The melancholic omega as sign of clinical depression and Darwin’s description of melancholy

To the Editor

The year of 2019 was a landmark of the 160th anniversary of the publication of On the Origin of Species, by Charles Darwin, first published on 24 November 1859. This book is widely considered Darwin’s main contribution to modern science. However, only in another book published in 1872, called The Expression of the Emotions in Man and Animals, Darwin made a direct contribution to psychiatry (Shorter, 2009). In this book, he gave a detailed description of melancholy, also depicting a physical sign, produced by what Darwin called ‘grief muscles’ (Shorter, 2009). Such sign would be later recognized as ‘the melancholic omega’, by German psychiatrist Heinrich Schule in 1878 (Shorter, 2009). This physical sign is caused by a pattern of contraction of the corrugator muscle region, wrinkling a specific part of the forehead skin between the eyebrows and above the nose, which reminds any observer of the Greek letter omega (Greden et al., 1985; Shorter, 2009). Interestingly, in the year of 1911, the melancholic facial expression was complemented by the description of the oblique folding on the region of the upper eyelids, which gives a sad appearance to the eyes; such sign was proposed as a diagnostic feature of melancholia by Otto Veraguth, a Swiss neuropsychiatrist (Greden et al., 1985; Shorter, 2009).

Therefore, here we report the case of a 51-year-old woman with bipolar disorder and Turner’s syndrome who presented for her monthly outpatient consultation with anhedonia, loss of motivation, feeling tearful, fatigue, hypersomnia, feelings of worthlessness and helplessness, appetite loss and sadness. Her symptoms had started 1 month prior to the consultation. Physical examination revealed a facial expression that was similar to the descriptions of Omega sign and Veraguth’s fold (Figure 1). The results of laboratory testing were unremarkable. This patient, in the past year of her outpatient follow-up, reported three distinct episodes of clinical depression, presenting the above-mentioned signs in all of them as a physical manifestation of depression. Interestingly, in all past three episodes, once her antidepressant treatment was adjusted and her depressive symptoms remitted, both the Omega sign and the Veraguth’s fold disappeared.

Figure 1.

Omega sign (black arrows), produced by the contraction of what Darwin used to call ‘grief muscles’, forming a specific wrinkle in the forehead which resembles the Greek letter omega (Ω). Veraguth’s fold (white arrows), produced by the oblique folding on the upper eyelids, which was believed to give the eyes a sad aspect characteristic of melancholic states. This picture was taken and is reproduced with the informed consent of the patient.

The Melancholic Omega and Veraguth’s fold were recently revisited in an Indian publication (Saraf and Nath, 2019), which highlighted their importance to clinical settings. Our manuscript, likewise, adds to scientific literature and emphasizes the importance of these signs as historical memorials of biological psychiatry and Darwin’s contribution to phenomenology and clinical psychiatry.