'Detention is morally exhausting': melancholia of detention centres in France.

How are ethics articulated in the organization of migrants' detention in France? While state agents enjoy discretionary power, it is the third sector that claims legal knowledge and good practice, exposing an unresisting and reverent attitude towards the 'rule of law'. This legalistic gaze on the state attests to the impasse in questioning (the moral grounds of) laws and flaunting intense emotions on a daily basis, an expression of their moral dilemma. In doing so, police officers, legal practitioners and other service providers display contrasting ideological disapproval but practical compliance, creating an environment infused with melancholy. Melancholy enables them to be humble operators of state rules and regulations and, at the same time, to suffer endless (moral and emotional) pain. This article analyses inter-organizational and inter-personal affective experiences in order to demonstrate how melancholy reflects the morale that is manifest in the organization of migrants' detention.

Incidence of melancholic depression by age of onset and gender in the Lundby population, 1947-1997.

Whether melancholic depression is a distinct syndrome or not has long been debated. There are few studies providing information about the epidemiology of melancholic depression. In this study, we investigate the incidence rates, overall as well as by gender and age of onset of melancholic depression according to Taylor and Fink and corresponding DSM-IV disorders: major depressive disorder (MDD) with melancholic specifier, MDD with psychotic features, MDD with postpartum debut and bipolar depression in the Lundby population. Incidence rates with 95% confidence intervals were calculated. The incidence rate of melancholic depression was 0.48 (CI 0.36-0.61) per 1000 person-years under risk. The rates of the corresponding DSM-IV disorders were as follows: MDD with melancholic specifier 0.38 (CI 0.27-0.49), MDD with psychotic features 0.13 (CI 0.07-0.21), MDD with postpartum debut 0.02 (CI 0.00-0.06) and bipolar depression 0.04 (CI 0.01-0.10). Females had a significantly higher incidence rate, with a peak in age group 40-49, in melancholic depression according to Taylor and Fink and MDD with melancholic specifier. There was no gender difference in incidence rates of MDD with psychotic features or bipolar depression. The diagnoses were set in retrospect and the number of subjects with MDD with postpartum debut and bipolar depression was low. Incidence of melancholia was low in the Lundby Study. There was a female preponderance to become melancholically depressed in line with research on undifferentiated depression.

Methods for quantifying the heterogeneity of psychopathology.

OBJECTIVES: Specifiers for a major depressive disorder (MDE) are supposed to reduce diagnostic heterogeneity. However, recent literature challenges the idea that the atypical and melancholic specifiers identify more homogenous or coherent subgroups. We introduce the usage of distance metrics to characterize symptom heterogeneity. We attempt to replicate prior findings and explore whether symptom heterogeneity is reduced using specifier subgroups. METHODS: We used data derived from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC Wave I; N = 5,749) and the Sequenced Treatment Alternatives to Relieve Depression study (STAR*D; N = 2,498). We computed Hamming and Manhattan distances from study participants' unique symptom profiles. Distances were standardized from 0-1 and compared by their within- and between-group similarities to their non-specifier counterparts for the melancholic and atypical specifiers. RESULTS: There was no evidence of statistically significant differences in heterogeneity for specifier (i.e., melancholic or atypical) vs. non-specifier designations (i.e., non-melancholic vs. non-atypical). CONCLUSION: Replicating prior work, melancholic and atypical depression specifiers appear to have limited utility in reducing heterogeneity. The current study does not support the claim that specifiers create more coherent subgroups as operationalized by similarity in the number of symptoms and their severity. Distance metrics are useful for quantifying symptom heterogeneity.

Neurocognitive function of patients with melancholic and non-melancholic major depressive episodes: An exploratory study.

OBJECTIVE: The aim of this exploratory study was to compare the neurocognitive performance of patients undergoing melancholic and non-melancholic major depressive episodes. Considering potential limitations of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) specifier, we employed an additional tool that has proven useful in identifying melancholia (the Sydney Melancholia Prototype Index). METHODS: One hundred forty-one depressed inpatients were classified as melancholic or non-melancholic according to the Sydney Melancholia Prototype Index and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria and compared on a neurocognitive battery selected to assess attention and processing speed, verbal memory, working memory and executive functions. Results were controlled for several potential confounders. RESULTS: Patients diagnosed as melancholic by the two diagnostic systems displayed lower scores in executive measures, semantic verbal fluency and phonological verbal fluency. On attention and processing speed, patients with melancholia underperformed those with non-melancholic depression only when diagnosed by the Sydney Melancholia Prototype Index. After controlling for confounders, associations between melancholic status and executive dysfunction remained significant for the Sydney Melancholia Prototype Index but not for the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) diagnosis. CONCLUSION: In this study, melancholia diagnosed by the Sydney Melancholia Prototype Index (but not by the Diagnostic and Statistical Manual of Mental Disorders [5th ed.] criteria) was characterized by a greater compromise of tests assessing executive functions than non-melancholic depressions, even after controlling for depressive severity. These preliminary results might contribute to generating hypotheses about differences in the cognitive profile and pathophysiological substrate between melancholic and non-melancholic depressions. Likewise, the pattern of findings supports the hypothesis that the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) melancholia specifier might identify more severe forms of depressive episodes rather than a qualitatively different subtype.

Revisiting the concept of bipolar depression: comparison of diagnostic validators between melancholic and non-melancholic episodes.

The current definition of bipolar disorder derives with minimal changes from one that emerged through expert consensus in the late 1970s, and the topic of its validity tended to be neglected in the literature. The aim of this exploratory study was to compare patients with bipolar disorder with a history of melancholic and non-melancholic depressive episodes in a series of external diagnostic validators. One hundred eight subjects were categorized as melancholic or non-melancholic in relation to their history of depressive episodes through the clinician-rated Sydney Melancholia Prototype Index (SMPI). The external validators used were clinical-demographic variables, family history of bipolar disorder, neurocognitive performance and functional outcome. There were 43.5% of the patients with a history of melancholia and 56.5% of non-melancholic depression. Non-melancholic depressions were overrepresented in females, while melancholic depressions had a female:male ratio closer to unity. Patients with melancholia had more history of BD in first-degree relatives and better functional outcome than those with non-melancholic depression. There were no differences between groups regarding neurocognitive performance. Results tended to be unchanged when controlled for confounders. Our preliminary results highlight the inherent heterogeneity in the current concept of bipolar depression, and suggest the need for further clinical research to elucidate its validity.

Ask depressed patients about brain fog to ensure melancholia is not mist.

OBJECTIVE: This study aims to highlight cognitive 'brain fog' as a key depression sub-typing symptom, being weighted to melancholic (as against non-melancholic) depression and note its common persistence after episode remission. METHOD: This paper weights clinical observation but considers several salient overview papers and research findings. RESULTS: While 'brain fog' is intrinsically non-specific in that it has multiple causes, when assessed as a second-order depressive sub-typing symptom, it has seemingly distinctive specificity to the melancholic sub-type, with many patients with melancholia resonating with such a descriptor question. As it may persist (albeit attenuated) after episode remission, psychostimulant medication may be of benefit in some patients. CONCLUSION: In the clinical assessment and differential diagnosis of those with a depressive disorder, inquiring into 'brain fog' can have distinct diagnostic benefit in differentiating melancholic and non-melancholic depression.

From Melancholia to Depression: Disordered Mood in Nineteenth-Century Psychiatry.

My book From Melancholia to Depression: Disordered Mood in Nineteenth-Century Psychiatry charts how melancholia was reconceptualized in the nineteenth century as a modern mood disorder and a precursor to clinical depression. The book shows how this occurred chiefly in two ways. First, the idea of disordered mood as a medical concept was created through the appropriation of language from experimental physiology into the realm of psychopathology. Second, the interplay of statistical and diagnostic practices formed the basis for modern psychiatric classification and facilitated the standardization of melancholia as a psychiatric diagnosis. These developments were key to the reconceptualization of melancholia and the subsequent emergence of clinical depression, and were foundational to modern psychiatric theory and practice.

Melancholia in late life in New South Wales and Victoria, Australia, 1871-1905: symptoms, behaviours and outcomes.

In the late nineteenth century, the prognosis of late-life melancholia was believed to be poor. The medical casebooks of 40 patients aged 60+years, admitted to two Hospitals for the Insane in New South Wales with melancholia between 1871 and 1905, were examined. Psychosis (87.5%), depressed mood (80%), suicidal behaviour (55%), physical ill health (55%), restlessness (50%) and fears of harm to self (50%) were identified. Main outcomes were discharge (40%) and death (37.5%). Victoria's Kew Hospital patient register for 1872-88 revealed 669 melancholia admissions with 30 aged 60+. Outcomes worsened significantly with age (chi square = 16.19, df = 4, p < 0.005), mainly due to higher mortality. Nineteenth-century late-life melancholia was a severe disorder despite many cases recovering.

Heterogeneity in major depression and its melancholic and atypical specifiers: a secondary analysis of STAR*D.

OBJECTIVES: The melancholic and atypical specifiers for a major depressive episode (MDE) are supposed to reduce heterogeneity in symptom presentation by requiring additional, specific features. Fried et al. (2020) recently showed that the melancholic specifier may increase the potential heterogeneity in presenting symptoms. In a large sample of outpatients with depression, our objective was to explore whether the melancholic and atypical specifiers reduced observed heterogeneity in symptoms. METHODS: We used baseline data from the Inventory of Depression Symptoms (IDS), which was available for 3,717 patients, from the Sequenced Alternatives to Relieve Depression (STAR*D) trial. A subsample met criteria for MDE on the IDS ("IDS-MDE"; N =2,496). For patients with IDS-MDE, we differentiated between those with melancholic, non-melancholic, non-melancholic, atypical, and non-atypical depression. We quantified the observed heterogeneity between groups by counting the number of unique symptom combinations pertaining to their given diagnostic group (e.g., counting the melancholic symptoms for melancholic and non-melancholic groups), as well as the profiles of DSM-MDE symptoms (i.e., ignoring the specifier symptoms). RESULTS: When considering the specifier and depressive symptoms, there was more observed heterogeneity within the melancholic and atypical subgroups than in the IDS-MDE sample (i.e., ignoring the specifier subgroups). The differences in number of profiles between the melancholic and non-melancholic groups were not statistically significant, irrespective of whether focusing on the specifier symptoms or only the DSM-MDE symptoms. The differences between the atypical and non-atypical subgroups were smaller than what would be expected by chance. We found no evidence that the specifier groups reduce heterogeneity, as can be quantified by unique symptom profiles. Most symptom profiles, even in the specifier subgroups, had five or fewer individuals. CONCLUSION: We found no evidence that the atypical and melancholic specifiers create more symptomatically homogeneous groups. Indeed, the melancholic and atypical specifiers introduce heterogeneity by adding symptoms to the DSM diagnosis of MDE.

Melancholia Scytharum: the early modern psychiatry of transgender identification.

Herodotus's enigmatic Scythian theleia nousos/morbus femininus and its Hippocratic interpretation interested many early modern authors. Its seeming dimension of transgender identification invited various medico-psychological and psychiatric reflections, culminating in nosologist de Sauvages' tentative 1731 term, melancholia Scytharum. This article identifies pertinent discussions and what turn out to have been entangled, tentative psychologizations in late-seventeenth through mid-nineteenth-century mental medicine: of 'effeminacy of manners' (mollities animi such as observed in London's Beaux and mollies) and male homosexuality (amour antiphysique/grec); of the mental masculinity of some women (viragines, Amazones); of ubiquitous attributions of impotence to sorcery (anaphrodisia magica); and lastly, of transfeminine persons encountered throughout the New World and increasingly beyond.

Melancholia: does this ancient concept have contemporary utility?

Many efforts have been made to develop coherent and clinically useful categories of depressive illness, especially to facilitate prediction of morbidity and guide treatment-response. They include proposals to resurrect the ancient concept of melancholia, as a form of severe depression with particular symptomatic and proposed psychobiological characteristics. However, modern research is inconsistent in supporting differences between melancholic and nonmelancholic depression. In our recent study of over 3200 patient-subjects with DSM-5 major depressive episodes with/without melancholic characteristics, and matched for illness severity, prevalence of melancholic features was 35.2% with remarkably few clinical and demographic differences between melancholic and nonmelancholic subjects. Also, our systematic review of trials comparing melancholic and nonmelancholic subjects found little difference in responses to antidepressant treatments. These findings indicate that the concept of melancholia may have limited value for clinical prediction and treatment-selection. Overlap of symptoms in melancholic and nonmelancholic depression, based on DSM criteria, may limit distinction of melancholia; alternative definitions can be sought, and psychomotor retardation is a particularly strong differentiating feature. For now, however, melancholia seems best considered a state-dependent depression-type strongly associated with greater symptomatic severity, rather than a distinct syndrome. Its DSM-5 current status as a depression-type specifier seems appropriate, and it may be a logical target for genetic and other biomedical studies.

Pseudo-melancholia.

OBJECTIVE: An incorrect false positive diagnosis of melancholia can lead to inappropriate treatment and illness prolongation. This paper therefore seeks to introduce the concept of 'pseudo-melancholia' to capture such instances and provide clinical examples of contributing at-risk scenarios. METHODS: The author draws on clinical experience to provide exemplars of circumstances most risking a false positive diagnosis of melancholia. RESULTS: Pseudo-melancholia can result from invalid measures of melancholia and from several functional and organic conditions presenting with suggested melancholic features. CONCLUSIONS: Recognising high-risk pseudo-melancholia scenarios has the potential to advance a change in diagnostic formulation, provide a more diagnosis-specific intervention and so avert a secondary diagnosis of 'treatment resistant depression'.

Impact, Diagnosis, Phenomenology, and Biology.

This section provides summaries of the epidemiology, phenomenology, nosology, and the suspected biological substrates of the depressive disorders. It particularly emphasizes the historical evolution of the pertinent diagnostic constructs and the prognostic import both of the various diagnostic groupings and of the individual symptoms and symptom clusters.

Through a glass darkly: patients of the Illinois State Hospital for the Insane at Jacksonville, USA (1854-80).

The State Hospital for the Insane at Jacksonville, Morgan County, Illinois, was the first public hospital of its kind to be established in the state and among the earliest to be built on the 'Kirkbride Plan'. It opened for patients in 1851. We describe the background to the establishment of the hospital and, so far as is possible from publicly available sources, its catchment area, the nature of the patients held there up to 1880, its mechanisms of discharge, and supposed causes of death. We end with a plea that after over 150 years, the release of hospital casebooks and similar records in digital form would be of considerable benefit to historians of psychology, scientific biographers, genealogists and demographers.

Putamen Volume Differences Among Older Adults: Depression Status, Melancholia, and Age.

BACKGROUND: Individuals with major depressive disorder (MDD) may exhibit smaller striatal volumes reflecting deficits in the reward circuit. Deficits may change with age and be more pronounced among the melancholic subtype. Limited research has investigated striatal volume differences in older adults and by depression subtypes. METHOD: We used baseline data from the Neurocognitive Outcomes of Depression in the Elderly study. We examined volumetric differences in the putamen and caudate nucleus among older adults (60 years and older), comparing healthy control participants (n = 134) to depressed participants (n = 226), and comparing nonmelancholic depressed participants (n = 93) to melancholic depressed participants (n = 133). Group-by-age interactions were examined. RESULTS: There were no significant group differences for the caudate nucleus. For the left putamen, investigation of the significant group-by-age interaction revealed that volume size was greater for the healthy controls compared to the depressed participants but only at younger ages (60-65 years); group differences diminished with increasing age. Examining volume by depression subtype revealed that the melancholic depressed participants had a smaller left putamen compared to the nonmelancholic depressed participants. Anhedonia symptoms were related to both smaller left and right putamen. CONCLUSION: Structural abnormalities in reward regions may underlie the anhedonic phenotype. Volume loss associated with MDD may attenuate in older age.

Gender differences in subtypes of depression by first incidence and age of onset: a follow-up of the Lundby population.

The Lundby Study is a prospective mental health survey in a community population (N = 3563), in which data were collected in 4 waves of field-work between 1947 and 1997. We investigated gender differences during the follow-up in overall first incidence rates, ages of onset, and incidence by age of onset patterns, in different subtypes of depression. The overall incidence rate in females was higher than males for most subtypes of depression. However, for depression with melancholic and/or psychotic features, the overall first incidence rate did not differ significantly between the genders. The mean age of onset did not differ significantly between females and males in any of the depressive subtypes. Nevertheless, females and males had different first incidence rates by age of onset patterns for unipolar non-melancholic DSM-IV mood disorder and major depressive disorder (MDD), with a consistent gender incidence gap across all ages, but with the most conspicuous gender gap in middle age. The first incidence rates by age of onset patterns for DSM-IV MDD with melancholic and/or psychotic features did not differ significantly between the genders. The findings support that females are more prone than males to develop depression with medium severity, but no gender differences were found in melancholic and/or psychotic depression. The findings may support that unipolar non-melancholic depression and melancholic and/or psychotic depression represents different disorders. Tentative explanations for this are discussed.

Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study.

BACKGROUND: Restless legs syndrome is a sensorimotor disorder and it is associated with several other diseases especially mental illnesses. AIMS: To analyze the relationship between the symptoms of restless legs syndrome and the severity of depressive symptoms and the prevalence of restless legs symptoms in depression subtypes. METHODS: A cross-sectional study of primary care patients in the Central Finland Hospital District. The prevalence of restless legs symptoms was studied in 706 patients with increased depressive symptoms and 426 controls without a psychiatric diagnosis by using a structured questionnaire. The depressive symptoms were evaluated with the Beck Depression Inventory (BDI) and the psychiatric diagnosis was confirmed by means of a diagnostic interview (Mini-International Neuropsychiatric Interview). The subjects with increased depressive symptoms were divided into three groups (subjects with depressive symptoms without a depression diagnosis, melancholic depression and non-melancholic depression). RESULTS: In the whole study population, the prevalence of restless legs symptoms increased with the severity of depressive symptoms. The prevalence of restless legs symptoms was highest in the melancholic and non-melancholic depressive patients (52 and 46%, respectively) and then in subjects with depressive symptoms without a depression diagnosis (43.4%), but the prevalence was also substantial (24.6%) in subjects without a psychiatric diagnosis. CONCLUSIONS: Restless legs symptoms are very common in primary care among subjects with depression, regardless of the depression type. The prevalence of restless legs symptoms increased with increasing severity of depressive symptoms, regardless of the diagnosis. These findings should be considered in clinical evaluation and treatment of patients visiting their physician due to restless legs or depressive symptoms.

Melancholic Response to War Destruction and the Emergence of a Group Assumption of Post-Ness.

What psychological response does war and forced displacement evoke in victims? How do survivors of war communicate their experiences to their children? Finally, what culture does the psychological response to loss shape? Using data collected through interviews, psychological consultations, and children's drawings from two sources-the ongoing Syrian civil war and the Bosnian war of 1992-1995, this paper suggests that the experience of the war generation becomes the organizing axis of their identity and that of their children. It seeks to demonstrate that survivor parents communicate their experience of loss through gesture, act, and object rather than through a coherent narrative. Whereas survivor children use metaphoric and metonymic readings of their parents' everyday performance in order to construct meaning and form their identities as descendants of a given family. This paper argues that such an identity is characterized by ambivalence towards the self and towards others, melancholic longing for an idealized pre-war past, and the impossibility of letting it go.

Revisiting The Depleted Self.

This article revisits Donald Capps's book The Depleted Self (The depleted self: sin in a narcissistic age. Fortress Press, Minneapolis, 1993), which grew out of his 1990 Schaff Lectures at Pittsburgh Theological Seminary. In these lectures Capps proposed that the theology of guilt had dominated much of post-Reformation discourse. But with the growing prevalence of the narcissistic personality in the late twentieth century, the theology of guilt no longer adequately expressed humanity's sense of "wrongness" before God. Late twentieth-century persons sense this disjunction between God and self through shame dynamics. Narcissists are not "full" of themselves, as popular perspectives might indicate. Instead, they are empty, depleted selves. Psychologists suggest this stems from lack of emotional stimulation and the absence of mirroring in the early stages of life. The narcissist's search for attention and affirmation takes craving, paranoid, manipulative, or phallic forms and is essentially a desperate attempt to fill the internal emptiness. Capps suggests that two narratives from the Gospels are helpful here: the story of the woman with the alabaster jar and the story of Jesus's dialogue with Mary and John at Calvary. These stories provide us with clues as to how depleted selves experienced mirroring and the potential for internal peace in community with Jesus.

Melancholic and atypical depression as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression.

BACKGROUND: Melancholic and atypical depression are widely thought to moderate or predict outcome of pharmacological and psychological treatments of adult depression, but that has not yet been established. This study uses the data from four earlier trials comparing cognitive behavior therapy (CBT) versus antidepressant medications (ADMs; and pill placebo when available) to examine the extent to which melancholic and atypical depression moderate or predict outcome in an "individual patient data" meta-analysis. METHODS: We conducted a systematic search for studies directly comparing CBT versus ADM, contacted the researchers, integrated the resulting datasets from these studies into one big dataset, and selected the studies that included melancholic or atypical depressive subtyping according to DSM-IV criteria at baseline (n = 4, with 805 patients). After multiple imputation of missing data at posttest, mixed models were used to conduct the main analyses. RESULTS: In none of the analyses was melancholic or atypical depression found to significantly moderate outcome (indicating a better or worse outcome of these patients in CBT compared to ADM; i.e., an interaction), predict outcome independent of treatment group (i.e., a main effect), or predict outcome within a given modality. The outcome differences between patients with melancholia or atypical depression versus those without were consistently very small (all effect sizes g < 0.10). CONCLUSIONS: We found no indication that melancholic or atypical depressions are significant or relevant moderators or predictors of outcome of CBT and ADM.