Journal of Affective Disorders 138 (2012) 180182

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Journal of Affective Disorders

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Mapping melancholia: The continuing typological challenge for

major depression
Jerome C. Wakeeld
Silver School of Social Work, New York University, New York, NY, United States
Department of Psychiatry, School of Medicine, New York University, New York, NY, United States
InSPIRES (Institute for Social and Psychiatric Initiatives), New York University, New York, NY, United States

a r t i c l e

i n f o

a b s t r a c t

Article history:
Received 2 February 2011
Accepted 3 February 2011
Available online 5 March 2011

The DSM's symptom-based diagnostic criteria for major

depression ignore the context in which the symptoms occur,
except for a limited bereavement exclusion. Thus, virtually
any depressive episode of 5 symptoms lasting 2 weeks is
classied as a mental disorder, even if the symptoms occur
after a major stressful event (e.g., romantic betrayal, nancial
reversal, or medical diagnosis) and are common and
proportional responses when coping with such loss and
stresssuch as sadness, insomnia, fatigue, decreased appetite,
and difculty concentrating on usual activities. The DSM's
decontextualized symptom-based approach deviates sharply
from 2400 years of diagnostic tradition in which the
symptoms of intense normal sadness and depressive disorder
were considered quite similar, and the context (i.e., whether
circumstances provide adequate grounds for a normal-range
emotional explanation of the symptoms) was thought to be
essential for telling them apart.
Horwitz and Wakeeld (2007) argued that the DSM's
descriptive approach to diagnosis of major depression, whatever
its scientic merits, greatly inates the prevalence of major
depression with false positivesmistaken diagnosis of normal
intense sadness reactions as mental disorders. This aw, they
argued, has potentially problematic consequences for prognosis,
treatment choice, informed consent, outcome research, community epidemiological surveys, screening, and policy.

PHD, DSW, Silver School of Social Work -NYU, 1 Washington Square N.,
New York, NY 10003, United States.
E-mail address: wakeeld@nyu.edu.
0165-0327/$ see front matter 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2011.02.013

In this issue, Parker et al. (2011this issue) undertake the

difcult but valuable service of transforming this conceptual
and theoretical claim into an empirically testable hypothesis.
To operationalize the Horwitz and Wakeeld thesis, Parker et
al. take clinician-judged melancholic versus non-melancholic
depression based on phenomenological features, where
melancholic depression is traditionally thought to be more
obviously pathological than non-melancholic depressive
episodes, as a rough approximation to the Horwitz and
Wakeeld distinction between disordered versus normal
sadness. They then test the Horwitz and Wakeeld thesis
that these two classes of depressive episodes differ in their
relationships to triggering stressors. This prediction goes against
current orthodoxy which holds that stressor relationships are
not useful in distinguishing types of depressive episodes.
Parker et al. tested whether melancholic versus nonmelancholic depression was associated with two of the Horwitz
and Wakeeld thesis's predicted correlates of disorder versus
non-disorder, out of the blueness and contextual disproportionality. Each was measured by patient self-report on two
opposite-valenced questions (My depressions can sometimes
come out of the blue without any particularly clear reason;
Every time I get depressed, I can nd some cause that explains
the depression to me; The severity of my depressive episodes
appear far worse than would be expected given the circumstances that may precede them or appear to cause them; The
severity of my depressions can be explained by the type of
stressful events that precede them and the impact that these
things have on me given my type of personality.) These
measures, although limited, do usefully allow for rough

J.C. Wakeeld / Journal of Affective Disorders 138 (2012) 180182

judgments of proportionalitythat is, whether the nature of a

triggering stressor is capable of explaining, within the normal
range of emotional processing, the severity of the resulting
symptoms.
The results were strongly in favor of the Horwitz and
Wakeeld thesis. Three of the four measures showed substantial
and highly signicant differences between melancholic and
non-melancholic episodes in the predicted direction, and the
fourth measure showed differences in the predicted direction
although not signicant. Additionally, there were large differences in number of triggers (e.g., 2 versus 1) along the lines that
would be predicted by Horwitz and Wakeeld.
As Parker et al. note, the previous literature is mixed on
whether melancholic versus non-melancholic patients' depressive episodes have a distinctive relationship to triggering
stressors. The changing research populations and denitions
of melancholia over time likely are responsible for the
inconsistent results. Studies cited as showing no differences
between subtypes of depression are often based on inpatient or
severe outpatient samples where all the subjects are likely to be
severely disordered, so the proposed Horwitz and Wakeeld
distinction may not emerge.
This is why Parker et al.'s contemporary outpatient sample is
of particular value. When the focus of psychiatry was on the
asylum, the initial formulation of operationalized denitions of
depression primarily served the function of differential diagnosis
of mood disorders among obviously disordered patients
for research purposes. Separating mood disorders from schizophrenia was a difcult task when many with mood disorders
displayed psychotic symptoms. However, in today's environment
of outpatient treatment, community epidemiological surveys,
and mass screening of the community in schools and physicians'
ofces, the primary challenge of a denition is distinguishing
extreme normal despair and sadness from mental disorder. The
criteria were not designed for this purpose, and one cannot rely
on the results from studies with older severely disordered
samples to inform us about this new, greatly expanded target
population.
To many, Horwitz and Wakeeld's attempt to typologize
depression is a replay of the classic debate over whether
reactive depression can be distinguished from endogenous
depression. However, as Parker et al. themselves point out, that
debate is over. In community surveys, there are relatively few
out of the blue depressions with no triggering component. As
has been amply recognized since antiquity, major stressors
often trigger depressive disorders that go beyond the bounds of
normal-range intense sadness responses.
Consequently, both the Horwitz and Wakeeld (2007) and
Parker et al. (2011this issue) approaches agree that the
distinction that is needed is more subtle than out of the blue
versus triggered, and that the optimal distinction must lie in
further features that distinguish among triggered episodes (see
also Parker et al., 2010). It is worth noting, however, that the
Horwitz and Wakeeld distinction between disorder and nondisorder is quite different from the melancholic versus nonmelancholic distinction, being anchored in the relation of
symptoms to context. Horwitz and Wakeeld accept that there
may be a substantial overlap between these distinctions (see
Wakeeld et al., 2007), thus making Parker et al.'s test relevant.
But they don't embrace the melancholic/non-melancholic
boundary as the same as the disorder/non-disorder boundary.

181

Contextual, durational, and other information, they claim, can

reveal that an episode satisfying melancholic criteria is most
likely an intense normal response, and can reveal a nonmelancholic episode to be clearly pathological.
Ever since skeptical conclusions were reached about
depressive typologies in several classic studies (Lewis, 1934;
Kendell, 1976), it has been assumed that unipolar depressive
episodes should be considered mostly essentially the same
condition. Parker et al.'s sort of study implies to the contrary that
there may be typological depths yet to be plumbed in
depression. The typological skepticism of the past may be
misguided in the present. The population to which the diagnosis
of major depression is applied, and the rates at which it is
attributed, have changed enormously over the past few decades.
Parker et al.'s results suggest that the eld may have reached a
premature skeptical consensus and should be open to further
examination of typological issues within the much-changed
terrain of contemporary DSM depression. It is possible that
typological distinctions that failed to emerge in the severely ill
samples of the past might now emerge in data about the current
much vaster and more variegated community population.
Finally, there is a critical detail in Parker et al.'s results that
can easily be missed but has important potential repercussions for DSM-5. One of the standard responses to the
Horwitz and Wakeeld thesis is that what is being distinguished is not disorder versus non-disorder but mild versus
severe disorder. That is, it is claimed that the supposedly
normal episodes are merely disorders falling on the milder
part of the severity dimension. It is thus important that Parker
et al. nd that their melancholic and non-melancholic
samples, although differing signicantly on the stressorrelated variables they use to test the Horwitz and Wakeeld
thesis, do not differ on symptom severity or impairment. This
is reassuring conrmation of what would appear in any event
to be true, that symptom severity and impairment alone
cannot make the needed distinctions; disorders can be mild
and normal grief can be severe.
The implication is that, as Wakeeld's (1992, 2006)
harmful dysfunction account of mental disorder suggests,
future typologies distinguishing depressive disorder from
normal sadness will require two dimensions severity of
symptoms (harm) and whether something has gone wrong
(dysfunction) rather than just the one dimension of symptom
severity. If so, then the notion, expressed in connection with
proposed changes in DSM-5, that a more formal symptom
severity measure will allow the discovery of a valid threshold
between depressive disorder and non-disorder, is misguided. A
prototype of the more subtle two-dimensional approach is the
major depression bereavement exclusion, which attempts to
distinguish normal versus disordered depressive episodes
among reactive depressions to loss of a loved one based not
on severity of symptoms but on selected features that are
considered to be strong dysfunction indicatorsand, ironically,
is proposed for elimination in DSM-5.

Role of funding source

Nothing declared.

Conict of interest
No conict declared.

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J.C. Wakeeld / Journal of Affective Disorders 138 (2012) 180182

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