To assess sociodemographic, clinical and treatment factors as well as depression outcome in a large representative clinical sample of psychiatric depressive outpatients and to determine if melancholic and atypical depression can be differentiated from residual non-melancholic depressive conditions.
Subjects/Materials and Method
A prospective, naturalistic, multicentre, nationwide epidemiological study of 1455 depressive outpatients was undertaken. Severity of depressive symptoms was assessed by the Hamilton Depression Rating Scale (HDRS) and the Self Rated Inventory of Depressive Symptomatology (IDS-SR30). IDS-SR30 defines melancholic and atypical depression according to DSM-IV criteria. Assessments were carried out after 6–8 weeks of antidepressant treatment and after 14–20 weeks of continuation treatment.
Melancholic patients (16.2%) were more severely depressed, had more depressive episodes and shorter episode duration than atypical (24.7%) and non-melancholic patients. Atypical depressive patients showed higher rates of co-morbid anxiety disorders and substance abuse. Melancholic patients showed lower rates of remission.
Citation: Gili M, Roca M, Armengol S, Asensio D, Garcia-Campayo J, Parker G (2012) Clinical Patterns and Treatment Outcome in Patients with Melancholic, Atypical and Non-Melancholic Depressions. PLoS ONE 7(10): e48200. https://doi.org/10.1371/journal.pone.0048200
Editor: Marianna Mazza, Catholic University of Sacred Heart of Rome, Italy
Received: June 5, 2012; Accepted: September 21, 2012; Published: October 26, 2012
Copyright: © 2012 Gili et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Almirall had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
The broad heterogeneity of clinical depression has long encouraged research seeking to identify depressive subtypes that show causal, and even more importantly, treatment specificity , . As yet inconsistencies in research findings have failed to convincingly demonstrate absolute depressive sub-types, contributing to the default model of differentiating depressive states dimensionally. The historical controversy about the nature, definition and classification of atypical and melancholic subtypes – in particular has gained strength in preparation of the DSM-5 manual , . Differing options for future DSM depressive categories include weighting depressive sub-types, as against providing specifiers for major depressive episodes or distinct qualitative affective disorders , , , –.
According to previous studies, melancholic depression affects about 25–30% of depressive populations ,  and is clinically characterized by distinct quality of mood, non-reactivity of mood to circumstances, anhedonia, psychomotor disturbance, cognitive impairment and symptoms of vegetative dysfunction such as terminal insomnia, diurnal mood variation with worsening in the morning and weight loss , . From a biological perspective, hypercortisolemia, neuroimaging features and disturbances in sleep architecture have been associated with melancholia , . Melancholic patients are held to respond better to Electroconvulsive therapy (ECT) and to certain pharmacological approaches such as tricylic antidepressants (TCA) rather than to selective serotonin reuptake inhibitors (SSRIs) . Compared to non-melancholic depression, melancholia rarely responds to placebos, psychotherapies or social interventions . Depressive patients with melancholic features have worse outcomes and reduced probability of remission from major depressive disorder compared to those with non-melancholic depression . Some authors have therefore argued that melancholia is a disease entity on the basis of its psychopathology, biology and differential response to treatment  and have proposed new diagnostic criteria .
By contrast, atypical depression (initially contrasted with the so-called ‘typical’ endogenous or melancholic depressive condition) is characterized by significant mood reactivity, severe fatigue, anxiety, hypersomnia, increased appetite and a personality style of rejection sensitivity. Selective response to monoamine oxidase inhibitors (MAOIs), polysomnographic changes and endocrine features have been interpreted by some authors as also positioning atypical depression as a distinct entity  while others have argued for the primacy of a personality style rejection sensitivity and response to salient stressors , . This condition appears common, with studies indicating rates ranging from 20% to 35% of depressed patients , , while it appears to have an earlier age of onset and a more chronic course of illness than melancholia .
While such studies prioritize these depressive subtypes as the most promising categorical candidates in future DSM-5 classificatory model, the available evidence is largely limited to clinical trial studies with narrow inclusion criteria and very stringent treatment conditions. The naturalistic design of the present study provides an opportunity to assess sociodemographic, clinical and treatment factors as well as depression outcome in a large representative clinical sample of psychiatric depressive outpatients, to determine if melancholic and atypical depression can be positioned as distinctive clinical entities.
Study design and population
The main objectives and details of the RESIST study have been described previously . Briefly, the RESIST is a large prospective naturalistic multicentre study conducted in regional outpatient Spanish settings. Four hundred psychiatrists proportionally distributed by regions within Spain's 17 regional communities were selected to participate, and each asked to recruit five outpatients. Inclusion in the study required participants to sign a written informed consent, to be over 18 years of age, to meet Major Depression diagnoses according to DSM-IV criteria, and to have had 6–8 weeks of antidepressant drug treatment.
Recruitment took place under naturalistic clinical conditions in outpatient settings. Data were collected during two routine visits after obtaining written consent, and with the first assessment occurring after at least six weeks of antidepressant therapy.
A total of 374 (86%) psychiatrists accepted the invitation to contribute, and 1870 patients were initially recruited. Of those, 140 patients were excluded from the current analyses as they were in remission at first assessment, 275 were excluded due to: change of treatment (n = 171, 9.1%), patients not having a second assessment (n = 68, 3.6%) incomplete or missing data (n = 36, 1.9%), leaving 1595 patients in the provisional sample. Data collection took place from February to June 2009 after receiving the approval of the Teknon Medical Center ethical committee (Barcelona, Spain). Thus, our analyses were undertaken on a sample of 1455 patients.
Sociodemographic and clinical characteristics.
Data collected at the first visit included sociodemographic characteristics (age, gender, current occupation, marital status, education, living status and environment), history and clinical features of the depressive disorder (age at onset, first or recurrent episode, number of previous episodes, length of current episode), DSM-IV-TR comorbid psychiatric diagnoses and comorbid medical diseases.
Severity and improvement assessment.
The severity of depressive symptoms was assessed by the Hamilton Depression Rating Scale (HDRS) and the Self Rated Inventory of Depressive Symptomatology (IDS-SR30). The HDRS21 includes 21 items, each rated on a 0–2 or 0–4 scale by the clinician, with a range for the total score from 0 (without depressive symptoms) to 66 (severe depressive symptoms).
The IDS-SR30 assesses 30 symptoms obtaining a total score with a range from 0 (without depressive symptoms) to 84 (severe depressive symptoms). At each assessment the HDRS21 and IDS-SR30 measures were administered. The IDS-SR30 to assess all core criterion diagnostic depressive symptoms as well as DSM-IV atypical and melancholic symptom features , .
Definition of melancholic and atypical depression
For the purpose of this study, melancholic and atypical depression were defined using algorithms from selected items of IDS-SR30 developed by the STAR*D research group , , and with such definitions corresponding to DSM-IV criteria. According to those specific definitions for assigned melancholic depression, patients were required to score 2 or 3 on the IDS-SR30 anhedonia and non-reactive mood items and score positively on at least 3 of the following criteria: distinct quality of mood, diurnal mood variation with worsening symptoms in the morning, psychomotor retardation, psychomotor agitation, appetite or weight decrease, early morning awakening and self-outlook. For assigned atypical depression, patients were required to score 0, 1 or 2 for mood reactivity and affirm at least two of the following items: 2 or 3 for leaden paralysis, 2 or 3 for weight gain or increased appetite, 2 or 3 for hypersomnia, and 3 for interpersonal sensitivity.
Antidepressant treatment characteristics
Treatment modality was determined by the clinician's individual decision. Any drug type, dose, regimen of antidepressant or concomitant medication was allowable and entirely at the discretion of the psychiatrist. Change of treatment for any reason resulted in exclusion from the study. Description of antidepressant treatment was collected at the second visit. For the present analysis antidepressant types were divided into three categories: Selective Serotonin Reuptake Inhibitors (SSRIs), Selective Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs) and Trycyclic Antidepressants (TCAs). Antidepressant regimes were classified as monotherapy (using only one antidepressant during the study period) and combination therapy (using more than one antidepressant during the study period). Concomitant medication was categorized as additional use of antipsychotic, mood stabilizer and anxiolytic/hypnotic (benzodiazepine) medication.
Definition of treatment outcomes
HDRS21 remission was defined as having a HDRS21 score ≤7, and IDS-SR30 remission was defined as having an IDS-SR30 score ≤14 after 16–20 weeks of antidepressant treatment.
T-tests compared differences between groups for quantitative variables. Chi-square tests and unadjusted odds ratios (ORs) were calculated to explore differences between patient groups for qualitative variables. In order to assess the relative strength of each variable, we ran separate binary logistic regression analyses. Each of these regressions was re-run controlling for age, gender and severity of depression as they were significantly different. These analyses examined for group differences and to quantify the magnitude of effects, being reported as adjusted ORs with 95% C.I. These control factors (age, gender and severity) were chosen to enhance our comparison procedures and to ensure that group differences were not likely due to differences on the demographic and clinical factors. Statistical analyses were conducted using SPSS for Windows Version 19.0. A probability level of 0.05 was considered statistically significant.
Final analyses were undertaken on 1455 subjects. Study criteria assigned 237 (16.2%) as having melancholic depression and 360 (24.7%) as having atypical depression. Sociodemographic characteristics associated with melancholic and atypical depression (after adjusting for severity of depression) are summarized in Table 1. Depressive subtypes did not differ significantly across sociodemographic variables except for gender and age. Melancholic patients were slightly older than non-melancholic and atypical depressive patients. Males were over-represented with a melancholic diagnosis whereas females had higher rates of atypical depression.
Melancholic patients were more severely depressed than non- melancholic patients after 6-8 weeks of Antidepressant Treatment (ADT) (mean 53.8, SD 9.1 vs 34.1, SD 11.2 on the IDS-SR30 measure and 26.7, SD 6.1 vs 16.9, SD 6.9 on the HDRS21 measure) and after 16–20 weeks (mean 19.1, SD 12.8 vs 15.6, SD 10.5–IDS-SR30, and 8.7, SD 6.4 vs 7.1, SD 5.0, HDRS21). Further, melancholic patients were more severely depressed than atypical patients after 6–8 weeks of treatment (mean 53.8, SD 9.1 vs 43.2, SD 10.0 in IDS-SR30 and 26.7, SD 6.1 vs 20.5, SD 7.0 on HDRS21) but did not differ in severity after 16–20 weeks. Also there were severity differences between atypical and non-atypical subjects after 6-8 weeks (mean 43.2, SD 10.0 vs 35.7, SD 13.4–IDS-SR30, and 20.5, SD 7.0 vs 17.9, SD 7.7, HDRS21 and after 16–20 weeks of treatment (mean 18.9, SD 11.9 vs 15.3, SD 10.5–IDS-SR30, and, 8.41, SD 5.5 vs 7.04–SD 5.2–HDRS21).
There were no statistical differences in age at depression onset but melancholic patients had more depressive episodes than the other depressed subjects (4.3 vs 3.6 in atypical and 3.6 in non-melancholic) and with shorter episode duration (11.6 weeks vs 14.4 in non-melancholic vs 14.4 in atypical).
Atypical depressive patients had higher rates of comorbid anxiety disorders (43.9% vs 34.2% in melancholic patients; OR = 1.35, CI = 1.06–1.7) and higher rates of co-morbid substance abuse (13.3% vs 8.4% in melancholic patients; OR = 0.52, CI = 0.3–0.79). (Table 2)
Measures of remission and their association to melancholic and atypical depression are compared in Table 3. The remission rates (as quantified by the HDRS21 and IDS-SR30) were significantly lower in melancholic patients compared with non-melancholic and atypical patients after adjustment for age, gender and severity at 6–8 weeks. Melancholic subjects showed a lower probability of remission (OR = 0.63, CI = 0.5–0.81–IDS-SR30 and OR = 0.75, CI = 0.59–0.96–HDRS21) than atypical subjects.
Treatment-related characteristics of the sample and differences by depressive subtypes are summarized in Table 4. Melancholic subjects received higher rates of SNRI medication than non-melancholic subjects (OR = 1.5, CI = 1.1–2.0) and lower rates of SSRI medication than non-melancholic (OR = 0.4, CI = 0.2–0.6) and atypical patients (OR = 2.0, CI = 1.3–3.2). Melancholic patients also had higher rates of receiving concomitant antipsychotic medication (OR = 2.7, CI = 1.7–4.4).
In our sample, 16.2% of the patients exhibited melancholic features and 24.7% atypical features of depression. Our study provides further empirical evidence in support of a different clinical profile and treatment outcome in melancholic and atypical depressive patients in comparison to those with non-melancholic depression, thus arguing for their positioning as qualitatively distinct from other forms of depression. Comparing both groups, melancholic patients were predominantly male, older, had higher depression severity scores, lower remission rates, more previous depressive episodes, while they were treated with SNRI and antipsychotics drugs more frequently. Patients with atypical depression were more likely to be female, younger, to have less severe depression, fewer episodes, longer duration of episodes, and higher comorbidity involving anxiety and substance abuse disorders. Both groups show no differences in other sociodemographic variables or in age of onset of their condition. Our study also supports the validity of melancholic and atypical depression as clinical subtypes differing from each other and from non-melancholic depressive patients.
The finding than men were more likely to be diagnosed as melancholic and women more likely to be diagnosed as having an atypical depression is consistent with published studies , , , . Older age in melancholic patients has also been described in previous works , . As no sociodemographic variables except gender and age showed differences between the studied groups, results support the hypothesis that psychosocial determinants have a limited role as contributing to these depressive subtypes. As overviewed in the Introduction, biological factors are likely to play a more relevant role in the development of melancholic or atypical clinical syndromes.
In our sample melancholic subjects were more likely to have briefer and more severe current index depressive episodes. In contrast to most ,  but not all previous studies , , we found no support for older age at initial onset in melancholic patients or an earlier age of onset and a more chronic course for atypical depression . Melancholia has been associated with severity and with a shorter duration of the index episode in the STAR*-D cohort and a slightly lower age at the time of study entry . In fact, a surprising finding of our sample was a significant higher number of previous episodes in melancholic patients compared with non-melancholic and atypical depressive patients. Despite the clinical and co-morbidity differences between first and recurrent affective episodes , , there are no long-term outcome studies on depressive features and recurrence or chronicity.
In our data, atypical depression was associated with several differing clinical characteristics when compared with melancholic patients: less depression severity, fewer episodes, longer duration of episodes and higher comorbidity with anxiety and substance abuse disorders. It has been reported that patients with atypical depression have an earlier age of onset and a more chronic course of illness compared with melancholic ones . In the STAR*-D cohort, participants with atypical features were more likely to be younger at depression onset, to have a longer index episode, a positive history of suicide, lower remission rates and anxious features or chronic depression .
Regarding anxiety and comorbid substance abuse disorder, while our findings are consistent with previous studies , , , it should be noted that some symptoms that are part of the definition of atypical depression used for this study (i.e. leaden paralysis and interpersonal rejection) are associated with anxiety itself and may have confounded results related to anxiety comorbid disorders. Links between atypical depression and comorbid anxiety deserve further investigation.
An important finding related to treatment outcome was the lower remission rate among individuals with melancholic and atypical depression. The naturalistic design of the study gives a special significance to this result as the majority of previous evidence comes from clinical trials comparing few antidepressant options and restricted inclusion criteria. The available data on melancholic depression favors tricyclic than narrow-action antidepressants , , . A meta-analysis of 38 double-blind studies concluded that the reversible MAOI moclobemide have higher response rates in depressed patients with melancholic features. While SSRI have shown efficacy compared to placebo in some studies , they appear less effective compared with the SNRI venlafaxine . However, the majority of those studies considered response but not remission as a primary endpoint. When remission is considered and compared, remission rates in melancholic depression with TCA were significantly better than with SSRI . In the STAR*-D cohort, melancholic depression (23.5% of 2,875 depressive patients included) was associated with a significant reduced rate of remission with citalopram, an SSRI. According to the authors of this STAR*-D report, this result could be attributed to the overlap between melancholic symptoms and core depressive symptoms rated by the assessment instruments . In atypical depression, the treatment data are quite controversial. MAOIs were reported as superior to TCA s in one study . However, fluoxetine was superior to nortryptiline in another study , while response and remission rates were similar between sertraline, fluoxetine and moclobemide in depressed patients with atypical features , .
Our study was not a comparative study of pre-selected antidepressants drugs, and it was intriguing that in such a ‘real world’ clinical setting we found that melancholic patients were treated more frequently with SNRI and antipsychotic medications. Our group of melancholic patients exhibited greater severity and at the same time lowers remission rates and more previous episodes. The combination of antidepressants plus antipsychotics drugs is currently one of the most evident strategies for resistant depression, and would appear to be preferentially provided by our clinicians to those with a melancholic depression.
A number of study limitations are offered in interpreting the results. First, the use of derived Hamilton and IDS-SR30 item scores to capture melancholic and atypical patients risks being somewhat arbitrary. As melancholia requires some symptoms to be present, melancholic patients tend to score higher on severity scales , , and it therefore remains unclear as to whether assigned melancholic patients therefore differed by type or by severity. It is difficult to differentiate between antidepressant drug response and clinical characteristics of the disorder. Second, baseline scores previous to pharmacological treatment were not assessed. Finally, TCAs and MAOIs are not currently used in clinical practice in our country while ECT was not prescribed by clinicians in our outpatient sample despite the published data on the efficacy of this treatment ,  and psychotherapy was not considered in data analyses. For that reason, conclusions on treatment differences between the groups needs further research clarification.
The main strengths of this study were its naturalistic design and large sample size, allowing differences between potential depressive sub-types to be pursued with some confidence.
In conclusion, our findings suggest important clinical pattern and remission differences in depressive outpatients with melancholic and atypical features. The clinical significance of these results is that it might be important to assess melancholic or atypical features in depressive patients prior to commencing treatment as such diagnostic decisions may contribute beneficially to treatment selection.
Conceived and designed the experiments: MG MR JGC SA. Performed the experiments: SA DA. Analyzed the data: MG JGC. Contributed reagents/materials/analysis tools: MR SA. Wrote the paper: MG MR GP.
- 1. Baumeister H, Parker G (2011) Meta-review of depressive subtyping models. J Affect Disord, doi:10.1016/j.jad.2011.07.015.
- 2. Sun N, Li Y, Cai Y (2012) A Comparison of melancholic and nonmelancholic recurrent major depression in Han chinese women. Depression and Anxiety 29: 4–9.
- 3. Ambrosini A, Stanghellini G, Langer AI (2011) Typus melancholicus from Tellenbach up to present day: a review about the premorbid personality vulnerable to melancholia. Actas Esp Psiquiatr 39: 302–11.
- 4. Fink M, Taylor MA (2007) Resurrecting melancholia. Acta Psychiatr Scand 115: 14–20.
- 5. Thase ME (2009) Atypical Depression: Useful Concept, but it's Time to Revise the DSM-IV Criteria. Neuropsychopharmacol 34: 2633–2641.
- 6. Maj M (2011) Refining the diagnostic criteria for major depression on the basis of empirical evidence. Acta Psychiatr Scand 123: 317.
- 7. Parker G, Kathryn F, Barret M, Synnot H, Breakspear M, et al. (2010) Inching toward Bethlehem: Mapping melancholia. J Affect Disord 123: 291–298.
- 8. Fink M, Bolwig TG, Parker G, Shorter E (2007) Melancholia: restoration in psychiatric classification recommended. Acta Psychiatr Scand 115: 89–92.
- 9. Kocsis JH (2010) Melancholia as a Distinct Mood Disorder? Recommendations for DSM-5. Am J Psychiatry 12: 167.
- 10. Leventhal AM, Rehm lP (2005) The empirical status of melancholia: implications for psychology. Clin Psychol Rev 25: 25–44.
- 11. Parker G (2011) Classifying clinical depression: an operational proposal. Acta Psychiatr Scand 123: 314–316.
- 12. Shorter E (2007) The doctrine of the two depressions in historical perspective. Acta Psychiatr Scand 115: 5–13.
- 13. Khan AY, Carrithers J, Preskorn SH, Lear R, Wisniewski SR, et al. (2006) Clinical and demographic factors associated with DSM-IV melancholic depression. Ann Clin Psychiatry 18: 91–8.
- 14. Rush AJ (2007) The varied clinical presentations of major depressive disorder. J Clin Psychiatry 68: 4–10.
- 15. Monzón S, Gili M, Vives M, Serrano MJ, Bauzá N, et al. (2010) Melancholic versus non-melancholic depression: differences on cognitive function. A longitudinal study protocol. BMC Psychiatry 17: 10–48.
- 16. Perry PJ (1996) Pharmacotherapy for major depression with melancholic features: relative efficacy of tricyclic versus selective serotonin reuptake inhibitor antidepressants. J Affect Disord 39: 1–6.
- 17. Brown C, Battista DR, Sereika SM, Bruehlman RD, Dunbar-Jacob J, et al. (2007) Primary care patients personal illness models for depression: relationship to coping behaviour and functional disability. Gen Hosp Psychiatry 29: 492–500.
- 18. McGrath PJ, Khan AY, Trivedi MH, Stewart JW, Morris DW, et al. (2008) Response to a selective serotonin reuptake inhibitor (citalopram) in major depressive disorder with melancholic features: a STAR*D report. J Clin Psychiatry 69: 1847–55.
- 19. Stewart JW, Mcgrath PJ, Quitkin FM, Klein DF (2009) DSM-IV Depression with Atypical Features: It is Valid? Neuropsychopharmacol 34: 2625–2632.
- 20. Parker G, Roy K, Mitchell P, Wilhelm K, Malhi G, et al. (2002) Atypical depression: a reappraisal. Am J Psychiatry 159: 1470–9.
- 21. Posternak MA, Zimmerman M (2002) Partial validation of the atypical features subtype of major depressive disorder. Arch Gen Psychiatry 59: 70–6.
- 22. Novick JS, Stewart JW, Wisniewski SR, Cook IA, Manev R, et al. (2005) Clinical and demographic features of atypical depression in outpatients with major depressive disorder: preliminary findings from STAR*D. J Clin Psychiatry 66: 1002–11.
- 23. Stewart JW, Mcgrath PJ, Quitkin FM, Klein DF (2007) Atypical depression: current status and relevance to melancholia. Acta Psychiatr Scand 115: 58–71.
- 24. Roca M, García-Toro M, García-Campayo J, Vives M, Armengol S, et al. (2011) Clinical differences between early and late remission in depressive patients. J Affect Disord 134: 235–41.
- 25. Rush AJ, Guillion CM, Basco MR, Jarret RB, Trivedi MH (1996) The Inventory of Depressive Symptomatology (IDS): psychometric properties. Psychol Med 26: 477–86.
- 26. Gili M, Luciano JV, Bauzá N, Aguado J, Serrano MJ, et al. (2011) Psychometric properties of the IDS-SR30 for the assessment of depressive symptoms in Spanish population. BMC Med Res Methodol 11: 131.
- 27. Levitan RD, Atkinson L, Pedersen R, Buis T, Kennedy SH, et al. (2009) A novel examination of atypical major depressive disorder based on attachment theory. J Clin Psychiatry 70: 879–87.
- 28. Parker G, Roy K, Hadzi-Pavlovic D, Wilhelm K, Mitchell P (2001) The differential impact of age on the phenomenology of melancholia. Psychol Med 31: 1231–6.
- 29. Rush AJ, Weissenburger JE (1994) Melancholic symptom features and DSM-IV. Am J Psychiatry 151: 489–98.
- 30. Uher R, Dernovsek MZ, Mors O, Hauser J, Souery D, et al. (2011) Melancholic, atypical and anxious depression subtypes and outcome of treatment with escitalopram and nortriptyline. J Affect Disord 132: 112–20.
- 31. Asnis GM, Mcginn LK, Sanderson WC (1995) Atypical depression: clinical aspects and noradrenergic function. Am J Psychiatry 152: 31–6.
- 32. Derecho CN, Wetzler S, Mcginn LK, Sanderson WC, Asnis GM (1996) Atypical depression among psychiatric inpatients: clinical features and personality traits. J Affect Disord 39: 55–9.
- 33. Angst J, Gamma A, Sellaro R, Zhang H, Merikangas K (2002) Towards validation of atypical depression in the community: results of the Zurich cohort study. J Affect Disord 72: 125–38.
- 34. Stewart JW, Mcgrath PJ, Rabkin JG, Quitkin FM (1993) Atypical depression: a valid clinical entity? Psych. Clin North Am 16: 479–495.
- 35. Stewart JW, McGrath PJ, Fava M, Wisniewski SR, Zisook S, et al. (2010) Do atypical features affect outcome in depressed outpatients treated with citalopram? Int J Neuropsychopharmacol 13: 15–30.
- 36. Davidson JR, Miller RD, Turnbull CD, Sullivan JL (1982) Atypical depression. Arch Gen Psychiatry 39: 527–34.
- 37. Horwath E, Johnson J, Weissman MM, Hornig CD (1992) The validity of major depression with atypical features based on a community study. J Affect Disord 26: 117–125.
- 38. Brown WA (2007) Treatment response in melancholia. Acta Psychiatr Scand 115: 125–129.
- 39. Peselow ED, Sanfilipo MP, Difiglia C (1992) Melancholic/endogenous depression and response to somatic treatment and placebo. Am J Psychiatry 149: 1324–1334.
- 40. Roose SP, Glassman AH, Woodring S (1994) Comparative efficacy of selective serotonin reuptake inhibitors and tricyclics in the treatment of melancholia. Am J Psychiatry 151: 1735–9.
- 41. Heiligenstein JH, Tollefson GD, Faries DE (1993) A double-blind trial of fluoxetine, 20 mg, and placebo in out-patients with DSM-III-R major depression melancholia. Int Clin Psychopharmacol 8: 247–51.
- 42. Tzanakaki M, Guazzelli M, Nimatousdis I, Zissis NP, Smeraldi E, et al. (2000) Increased remission rates with venlafaxine compared with major depression and melancholia. Int Clin Psychopharmacol 15: 29–34.
- 43. Quitkin FM, McGrath PJ, Stewart JW, Harrison W, Tricamo E, et al. (1990) Atipical depression, panic attacks, and response to imipramine and phenelzine. A replication. Arch Gen Psychiatry 47: 935–41.
- 44. Joyce PR, Mulder RT, Luty SE, Sullivan PF, McKenzie JM, et al. (2002) Patterns and predictors of remission, response and recovery in major depression treated with fluoxetine or nortriptyline. Aust N Z J Psychiatry 36: 384–91.
- 45. Lonnqvist J, Sihvo S, Syvälahti E, Kiviruusu O (1994) Moclobemide and fluoxetine in atypical depression: a double-blind trial. J Affect Disord 32: 169–77.
- 46. Søgaard J, Lane R, Latimer P, Behnke K, Christiansen PE, et al. (1999) A 12-week study comparing moclobemide and sertraline in the treatment of outpatients with atypical depression. J Psychopharmacol 13: 406–14.
- 47. Coryell W (2007) The facets of melancholia. Acta Psychiatr Scand 115: 31–36.
- 48. Parker G (2007) Defining melancholia: the primacy of psychomotor disturbance. Acta Psychiatr Scand 115: 21–30.
- 49. Bolwig TG, Madsen TM (2007) Electroconvulsive therapy in melancholia: the role of hippocampal neurogenesis. Acta Psychiatr Scand 433: 130–5.
- 50. Petrides G, Fink M, Husain MM, Knapp RG, Rush AJ, et al. (2001) ECT remission rates in psychotic versus nonpsychotic patients : a report from CORE. J ECT 17: 244–53.