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Neurotic and Melancholic Depression: A Key Distinction

We should differentiate neurotic from melancholic depressions.

As I have noted repeatedly in my posts and professional writings, we should consider depression a state of behavioral shutdown and we should divide it up into depressive reactions, depressive disorders, and depressive diseases. I think it would help further if we labeled depressive disorders “neurotic” and depressive diseases “melancholic." These terms have been floating around for a long time; here is how I think about them.

We see “neurotic depressions” all the time in the clinic room. A neurotic depression usually involves a cluster of symptoms that include the following:

  1. General distress and heightened negative emotion, especially sadness, irritability, disappointment, futility, or agitation/anxiety.
  2. General life dissatisfaction.
  3. Low self-esteem and identity problems.
  4. Life problems, usually involving relationships (loneliness or conflict), work (meaningless, stressful), finances (low), and the absence of play and purpose.

It is marked by feelings of defensiveness and pessimism and often coping via avoidance. As with all mental disorder/distress, histories of trauma and psychological injury are often central. In terms of ‘diagnoses," such individuals will often meet criteria for persistent depressive disorder (formerly known as dysthymia); adjustment disorder with depressed mood; major depressive disorder in the mild-to-moderate range; or depressed—otherwise specified category. This presentation is part of a large class of “internalizing disorders" that includes the anxiety disorders and it overlaps with them. Individuals with neurotic depression still work and function and they may go about their lives with few people knowing they are dealing with serious distress. (See why I endorse using the term "neurotic.")

Melancholic depression looks different. (See here for a similar view.) This is when the behavioral shutdown is so massive it has “infiltrated” the body, as it were. So you see massive psychomotor retardation, marked changes in cognitive abilities (i.e., the individual can’t concentrate, or think in complex ways), and an emotional shift into either numbness or pure despair. There is a complete absence of energy and the body's basic sleep and eating patterns are disrupted. Put in terms of behavioral shutdown, the mild loss of interest often seen with neurotic depression is qualitatively more pronounced here. Nothing is desirable or enjoyable, and the individual has no energy to do anything. As such, everyone who knows the person will know something is wrong. Their body will be in full “sick mode” and they will be missing work, not returning messages, and staying in bed. Their mindset will be that they literally cannot do anything and to do anything is overwhelming. It is a state of severe illness, and the person must be treated as such.

I think it is important to make this distinction for a host of reasons, as the experience, presentation, and treatment are all quite different. Psychiatry used to make basically this distinction with reactive versus endogenous. I think we should revive it and use these labels and clarify how they should be treated differently.