Descriptive Psychopathology: The Signs and Symptoms of ...

376 Section 4: Evidence-based classificationoccur. Other patients with melancholia are agitated, restless, and perseverative intheir ruminations and actions. Disturbances in vegetative body functions are alwayspresent. Patients lose their appetites and weight, sleep little, and lose interest insex and family activities. The disturbances impair recall and concentration andsufferers are unable to work efficiently. Self-care is abandoned. Thoughts arepre-occupied by despondency, death and considerations of self-harm. Delusionsbecome prominent with thoughts of illness, guilt, worthlessness and dangeroverwhelming their actions. The DSM shortlist of “melancholic features” doesnot capture the melancholia syndrome.Laboratory verificationThe clinical features of melancholia mimic features of acute and chronic stress,and melancholia is considered a process eliciting an abnormal stress response. 17Afternoon serum cortisol levels and the dexamethasone suppression test (DST)assess this abnormal response, and when melancholia is defined by its threesymptom clusters rather than the shortlist DSM approach, 70% of patients havea positive test (i.e. non-suppression of serum cortisol following a challenge with1–2mg of dexamethasone). 18 A meta-analysis of 14 studies found non-suppressionto be substantially higher in psychotic depressed patients (64%) than in nonpsychoticpatients (36%). 19 Patients with schizophrenia typically do not showabnormal cortisol levels or non-suppression, arguing that high HPA activity isnot characteristic of psychosis but of melancholia. Test results normalize withsuccessful treatment, and re-emerged as abnormal when patients relapse. Melancholiais also characterized by sleep abnormalities with a pattern of delayed sleeponset, reduced REM latency and increased REM percent time. These featuresdistinguish melancholia from other disorders of mood. 20Pathophysiologic disturbances in persons with depression (e.g. brain metabolicand structural changes) also support the melancholia construct as most of thereports, while not specifically identifying the patients as melancholic, characterizethem as severely ill, psychotic, or hospitalized. Half of hospitalized depressedpatients and most with psychotic depression will be melancholic. Genetic studiesalso find the highest heritability in the most severely ill depressed patients. 21Treatment validationThe efficacy of ECT and to lesser extent tricyclic antidepressants in remittingmelancholic depressive illness supports the diagnosis. About 90% of patients withmelancholia who receive a full course of bilateral ECT remit within 3weeks. In themulti-site collaborative ECT study of continuation ECT versus pharmacotherapy(CORE), bilateral ECT achieved an overall remission rate of 87% among theseverely depressed patients who completed treatment, and a 95% rate for the 30%