A number of Meso-American artifacts which appear to depict subjects presenting severe depressive episodes have been identified, showing that concern with depressive disorders is not a recent phenomenon. Atypical presentations of depression in modern Mexico are characterized by a high degree of somatization, perhaps to avoid the stigma of “mental disorders”. Other characteristics are mood reactivity, substantial anxiety, phobias and the reversed vegetative manifestations. There is a high comorbidity with panic disorder and with bipolar depression. Nosological terminology is not fully standardized, and commonly encountered diagnoses include “neurasthenia”, “neurotic depression”, “mixed depression”, “resistant depression”, etc. Treatment involves a variety of modalities, including TCAs, MAOIs, and anxiolytics, together with a number of drug combinations; open trials are underway with newer agents such as SAMe, SSRIs and the RIMAs.

In the UK, the majority of patients with depressive disorders are treated by general practitioners, and there is little agreement on the nomenclature for atypical disorders including dysthymia, atypical depression, neurasthenia and recurrent brief depression. Mixed depressive and anxiety symptoms are considered to be the norm, and antidepressant drugs are increasingly being used in place of benzodiazepines. Unfortunately, antidepressant regimens prescribed by GPs tend to be inadequate in terms of both duration and dosage, and an educational campaign is underway to remedy this problem. British psychiatrists employ the full range of available antidepressant drugs for depression, and the severity of the disorder is not a primary determinant for choice of drug; on the other hand, ECT is reserved primarily for psychotic depression. Neurasthenia is frequently diagnosed as “chronic fatigue syndrome”, or “myalgic encephalomyelitis”, and a psychological treatment protocol has given encouraging initial results.

Depressive conditions such as treatment-resistant depression, persistent depression and chronic mild depression have recently been the subject of much interest in Japan. The term “atypical depression” is not in common use, however depressive states falling outside the “typical” categories of the major depressive disorders (MDD) can be discussed in terms of symptomatology, etiology, and response to treatment. The term “neurasthenia” which refers to a hypochondriacal disorder with or without physical illness, as well as to a subtype of neurosis (ICD-9, 300.5), is no longer extensively used. “Dysthymia” is classically employed to signify either a dysphoric state accompanied by mild depression and irritability, as defined by the German school, or a mild depressive personality disorder; it is currently used as an alternative to “neurotic depression” (ICD-9 300.4), or “dysthymic disorder” (DSM III-R). Recurrent brief depression is not yet a prevalent concept in Japan. Despite the observation of depression with hyperphagia and/or hypersomnia, these phenomena have not received a specific designation. Therapeutic approaches to depression include both non-drug modalities (psychotherapy, environmental modification, etc) and the standard drug regimens (antidepressants, anxiolytics, etc); clinical trials are currently underway with selective serotonin reuptake inhibitors which we expect to be effective in treatment-resistant depression. Plant-based traditional remedies are still widely employed in Japan, and several of these are described. Finally, we discuss the Morita therapy, a specifically Japanese modality for treatment of mild depression with obsessive-compulsive symptoms based upon the Zen philosophy. This approach involves an initial period of absolute bed-rest, followed by gradual resumption of work and social activities with support and counseling.

Atypical depression differs from typical (endogenomorphic) depression not only in terms of the primary determinant, mood reactivity, but also by the presence of at least one of four atypical symptoms, hyperphagia, hypersomnia, rejection sensitivity and leaden paralysis. In addition to the differential therapeutic response reported by various authors, these two types of depression can be differentiated by various biological measures including the dexamethasone suppression test, tyramine excretion following loading, REM latency, etc. A series of studies comparing phenelzine with imipramine and placebo in subgroups of atypical depressives showed better results with the tricyclic than with placebo; however phenelzine consistently gave the best results in this type of depression. The hypothesis is advanced that the difference between typical and atypical classes of depression could be accounted for by the loss of the ability to experience both “anticipatory” or “consummatory” pleasure in typical depression, but only anticipatory pleasure in atypical depression.

More than half of all patients consulting at public health facilities in Cali, Colombia have been shown to present mental disorders, the majority of which were non-psychotic; there is a high female preponderance amongst the affective disorders. As in other developing countries, in Colombia depressive disorders tend to present as somatic complaints, rather than as mood disturbances. The nomenclature used to describe these disorders is poorly codified, with most patients classed as “neurotic” or “depressed”; the diagnosis of “dysthymia” is very seldom encountered. Mental disorders are frequently misdiagnosed in primary care settings; when identified, treatment of depression by GPs generally involves TCAs or MAOIs, sometimes in conjunction with anxiolytics or neuroleptics. Only very severe cases are referred to psychiatrists, and many patients purchase drugs upon the recommendation of a pharmacist. Diagnostic trends and treatment results of a comparative study of amisulpride and viloxazine carried out in 80 patients assessed by DSM III-R criteria are reported.

A two-part survey of French General practitioners was carried out to determine attitudes and diagnostic criteria for definition of atypical depression, major depressive episodes, and anxiety disorder. Following a preliminary phase in which 90 physicians were interviewed, 500 general practitioners received detailed questionnaires based upon DSM III-R criteria, as well as supplementary questions based upon the Leibowitz and Akiskal criteria. Principal criteria analysis and regression analysis were carried out on the 280 analyzable files received. Results showed that anxiety disorders were primarily defined in terms of somatic criteria, and that there were a number of factors common to anxiety and depression. Minor depression was also defined primarily on the basis of somatic complaints, together with loss of energy and fatigue. Major depression was defined primarily by asthenia, apragmatism and loss of drive, together with less strongly weighted cognitive factors (sadness, Pessimism, inhibition, etc). From a dimensional standpoint, depression is defined as a “vital deficit”, with a failure to cope with social and environmental demands. It is interesting to note that the duration criterion was not considered to be of nosological relevance by the physicians, and was generally ignored in the definition of mental pathologies. The international subtyping of depressive disorders does not form part of the Practice of French practitioners, who prefer to retain the older, psychosocial models.

In Germany a major distinction is made between endogenous and neurotic depression. While traditionally neurotic depression was seen as being amenable only to psychotherapy, there is an increasing tendency to treat neurotic patients presenting the full depressive syndrome with antidepressant drugs. Those psychiatrists who are aware of the concept of atypical depression in the stricter sense (anxiety-depression, depression with reversed somatic symptoms, etc) tend to treat these patients with monoamine oxidase inhibitors. The diagnosis of “dysthymia”, Possibly equivalent to “neurotic depression”, has not yet come into common usage. While the term “neurasthenia” is traditional, general Practitioners prefer other designations; treatment involves supportive psychotherapy, benzodiazepines and sedative antidepressants. Mixed anxiety-depression is treated with anxiolytic antidepressants, sedatives or, for the milder cases, with low-dose neuroleptics. This indication for neuroleptics is controversial, and a treatment protocol has been codified for use by the general practitioners so as to avoid the potential major adverse reactions seen with the class. The new concept of recurrent brief depression is confined to academic milieu, where treatment is the same as for unipolar depression.

In an attempt to better delineate demographic and clinical characteristics of mild chronic depressions, 46 outpatients fulfilling DSM III-R criteria for dysthymia were compared with patients suffering from a chronic major depressive episode. The profile obtained from our dysthymic sample matches with those reported by other authors. The comparison between “minor” and major chronic depression was also carried out by subdividing these latter into unipolar - recurrent and single episode - and bipolar depression. Dysthymics showed a bipolar family history closer to that of bipolar chronic major depressives which was significantly higher than that recorded in the other sub-categories.