Das Absurde am Leben macht es erst erträglich.

Le jour des morts, Adolphe William Bouguereau, 1859.

The descriptions of melancholia over millennia by medical authorities, writers, and public figures have face validity. The recognition led to the inclusion of ‘‘melancholia’’ in some form in all psychiatric classification systems. This heritage regards melancholia as a disorder in mood accompanied by perturbations in circadian and ultradian rhythms. Psychomotor disturbance is always present, expressed as agitation or inactivity, slowness of movement and speech, catatonia, or stupor. Ruminations of despondency and death dominate the suVerer’s waking thoughts. Suicide is all too frequent.

Melancholia is the classic depressive mood disorder. Psychotic depression, manicdepressive depression, puerperal depressions, and abnormal bereavement are part of the melancholia picture. Diverse disease processes, such as endocrinopathies and seizure disorder, induce it. It is recognized worldwide and at all ages, becoming most prominent in older adults. Melancholia is less recognized in young children, but that omission may be a distortion of classification.

Despite its long history, the position of melancholia in psychiatric taxonomy is unclear. Traditionally it was considered a distinct illness. More recently it has been viewed as a stage of illness, not fundamentally diVerent in pathophysiology from other depressive illnesses. Which view is correct?

The historical record clearly presents melancholia as a distinct disorder of mood that is present from its onset. Simple retardation was considered a mild form. There appears gradually a sort of mental sluggishness; thought becomes diYcult; the patients find diYculty in coming to a decision and in expressing themselves. It is hard for them to follow the thought in reading or ordinary conversation. They fail to find the usual interest in their surroundings.

The process of association of ideas is remarkably retarded . . . they have nothing to say; there is a dearth of ideas and a poverty of thought . . . It is hard to remember the most commonplace things. They appear dull and sluggish, and explain that they really feel tired and exhausted . . .

Melancholia was viewed as a distinct disease, not a stage of illness. The milder features occurring at the onset of an episode were considered as typical of melancholia as were its most severe symptoms. By contrast, the historical record does not recognize most of the depression syndromes in the present classifications, although some diagnoses, such as abnormal bereavement and postpartum depression, can be seen as variants of melancholia. Other Diagnostic and Statistical Manual (DSM) depression options, such as dysthymia and adjustment disorder, have unclear meaning or validity.

Depressive-like states are classified by severity or episode duration into major and minor categories on the assumption that all have the same pathophysiology. This assumption lacks proof and the mixing of the variations in depressive illnesses, like the mixing of apples and oranges in discussing fruits, clouds the traditional face of melancholia.