Le monde est un chaos, et son désordre excède tout ce qu'on y voudrait apporter de remède.

Der Kuß, Gustav Klimt, 1907.

Melancholia defined by a specific event

Clinicians often ascribe etiologic significance to a special event preceding an episode of mood disorder, but the causal association is not established and the depressive illnesses that occur under such circumstances do not diVer from classical melancholia.
Descriptions of postpartum melancholia, vascular or late-life depression, abnormal bereavement, and seasonal depression are examples of disorders labeled according to the presence of hypothecated precipitants.

The circumstances assumed to be precipitants do not alter the typical features of the melancholic syndrome, the characteristic laboratory findings, or the treatment response. The melancholic syndromes are indistinguishable in characteristics and to the extent known, in their biology. It is confusing for clinicians and inhibiting of scientific assessments to separate patients with episodes of illness that meet the criteria for melancholia simply because the episodes are associated with a specific circumstance. Adverse events are commonly associated with emerging disease, but a myocardial infarction is no less a heart attack for occurring amidst personal turmoil, and neither is depressive illness.

Abnormal bereavement is melancholia

The DSM psychiatric classification includes abnormal bereavement as a specified form of depressive mood disorder. The dying and death of a loved one is traumatic. About half of women and 10% of men over age 65 have had a spouse die. By age 85, over 80% of women and 40% of men have had a spouse die. Although grief may persist for several years and one-third of widowed older persons initially meet DSM criteria for major depression, the common signs of depression rarely last beyond several weeks. Features persisting past 1 month after the death are associated with continuing mood disorder. Suicide remains a persistent risk. The clinical dilemma is the uncertainty of whether these prolonged symptoms reflect the circumstances and the patient’s personality, or are signs of an illness that requires treatment.

Abnormal bereavement is not distinguishable from melancholia, and the DSM criteria for it could easily be used as descriptors of melancholia. Sleep architecture and immune functions are disturbed in the normal bereaved, and their morbidity and mortality rates are high.
While disturbances in general medical health do not distinguish melancholia, the dexamethasone suppression test may be helpful as normal grieving is not associated with high cortisol levels and non-suppression. Four weeks following the death of a parent, children and adolescents have normal cortisol functioning. In one study of bereavement, however, 39% were non-suppressors. These patients had many melancholic features and were suicidal, clinically meeting criteria for melancholia as well as abnormal bereavement.

Identifying a syndrome of abnormal bereavement is unnecessary. The literature offers no defining characteristics that would distinguish this form of melancholia from any other. When bereavement is followed by a severe depressive illness and the illness meets criteria for melancholia, the illness warrants treatment for melancholia.

Features of abnormal bereavement

Sustained and non-reactive mood disturbance
Psychosis
Marked psychomotor impairment
Failure to regain level of pre-death social functioning within 2 months
Preoccupation with worthlessness and desire to die
Suicide attempt