genius. This fashionable melancholy became a prominent theme in literature, art, and music of the era.[citation needed]
Between the late 18th and late 19th centuries,melancholia was a common medical diagnosis.[11] In this period, the focus was on the abnormal beliefs associated with the disorder, rather than depression and affective symptoms.[7] In the 19th century, melancholia was considered to be rooted in subjective 'passions' that seemingly caused disordered mood (in contrast to modern biomedical explanations for mood disorders). In Victorian Britain, the notion of melancholia as a disease evolved as it became increasingly classifiable and diagnosable with a set list of symptoms that contributed to a biomedical model for the understanding mental disease.[12] However, in the 20th century, the focus again shifted, and the term became used essentially as a synonym for depression.[7] Indeed, modern concepts of depression as amood disorder eventually arose from this historical context.[13] Today, the term "melancholia" and "melancholic" are still used in medical diagnostic classification, such as inICD-11 andDSM-5, to specify certain features that may be present in major depression.[14][15]
Related terms used in historical medicine includelugubriousness (fromLatinlugere: "to mourn"),[16][17]moroseness (from Latinmorosus: "self-will or fastidious habit"),[17][18]wistfulness (from a blend of "wishful" and the obsolete Englishwistly, meaning "intently"),[17][19] andsaturnineness (from LatinSaturninus: "of theplanet Saturn).[20][21]
The name "melancholia" comes from the old medical belief of the fourhumours: disease or ailment being caused by an imbalance in one or more of the four basic bodily liquids, or humours. Personality types were similarly determined by the dominant humor in a particular person. According toHippocrates and subsequent tradition, melancholia was caused by an excess of black bile,[22] hence the name, which means "black bile", fromAncient Greek μέλας (melas), "dark, black",[23] and χολή (kholé), "bile";[24] a person whose constitution tended to have a preponderance of black bile had amelancholic disposition. In the complex elaboration of humorist theory, it was associated with the earth from theFour Elements, the season of autumn, thespleen as the originating organ and cold and dry as related qualities. Inastrology it showed the influence ofSaturn, hence the related adjectivesaturnine.[20][21]
Melancholia was described as a distinctdisease with particular mental and physical symptoms in the 5th and 4th centuries BC. Hippocrates, in hisAphorisms, characterized all "fears and despondencies, if they last a long time" as being symptomatic of melancholia.[4] Other symptoms mentioned by Hippocrates include: poor appetite,abulia, sleeplessness, irritability, agitation.[5] The Hippocratic clinical description of melancholia shows significant overlaps with contemporary nosography of depressive syndromes (6 symptoms out of the 9 included in DSM[25] diagnostic criteria for a Major Depressive).[26]
Inancient Rome,Galen added "fixed delusions" to the set of symptoms listed by Hippocrates. Galen also believed that melancholia caused cancer.[6]Aretaeus of Cappadocia, in turn, believed that melancholia involved both a state of anguish, and a delusion.[7] In the 10th centuryPersian physicianAl-Akhawayni Bokhari described melancholia as achronic illness caused by the impact of black bile on the brain.[27] He described melancholia's initial clinical manifestations as "suffering from an unexplained fear, inability to answer questions or providing false answers, self-laughing and self-crying and speaking meaninglessly, yet with no fever."[28]
In Middle-Ages Europe, the humoral, somatic paradigm for understanding sustained sadness lost primacy in front of the prevailing religious perspective.[8][9] Sadness came to be a vice (λύπη in the Greek vice list by Evagrius Ponticus,[29] tristitia vel acidia in the 7 vice list byPope Gregory I).[30] When a patient could not be cured of the disease it was thought that the melancholia was a result ofdemonic possession.[10][31]
In his study of French and Burgundian courtly culture,Johan Huizinga[32] noted that "at the close of the Middle Ages, a sombre melancholy weighs on people's souls." In chronicles, poems, sermons, even in legal documents, an immense sadness, a note of despair and a fashionable sense of suffering and deliquescence at the approaching end of times, suffuses court poets and chroniclers alike: Huizinga quotes instances in the ballads ofEustache Deschamps, "monotonous and gloomy variations of the same dismal theme", and inGeorges Chastellain's prologue to his Burgundian chronicle,[33] and in the late 15th-century poetry ofJean Meschinot. Ideas of reflection and the workings of imagination are blended in the termmerencolie, embodying for contemporaries "a tendency", observes Huizinga, "to identify all serious occupation of the mind with sadness".[34]
Painters were considered byVasari and other writers to be especially prone to melancholy by the nature of their work, sometimes with good effects for their art in increased sensitivity and use of fantasy. Among those of his contemporaries so characterised by Vasari werePontormo andParmigianino, but he does not use the term ofMichelangelo, who used it, perhaps not very seriously, of himself.[35] A famousallegoricalengraving byAlbrecht Dürer is entitledMelencolia I. This engraving has been interpreted as portraying melancholia as the state of waiting for inspiration to strike, and not necessarily as a depressive affliction. Amongst other allegorical symbols, the picture includes amagic square and a truncatedrhombohedron.[36] The image in turn inspired a passage inThe City of Dreadful Night byJames Thomson (B.V.), and, a few years later, a sonnet byEdward Dowden.
The most extended treatment of melancholia comes fromRobert Burton, whoseThe Anatomy of Melancholy (1621) treats the subject from both a literary and a medicalperspective. His concept of melancholia includes all mental illness, which he divides into different types. Burton wrote in the 17th century that music and dance were critical in treating mental illness.[37]
But to leave all declamatory speeches in praise of divine music, I will confine myself to my proper subject: besides that excellent power it hath to expel many other diseases, it is a sovereign remedy against despair and melancholy, and will drive away the devil himself. Canus, a Rhodian fiddler, in Philostratus, when Apollonius was inquisitive to know what he could do with his pipe, told him, "That he would make a melancholy man merry, and him that was merry much merrier than before, a lover more enamoured, a religious man more devout." Ismenias the Theban, Chiron the centaur, is said to have cured this and many other diseases by music alone: as now they do those, saith Bodine, that are troubled with St. Vitus's Bedlam dance.[38][39][40]
In theEncyclopédie ofDiderot andd'Alembert, the causes of melancholia are stated to be similar to those that causeMania: "grief, pains of the spirit, passions, as well as all the love and sexual appetites that go unsatisfied."[41]
During the later 16th and early 17th centuries, a curious cultural and literary cult of melancholia arose in England. In an influential[42][43] 1964 essay inApollo, art historianRoy Strong traced the origins of this fashionable melancholy to the thought of the popularNeoplatonist andhumanistMarsilio Ficino (1433–1499), who replaced the medieval notion of melancholia with something new:
Ficino transformed what had hitherto been regarded as the most calamitous of all the humours into the mark of genius. Small wonder that eventually the attitudes of melancholy soon became an indispensable adjunct to all those with artistic or intellectual pretentions.[44]
The Anatomy of Melancholy (The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it... Philosophically, Medicinally, Historically, Opened and Cut Up) by Burton, was first published in 1621 and remains a defining literary monument to the fashion. Another major English author who made extensive expression upon being of an melancholic disposition is SirThomas Browne in hisReligio Medici (1643).
Night-Thoughts (The Complaint: or, Night-Thoughts on Life, Death, & Immortality), a long poem in blank verse byEdward Young was published in nine parts (or "nights") between 1742 and 1745, and hugely popular in several languages. It had a considerable influence on earlyRomantics in England, France and Germany.William Blake was commissioned to illustrate a later edition.
In the visual arts, this fashionable intellectual melancholy occurs frequently in portraiture of the era, with sitters posed in the form of "the lover, with his crossed arms and floppy hat over his eyes, and the scholar, sitting with his head resting on his hand"[44] – descriptions drawn from the frontispiece to the 1638 edition of Burton'sAnatomy, which shows just such by-then stock characters. These portraits were often set out of doors where Nature provides "the most suitable background for spiritual contemplation"[45] or in a gloomy interior.
In music, the post-Elizabethan cult of melancholia is associated withJohn Dowland, whose motto wasSemper Dowland, semper dolens ("Always Dowland, always mourning"). The melancholy man, known to contemporaries as a "malcontent", is epitomized by Shakespeare'sPrince Hamlet, the "Melancholy Dane".
Until the 18th century, writings on melancholia were mainly concerned with beliefs that were considered abnormal, rather than affective symptoms.[7]
Melancholia was a category that "the well-to-do, the sedentary, and the studious were even more liable to be placed in the eighteenth century than they had been in preceding centuries."[47][48]
In the 20th century, "melancholia" lost its attachment to abnormal beliefs, and in common usage became entirely a synonym for depression.[7] Sigmund Freud published a paper onMourning and Melancholia in 1918.
In 1907, the German psychiatristEmil Kraepelin influentially proposed the existence of a condition he called 'involutional melancholia', which he thought could help explain the more frequent occurrence of depression among elderly people.[49] He surmised that in the elderly "the processes of involution in the body are suited to engender mournful or anxious moodiness", though by 1913 he had returned to his earlier view (first expounded in 1899) that age-related depression could be understood in terms ofmanic-depressive illness.[49]
In 1996, Gordon Parker and Dusan Hadzi-Pavlovic described "melancholia" as a specific disorder of movement and mood.[50] They attached the term to the concept of "endogenous depression" (claimed to be caused by internal forces rather than environmental influences).[51]
In 2006, Michael Alan Taylor and Max Fink also defined melancholia as a systemic disorder that could be identified by depressive mood rating scales, verified by the presence of abnormalcortisol metabolism.[52] They considered it to be characterized by depressed mood, abnormal motor functions, and abnormal vegetative signs, and they described several forms, includingretarded depression,psychotic depression andpostpartum depression.[52]
severely depressed mood, wherein the person often feels despondent, forlorn, disconsolate, or empty
pervasive anhedonia – loss of interest or pleasure in most activities that are normally enjoyable
lack of emotional responsiveness (mood does not brighten, even briefly) to normally pleasurable stimuli (such as food or entertainment) or situations (such as warm, affectionate interactions with friends or family)
terminal insomnia – unwanted early morning awakening (two or more hours earlier than normal)
marked psychomotor retardation or agitation
marked loss of appetite or weight loss
A specifier essentially is a subcategory of a disease, explaining specific features or symptoms that are added to the main diagnosis.[54] According to theDSM-IV, the "melancholic features" specifier may be applied to the following only:
It is important to note, however, that people who suffer from melancholic depression do not need to have melancholic features in every depressive episode.[55]
The causes of melancholicdepressive disorder are believed to be mostly biological factors that can be hereditary. Biological origins of the condition include problems with theHPA axis andsleep structure of patients.[57]MRI studies have indicated that melancholic depressed patients have issues with the connections between different regions of the brain, specifically theinsula andfronto-parietal cortex.[58] Some studies have found that there arebiological marker differences between patients with melancholic depression and other subtypes of depression.[59]
The research regarding melancholic depression consistently finds that men are more likely to receive a melancholic depression diagnosis.[60]
Melancholic depression is often considered to be a biologically based and particularly severe form of depression. Therefore, the treatments for this specifier of depression are more biomedical and less psychosocial (which would include talk therapy and social support).[63] The general initial or "ideal" treatment for melancholic depression is antidepressant medication, and psychotherapy is added later on as support if at all.[55] The scientific support for medication as the best treatment is that patients with melancholic depression are less likely to improve with placebos, unlike other depression patients. This indicates the improvements observed after medication actually come from the biological basis of the condition and the treatment.[57] There are several types of antidepressants that can be prescribed includingSSRIs,SNRIs,tricyclic antidepressants, andMAOIs; the antidepressants tend to vary on how they work and what specificchemical messengers in the brain they target.[56] SNRIs are generally more effective than SSRIs because they target more than one chemical messenger (serotonin andnorepinephrine).[60]
Althoughpsychotherapy treatments can be used such as talk therapy and cognitive behavioral therapy (CBT), they have shown to be less effective than medication.[57] In arandomized clinical trial, it was shown that CBT was less effective than medication in treating symptoms of melancholic depression after 12 weeks.[64]
Electroconvulsive therapy (ECT) was previously believed to be an effective treatment for melancholic depression.[65] ECT has been more commonly used for patients with melancholic depression due to the severity. In 2010, a study found that 60% of depression patients treated with ECT had melancholic symptoms.[55] However, studies since the 2000s have failed to demonstrate positive treatment results from ECT, although studies also indicate a more positive response to ECT in melancholic patients than other depressed patients.[57][66]
It has been observed in studies that patients with melancholic depression tend to recover less often than other types of depression.[60]
The prevalence of having the melancholic depression specifier among patients diagnosed with clinical depression is estimated to be about 25% to 30%.[55]
The incidence of melancholic depression has been found to increase when the temperature and/or sunlight are low.[67]
^abAzzone P (2012) Sin of Sadness: Acedia vel Tristitia Between Sociocultural Conditioning and Psychological Dynamics of Negative Emotions. Journal of Psychology and Christianity, 31: 50–64.
^abWorld Health Organization, "6A80.3 Current depressive episode with melancholia", International Statistical Classification of Diseases and Related Health Problems, 11th rev. (September 2020).
^abcPorter, Stanley C.; Malcolm, Matthew R., eds. (2013-04-25).Horizons in Hermeneutics: A Festschrift in Honor of Anthony C. Thiselton.William B. Eerdmans Publishing Company. p. 162.ISBN978-0-8028-6927-2.Melancholia [is] also translated as "lugubriousness," "moroseness," or "wistfulness".
^abWallace, Ian, ed. (2015).Voices from Exile: Essays in Memory of Hamish Ritchie.Brill. p. 213.ISBN978-90-04-29639-8.[This is] what humour-based physiology of the renaissance and baroque periods described as saturnine melancholia.
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^Guillamont A., Guillamont C. (Eds.) (1971) Évagre le Pontique. Traité pratique ou le moine, 2 VV.. Sources Chrétiennes 170–171, Les Éditions du Cerf, Paris
^Gregorius Magnus. Moralia in Iob. In J.-P. Migne (Ed.) Patrologiae Latinae cursus completus (Vol. 75, col. 509D – Vol. 76, col. 782AG)
^Britton, Piers,"Mio malinchonico, o vero... mio pazzo": Michelangelo, Vasari, and the Problem of Artists' Melancholy in Sixteenth-Century Italy,The Sixteenth Century Journal, Vol. 34, No. 3 (Fall, 2003), pp. 653–675,doi:10.2307/20061528,Archived 2020-11-14 at theWayback Machine
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^Cf.The Anatomy of Melancholy, subsection 3, on and after line 3480, "Music a Remedy":
^Aung, Steven K.H.; Lee, Mathew H.M. (2004). "Music, Sounds, Medicine, and Meditation: An Integrative Approach to the Healing Arts".Alternative & Complementary Therapies.10 (5):266–270.doi:10.1089/act.2004.10.266.
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^Ribeiro, Aileen (2005).Fashion and Fiction: Dress in Art and Literature in Stuart England. New Haven CN; London: Yale University Press. p. 52.ISBN978-0-300-10999-3.
^abStrong, Roy (1964). "The Elizabethan Malady: Melancholy in Elizabeth and Jacobean Portraiture".Apollo.LXXIX., reprinted inStrong, Roy (1969).The English Icon: Elizabethan and Jacobean Portraiture. London: Routledge & Kegan Paul.
^Ribeiro, Aileen (2005).Fashion and Fiction: Dress in Art and Literature in Stuart England. New Haven, CN; London: Yale University Press. p. 54.ISBN978-0-300-10999-3.
^abKendler KS, Engstrom EJ (2020). "Dreyfus and the shift of melancholia in Kraepelin's textbooks from an involutional to a manic-depressive illness".Journal of Affective Disorders.270:42–50.doi:10.1016/j.jad.2020.03.094.PMID32275219.S2CID215726731.
^McGrath, Patrick; Ashan Khan; Madhukar Trivedi; Jonathan Stewart; David W Morris; Stephen Wisniewski; Sachiko Miyahara; Andrew Nierenberg; Maurizio Fava; John Rush (2008). "Response to a Selective Serotonin Reuptake Inhibitor (Citalopram) in Major Depressive Disorder with Melancholic Features: A STAR*D Report".Journal of Clinical Psychiatry.69 (12):1847–1855.doi:10.4088/jcp.v69n1201.PMID19026268.
^Radua, Joaquim; Pertusa, Alberto; Cardoner, Narcis (28 February 2010). "Climatic relationships with specific clinical subtypes of depression".Psychiatry Research.175 (3):217–220.doi:10.1016/j.psychres.2008.10.025.PMID20045197.S2CID21764662.
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