A contemporary, Denis Hill (1968), found no merit in the subdivisions of the mood disorders, concluding that the treatments defined the condition:

It is a striking fact that the antidepressant drugs and ECT have their profoundest therapeutic eVect when the primary functional changes of depression are most in evidence and that, given these, the secondary symptoms disappear as the primary functional changes are alleviated. To put the matter at its greatest simplicity there is little to contradict in the statement that biological therapeutic agents operate only on biological functional systems.

Kraepelin’s formulation of melancholia as a core mental disorder had many critics. The strongest attacks came from Freud and his followers, who oVered a ‘‘mental’’ or ‘‘psychological’’ basis for melancholia. Their theory pictured active exchanges of energies within a tripartite mental apparatus defined as the superego, ego, and id.

Mourning for the loss of a love object deranged the energetics so that melancholia emerged. The physical attributes of the illness resulted from a displacement of energies from the ego – the emotional part that related to the outside world – to the id – the hidden source of drives and emotions. When a loss could be associated with a specific subject or event in the subject’s history, ‘‘reactive depression’’ ensued.

When a loss was not identifiable and the condition seemed unrelated to history, a ‘‘psychotic depression’’ ensued. As psychodynamic theory came to dominate American psychiatry, interest in the biological aspects of melancholia diminished. Adolf Meyer, a leading professor of psychiatry in the USA, is described as:

desirous of eliminating the term melancholia, which implied a knowledge of something that we did not possess, and which had been employed in diVerent specific ways by diVerent writers. If, instead of melancholia, we applied the term depression to the whole class, it would designate in an unassuming way exactly what was meant by the common use of the term melancholia; and nobody would doubt that for medical purposes the term would have to be amplified so as to denote the kind of depression . . . We might distinguish the pronounced types from the simple insuYciently diVerentiated depressions. Besides the manic-depressive depressions, the anxiety psychoses, the depressive deliria and depressive hallucinations, the depressive episodes of dementia praecox, the symptomatic depressions, non-diVerentiated depressions will occur.