This study examines rates of diagnostic recognition and treatment in a sample of 5131 community respondents with a diagnosis of major depression or dysthymia according to DSM-IV criteria. Findings reveal that only one third of all definite depressive disorders were recognized by primary care physicians or mental health specialists or reported evidence for any type of therapeutic interventions. Recognition and treatment rates were particularly poor among adolescents and young adults. Although recognition and treatment probability were higher, particularly among those being older as well as among those with severe and recurrent depression, the problem of unmet needs was evident for all subtypes of depressive disorders. Almost 40% of those with severe depression, 26% of depressions of the melancholic subtype and 25% of those with recurrent depression indicate having never received at any point of their life any depression-specific treatment by either their primary care nor by a mental health specialist. The poor recognition and treatment rate of depressive disorders is remarkable and requires increased efforts to identify the determinants for this situation.

The paper examines the influence of attitudes and behaviors (illness behavior) in a community sample of depressed cases on the probability of professional recognition and treatment. Particular emphasis is laid upon the identification of a pattern of atypical depression and associated symptoms, believed to be particular frequent among young. This pattern has been labeled >> Sisi-syndrome << referring to medical history research, that suspect that >>Kaiserin Elisabeth< (>$$) over bar>Sisi<<, 1837-1898) had suffered from an unrecognized depressive: illness, characterized besides others by:increased activities and the denial of depressed mood. By using an epidemiological data set of 5131 subjects from general population surveys in Germany the paper examines to what degree such atypical presentations are frequent manifestations and. whether they-explain poor recognition and treatment rates. After controlling for potential confounding variables (severity, course, comorbidity; age, etc) findings,reveal that atypical symptoms, behaviors, and attitudes described in the >>Sisi-construct<< are indeed associated significantly with low treatment rates. Using clusteranalytic methods, a stable and homogenous, almost prototypical >>Sisi-cluster<< of predominantly young. women with major depression, and another less stable cluster of older women was identified, both characterized by very low treatment rates. For males a less stable and less homogenous,>>Sisi-cluster<< was found. Overall about one third of all depressed in the community were assigned to one of these >>Sisi clusters<<. It is concluded,that patient variables and more generally the illness behavior are. important variables in explaining the mechanisms involved in underrecognition of depressive disorders. The >>Sisi-variables<< identified might be useful as simple targets for programs aiming at improvement of poor recognition,in primary care and might facilitate the design of mere sensitive questionnaires.