Descriptive Psychopathology: The Signs and Symptoms of ...

377 Chapter 16: An evidence-based classificationof patients with psychotic depression. 22 More than 80% of the sample metsymptom criteria for melancholia. 23 Successful ECT also reverses the hormoneimbalances seen in depressive illness. 24Broad pharmacodynamic spectrum antidepressants (e.g. tricyclic agents) aremore effective in melancholic than in non-melancholic patients. 25 Lithiummoderates abnormal mood and reduces suicidal drive, and is the most effectiveaugmenting agent in the treatment of acute depressive illness, unipolar andbipolar, when the depression is melancholic. It is efficient as continuation therapyfor melancholic patients, especially when combined with the tricyclic antidepressant(TCA) nortriptyline. 26Although SSRI and similar agents are widely recommended in treatmentalgorithms as the first agents for major depression, their overall 30–40% remissionrates differ only minimally from placebo rates. 27 There is virtually noplacebo response among severely depressed patients.Most of the recent head-to-head drug trials are industry-sponsored and reportSSRI and TCA to be equally effective for major depression. But close inspection ofthese efforts find them misleading, with an advantage for TCA for the hospitalizedand more severely ill. 28 A review of 186 randomized control trials found thatamitriptyline had a better recovery rate than any of the alternative drugs,although it was less well tolerated. 29 Another meta-analysis found efficacy tofavor TCA for hospitalized depressed patients (more likely to be melancholic),but not for other groups. 30 A third meta-analysis found TCA more effective thanSSRI in severely depressed and elderly patients, also more likely to be melancholic.31 Other reports find TCA superior to an SSRI with similar drop out ratesand no significant cardiovascular problems with the TCA. 32 Three Danishdouble-blind randomized controlled antidepressant drug trials that included292 inpatients, most of whom with melancholia, report clomipramine to besuperior to several comparison non-TCA agents. 33Melancholic depressive disorderOnce major depression is separated into melancholia and non-melancholiadepressive disorders, several present distinctions are best considered severitymodifiers of melancholia rather than as separate conditions. This permits theapplication of the more specific treatments for melancholia.Psychotic depressionApproximately one-third of melancholic patients are psychotic. 34 Nearly allpatients with psychotic depression are melancholic. 35 Psychotic depression andnon-psychotic melancholia are not different diseases. 36 Psychotic depression is a