Involutional melancholia

Involutional melancholia or involutional depression is a traditional name for a supposed psychiatric disorder which was thought to affect mainly elderly or late middle-aged people, often in association with paranoia. It was classically defined as "depression of gradual onset occurring during the involutional years (40-55 in women and 50-65 in men), with symptoms of marked anxiety, agitation, restlessness, somatic concerns, hypochondriasis, occasional somatic or nihilistic delusions, insomnia, anorexia, and weight loss."

As with other historical descriptions of melancholia, this diagnostic label is not recognized as a psychiatric disorder by the DSM-5, the American Psychiatric Association's (APA) classification and diagnostic tool.

History

In 1907, the German psychiatrist Emil Kraepelin was the first to propose (in the seventh edition of his influential textbook) the existence of involutional melancholia as a distinct clinical entity, separate from the manic-depressive psychosis. At the time, he believed that 'the processes of involution in the body are suited to engender mournful or anxious moodiness', and that this could help explain the more frequent occurrence of depression among elderly people. Later, Kraepelin's stance changed, broadly in line with the results of a study he had commissioned by his colleague Georges L. Dreyfus: by the time of the publication of the eighth edition of his textbook in 1913, he had incorporated involutional melancholia under the general heading of 'manic-depressive illness'.

Dreyfus (1907) had challenged Kraepelin's concept of an acquired origin, maintaining it to be endogenous in origin, although statistical review of Dreyfus's analysis of his case series has questioned his conclusion that the natural history of involutional melancholia was similar to that of depression in younger people. Kirby (1909) described it as a distinctive syndrome, as did Hoch and MacCurdy in 1922. Titley (1936) described the premorbid personality and narrow range of interests, etc. Kallman (1959) noted a raised incidence of schizophrenia in the families of such patients.

Debate about its status as a clinical entity, as well as possible causation - endogenous or environmental - continued into the late twentieth century. It was noted that whereas "involutional melancholy was conceptualized as an acquired rather than constitutional disorder, these ideas have not survived careful scrutiny." R. P. Brown in 1984 maintained that "there is insufficient evidence to view involutional melancholy as a separate clinical entity".

Characteristics

Symptoms were thought to include agitation, depersonalization, and delusions of bodily change, in the absence of manic features. Symptoms of fear are also considered to occur, as well as despondency and hypochondriacal delusions. In the absence of treatment, the disorder was thought to have a prolonged, deteriorating course with poor prognosis.

Treatments

Involutional melancholia is classically treated with antidepressants and mood elevators.

Electroconvulsive therapy (ECT) was also used. Mid-century, there was some consensus that ECT was the most effective treatment option, and could prevent years of hospitalization. (Such an approach has been reported in the 21st century.)

Psychoanalysis

Otto Fenichel considered that "psychoanalytically, not much is known about the structure and mechanism of involutional melancholias; they seem to occur in personalities with an outspoken compulsive character of an especially rigid nature. In the climacterium the compulsive defensive systems fail."

See also

• Geriatric psychiatry
• Late life depression

Further reading

• Moses R. Kaufmann, "Psychoanalysis in Late-Life Depression", Psychoanalytic Quarterly vi (1937)