Melancholic and atypical specifiers — structured clinical viva

Criteria hinge. Both are feature specifiers on a full major depressive (or bipolar depressive) episode. Melancholia: near-total anhedonia or lack of reactivity, plus three from morning worsening, early waking, psychomotor change, anorexia/weight loss, distinct quality of mood, excessive guilt. Atypical: mood reactivity required, plus two from weight gain/increased appetite, hypersomnia, leaden paralysis, long-standing rejection sensitivity with impairment. Parker frames melancholia as a rich historical construct retained as a specifier. [5][6]

Mechanisms. Melancholia linked in research to HPA hyperactivity (DST is history/research, not a routine diagnostic gate). Atypical teaching emphasises reverse vegetative drive and rejection-sensitivity interpersonal loops, with historical preferential MAOI response. [1][2][6]

Management. Severe melancholia → biological intensity; early ECT for food refusal, psychosis, catatonia, high suicide risk (UK ECT Review Group; RANZCP). Atypical → modern antidepressants and psychotherapy first; Columbia phenelzine preferential signal; Jarrett CT versus phenelzine; if MAOI used — tyramine diet, washouts (~5 weeks after fluoxetine), no serotonergic combinations. [3][4][5][7]

Pitfalls. Dual-coding conflicting reactivity; atypical ≠ mild; missing bipolarity; delaying ECT; MAOI without safety infrastructure. [5][7]