How do you treat melancholic depression?

by | Nov 4, 2021 | Curbside Consults

Q; Never heard of chronic involutional melancholia. I give some activating drugs like venlafaxine or duloxetine for new onset of melancholia and do check-up for signs of any type of dementia and consider lithium and other brain supplements for dementia prevention.

PL: Kraepelin used the phrase “involutional melancholia” to describe middle age and later onset severe depression. It was chronic in its course, ie, it didnt come and go, it just stayed. Our view is that it likely reflects what now is called vascular depression, which has middle and later onset, and is chronic. The “melancholic” features are not central in our view for that condition, and in Kraepelin’s era all depression was melancholic because otherwise it didn’t lead to hospitalization, which is where Kraepelin saw his patients.

Regarding treatment of melancholia with “activating” agents like venlafaxine or duloxetine, you may be right, but the proof is greater for older tricyclic antidepressants. Why not just use them? Venlafaxine has major cardiac risks, if that’s a reason to avoid TCAs. Further, the efficacy is short-term. Long-term use of venlafaxine or duloxetine for melancholia may not be necessary if the melancholia is episodic, as opposed to chronic. In that case, when the episode resolves, the antidepressants can be stopped and long-term prevention of episodes can occur with standard dose, not low-dose, lithium or possibly other mood stabilizers.

Of course ECT is the most effective treatment for melancholia, although again short-term for the actual episode, not long-term for prevention, which is disproven.