This issue features groups of papers on deliberate self-harm, neuroimaging, cognitive impairment, treatment of depression in primary care, neuroticism and attachment as aetiological factors. In an additional editorial Tavares et al. (pp. 959–967) review recent studies of cognition in mania and depression.

Deliberate self-harm (DSH) is the most important factor associated with risk of suicide. It also poses a considerable burden on health and social services. Repetition of DSH after hospital presentation is common, with most studies reporting between 12 and 25% of patients repeating within a year and again presenting to hospital (Owens et al. 2002) and many more being involved in repeat episodes which do not bring them to clinical attention (Guthrie et al. 2001). Repetition itself increases the risk of a fatal outcome (Sakinofsky, 2000). The results of both psychosocial and pharmacological interventions to prevent repetition have been fairly disappointing (Hawton et al. 1998, 2000), although the findings of treatment trials have not all been negative. Dialectical behaviour therapy had a substantial initial impact on repetition of self-harm, although this did not persist in a treatment study of female patients with borderline personality disorders (Linehan et al. 1991) and depot flupenthixol reduced repetition in frequent self-harmers (Montgomery, 1987). A recent trial of brief psychotherapy was more effective than treatment as usual (Guthrie et al. 2001) and a meta-analysis of trials of problem-solving therapy suggested beneficial effects for depression, hopelessness and specific problems (Townsend et al. 2001).

The inclusion of cognitive symptoms in the DSM-IV criteria for major depressive and manic episodes highlight the importance of cognition in both of these psychiatric disorders (American Psychiatric Association, 1994). For example, criteria for diagnosis of these conditions include a diminished ability to concentrate and indecisiveness. In addition, numerous studies have demonstrated wide-ranging cognitive deficits in depression (for example Elliott et al. 1996; Purcell et al. 1997; Murphy et al. 2003) and mania (Goldberg et al. 1993; Murphy et al. 1999, 2001; Sweeney et al. 2000). These include deficits in early information processing (Tsourtos et al. 2002), recollection memory (MacQueen et al. 2002) and planning (Elliott et al. 1996) as well as affective biases (Murphy et al. 1999) and abnormal responses to negative feedback (Elliott et al. 1996, 1997; Murphy et al. 2003). Some residual deficits are also evident in a proportion of remitted subjects, even when controlling for mood (for example, Clark et al. 2002).

Background. We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm.

Method. Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months.

Results. Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0·78, 95% CI 0·53 to 1·14, P=0·20).

Conclusion. Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

Background. Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death.

Method. Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves.

Results. Differences in total cost per patient were statistically significant at 6 months in favour of MACT (−£897, 95% CI −1747 to −48, P=0·04), but these differences did not remain significant at 12 months (−£838, 95% CI −2142 to 466, P=0·21). Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is >90% probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual. The results for quality of life were not conclusive.

Conclusion. Cost-effectiveness acceptability curves demonstrate that, based on the evidence currently available, to reject MACT on traditional grounds of statistical significance and to continue funding current practice has <10% chance of being the correct decision in terms of cost-effectiveness.

Background. Trends in deliberate self-harm (DSH) are important because they have implications for hospital services, may indicate levels of psychopathology in the community and future trends in suicide, and can assist in identification of means of suicide prevention.

Method. We have investigated trends in DSH and characteristics of DSH patients between 1990 and 2000 based on data collected through the Oxford Monitoring System for Attempted Suicide.

Results. During the 11-year study period 8590 individuals presented following 13858 DSH episodes. The annual numbers of persons and episodes increased overall by 36·3% and 63·1% respectively. Rates (Oxford City) declined, however, in the final 3 years. There were gender- and age-specific changes, with a rise in DSH rates in males aged [ges ]55 years and in females overall and those aged 15–24 years and 35–54 years. Repetition of DSH increased markedly during the study period. Antidepressant overdoses, especially of SSRIs, increased substantially. Paracetamol overdoses declined towards the end of the study period. Alcohol abuse, use of alcohol in association with DSH, and violence increased, especially in females, and the proportion of patients in current psychiatric care and misusing drugs also rose.

Conclusions. While overall rates of DSH did not increase markedly between 1990 and 2000, substantial changes in the characteristics of the DSH population and a rise in repetition suggest that the challenges facing clinical services in the management of DSH patients have grown.

Background. High and low frequency repetititve transcranial magnetic stimulation (rTMS) are both effective in treating depression but have contrary effects on motor cortical activity. This study aimed to understand further the mechanisms of action of high and low frequency rTMS by examining their acute effects on regional cerebral blood flow (rCBF) in depressed patients.

Method. Eighteen depressed subjects underwent brain single photon emission computerized tomography (SPECT) scanning using split-dose 99mTc-HMPAO, and were examined during sham and active rTMS to the left prefrontal cortex, at 15 Hz or 1 Hz (N=9 each). Relative rCBF changes were examined by statistical parametric mapping and by regions of interest analysis.

Results. High (15 Hz) frequency rTMS resulted in relative rCBF increases in the inferior frontal cortices, right dorsomedial frontal cortex, posterior cingulate and parahippocampus. Decreases occurred in the right orbital cortex and subcallosal gyrus, and left uncus. Low (1 Hz) frequency rTMS led to increased relative rCBF in the right anterior cingulate, bilateral parietal cortices and insula and left cerebellum. High frequency rTMS led to an overall increase, whereas low frequency rTMS produced a slight decrease, in the mean relative rCBF in the left dorsolateral prefrontal cortex.

Conclusions. High (15 Hz) and low (1 Hz) frequency rTMS led to different frontal and remote relative rCBF changes, which suggests different neurophysiological and possibly neuropsychiatric consequences of a change in frequency of rTMS.

Background. There is considerable variability between patients in their expression of the diverse range of symptoms encompassed by the syndrome of schizophrenia, which may modulate functional activation to cognitive processing.

Method. Here we investigate associations between schizophrenic subsyndrome scores, identified by factor analysis, and experimentally controlled brain activation. Five factors were defined by rotated principal components analysis of PANSS rating scale measurements in 100 patients with schizophrenia. A subsample of 30 patients and a group of 27 comparison subjects were studied using functional magnetic resonance imaging (fMRI) during the performance of two periodically designed cognitive activation experiments: verbal working memory and psychomotor sequencing.

Results. Factor analysis replicated the five dimensions consistently reported. Within the patient group, power of activation by working memory was negatively associated with global symptom severity in left lingual and temporo-parietal cortices; negatively associated with positive subsyndrome scores in left inferior frontal and superior temporal cortices and basal ganglia; and positively associated with negative subsyndrome scores in lateral and medial premotor cortex. No relationship was observed between subsyndrome scores and functional activation during the motor task. Between-group comparisons demonstrated reduced power of response to the working memory task by patients in bilateral dorsolateral prefrontal and left pre- and post-central cortices.

Conclusions. In this study we observed task-specific modulation of functional response associated with symptom expression in schizophrenia. Our findings are compatible with previous empirical findings and theoretical conceptualization of human brain function, in terms of capacity constraints on activation in the face of competing demands from pathological and task-related cognitive activity.

Background. Morphometric studies on the corpus callosum (CC) in schizophrenia have yielded contradictory results. The aim of the present study was to investigate magnetic resonance imaging (MRI) abnormalities of the CC in first-episode patients with schizophrenic psychoses.

Method. We assessed volumetric MRI in 31 patients with diagnoses of schizophrenia, schizophreniform or schizoaffective disorder (DSM-IV) and a maximum exposure to neuroleptics of 2 weeks. As a control group, 12 healthy age- and sex-matched individuals were included in the study. A whole body scanner at 1.5 Tesla was used to obtain 3D T1- and T2-weighted MR datasets. The data were evaluated semi-automatically (intracranial volume, total brain volume) and manually (CC) with the software NMRwin.

Results. Patients had smaller CC and CC subdivisions than controls. Schizophrenic and unaffected women exhibited larger total CC and rostral subdivisions than men in both groups. Handedness did not exert an influence.

Conclusions. Our findings are in line with other in vivo morphometric studies on the CC in schizophrenia. The larger CC area in women may reflect general gender-related differences in CC size as described in healthy individuals.

Background. Mild cognitive impairment (MCI) is associated with an increased risk of developing dementia. Recently published results of the Current Concepts in MCI Conference suggested subclassifications for MCI (MCI-amnestic, MCI-multiple domains slightly impaired, MCI-single nonmemory domain) based on the recognized heterogeneity in the use of the term. These subclassifications have not been empirically validated to date.

Method. A community sample of 1045 dementia-free individuals aged 75 years and over was examined by neuropsychological testing in a three-wave longitudinal study. The prevalences and the predictive validities for the subclassifications of MCI and their modifications (original criteria except for the report of subjective decline in cognitive function) were determined.

Results. The prevalence was 1 to 15% depending on the subset employed. Subjects with a diagnosis of MCI progressed to dementia at a rate of 10 to 55% over 2·6 years, depending on the subset employed. MCI-amnestic achieved the highest positive predictive power (PPP). ROC curves of the subclassifications for MCI indicate that all but one subset for MCI failed to predict dementia (MCI-multiple domains slightly impaired-modified: AUC=0·585, P<0·01, 95% CI, 0·517–0·653). The use of modified criteria for MCI (original criteria except for the report of subjective decline in cognitive function) is associated with a higher diagnostic sensitivity but also with a reduction in diagnostic specificity and PPP.

Conclusions. Modified criteria should be applied if a concept for MCI with a high sensitivity is required and the original criteria (including subjective cognitive complaint) if a concept with high specificity and high PPP is required.

Background. Early diagnosis of dementia is important for those who might benefit from treatment. We designed a brief comprehensive neuropsychological test battery to help differentiate control subjects from patients with mild cognitive impairment (MCI) and dementia.

Method. The battery included tests of memory, attention, executive function, speed, perception and visuospatial skills. It was administered to subjects from the OPTIMA cohort: 51 controls, 29 with MCI, 60 with ‘possible’ or ‘probable’ Alzheimer's disease (AD) (NINCDS/ADRDA) and 12 with cerebrovascular disease (CVD). Mann–Whitney U tests were used to compare performance of controls with other diagnostic groups. The sensitivity and specificity of the tests were determined using Receiver Operating Characteristic curve analyses. The effects of age, gender and years of education on test performance were determined with Spearman's rank correlations.

Results. The AD group performed worse than controls on all tests except an attention task. The Hopkins Verbal Learning Test and The Placing Test for episodic memory showed significant discriminative capacity between controls and other groups. Attention and processing speed tests discriminated CVD from controls. Category fluency, episodic memory tests and the CLOX test for executive function distinguished MCI from AD. Spearman's correlations showed negative associations between age and processing speed. Years of education affected performance on all tests, except The Placing Test.

Conclusions. Certain neuropsychological tests have been shown to be sensitive and specific in the differential diagnosis of various types of dementia and may prove to be useful for detection of MCI.

Background. Few data are available with which to evaluate the association between depressed subgroups, type of treatment and patient retention during episodes of major depression.

Method. This observational study followed 1117 depressed patients over a 12-month period in the primary care setting of six different international sites. The patients were divided into three severity-linked subgroups: moderate to severe depression; moderate depression co-morbid with serious medical conditions; and mild depression.

Results. In general, a low dropout rate was found, with significant differences in the rates across the six sites. However, while there was no statistical significance in the association between the three subgroups of depression and overall dropout rates, we did find that older patients were less likely to drop out, more depressed patients were more likely to drop out, and if patients were on antidepressants they were less likely to drop out. Among the three subgroups of depression, patients with moderate depression co-morbid with serious medical conditions received the lowest amount of antidepressants and had the lowest quality of life.

Conclusion. Although the overall dropout rate in this study was found very low and did differ between the six sites, an association between the use of antidepressants and patient retention was seen. The group of patients with serious co-morbid medical conditions received fewer antidepressants even when the level of their depressive states was taken into consideration. This group was the least satisfied with treatment and had the lowest self-reported quality of life.

Background. A randomized trial of a primary care-based intervention to prevent depression relapse resulted in improved adherence to long-term antidepressant medication and depression outcomes. We evaluated the effects of this intervention on behavioural processes and identified process predictors of improved depressive symptoms.

Method. Patients at high risk for depression recurrence or relapse following successful acute phase treatment (N=386) were randomly assigned to receive a low intensity 12-month intervention or continued usual care. The intervention combined education about depression, shared decision-making regarding use of maintenance pharmacotherapy and cognitive-behavioural strategies to promote self-management. Baseline, 3, 6, 9 and 12-month interviews assessed patients' self-care practices, self-efficacy for managing depression and depressive symptoms.

Results. Intervention patients had significantly greater self-efficacy for managing depression (P<0·01) and were more likely to keep track of depressive symptoms (P<0·0001), monitor early warning signs (P<0·0001), and plan for coping with high risk situations (P<0·0001) at all time points compared to usual care control patients. Self-efficacy for managing depression (P<0·0001), keeping track of depressive symptoms (P=0·05), monitoring for early warning signs (P=0·01), engaging in pleasant activities (P<0·0001) and engaging in social activities (P<0·0001) positively predicted improvements in depression symptom scores.

Conclusions. A brief intervention designed to target cognitive-behavioural factors and promote adherence to pharmacotherapy in order to prevent depression relapse was highly successful in changing several behaviours related to controlling depression. Improvements in self-efficacy and several self-management behaviours that were targets of the intervention were significantly related to improvements in depression outcome.

Background. Many people who are depressed do not receive any professional help and their beliefs about the helpfulness of treatment do not always correspond with those of health professionals. To facilitate choices about treatment, the present study examined the effects of providing depressed people in the community with evidence on whether various treatment options work.

Method. A randomized controlled trial was carried out with 1094 persons selected at random from the community who screened positive for depressive symptoms and agreed to participate. Participants were mailed either an evidence-based consumer guide to treatments for depression or, as a control, a general brochure on depression. Outcomes were the rated usefulness of the information provided, changes in attitudes to depression treatments, actions taken to reduce depression, and changes in depressive symptoms, anxiety symptoms and disability.

Results. Participants rated the evidence-based consumer guide as more useful than the control brochure. Attitudes to some treatments changed. Improvements in symptoms and disability did not differ significantly between interventions.

Conclusion. Providing people who are depressed with evidence on which treatments work produces some changes in attitudes and behaviour. However, this intervention may need to be enhanced if it is to produce symptom change.

Background. Published studies of emotional processing and cognitive style in bipolar disorders tend to have small sample sizes or use non-clinical samples. Larger clinically representative studies are needed.

Method. Self-esteem, dysfunctional attitudes and personality style were compared in unipolar (N=16) and bipolar disorder (N=77); and then investigated in the different phases of bipolar disorder (remitted=26; depressed=38; hypomanic=13). One-year outcome was assessed in 36 bipolar subjects.

Results. Unipolar subjects and bipolar subjects differed significantly in their mean levels of negative self-esteem (unipolar=15·5; bipolar=12·7; P<0·05). Bipolar subjects with hypomania reported mean levels of dysfunctional beliefs that were higher than individuals in remission but lower than depressed subjects (remitted=136·7; depressed=153·8; hypomanic=144·8; P<0·05). Hypomanic subjects recorded the highest levels of negative as well as positive self-esteem. In the exploratory analysis of outcome, negative self-esteem (Exp [B] 1·91; 95% CI 1·11 to 3·32; P<0·05) was the most robust predictor of relapse.

Conclusions. There are similarities in the cognitive style of individuals with unipolar as compared to bipolar disorders. Cognitive style in hypomania represents a phase between remission and depression rather than the polar opposite of depression. The implications of these findings are considered for psychological and neural network models.

Background. The aims of this research were to examine the associations between the personality trait of neuroticism in adolescence and later psychotic symptoms, taking into account potential confounding factors.

Method. Data were gathered over the course of a longitudinal study of a birth cohort of New Zealand born young people (N=1265). Over the course of the study, data were gathered on: (a) neuroticism at age 14; (b) psychotic symptoms predominantly subclinical, assessed on the Symptom Checklist (SCL-90), at ages 18 and 21; (c) a range of potential confounding factors including measures of childhood adversity and co-morbid mental disorders.

Results. Young people in the highest quartile of neuroticism at age 14 had rates of psychotic symptoms that were two to three times higher than those in the lowest quartile. After statistical adjustment for confounding factors, including childhood adversity and co-morbid mental disorders, the association between neuroticism and later psychotic symptoms reduced but remained statistically significant (P<0·05). After adjustment for confounding, young people with high levels of neuroticism had rates of psychotic symptoms that were between 1·5 to 1·8 times higher than those with low levels of neuroticism.

Conclusions. Early neuroticism may be a precursor to the onset of psychotic symptoms. The mechanisms underlying this association are unclear, but may relate to overlapping features between prodromal phases of psychosis and items that measure neuroticism.

Background. The Vulnerable Attachment Style Questionnaire (VASQ) was developed to provide a brief self-report tool to assess adult attachment style in relation to depression and validated against an existing investigator-based interview (Attachment Style Interview – ASI). This paper describes the development and scoring of the VASQ and its relationship to poor support and major depression.

Method. Items for the VASQ reflected behaviours, emotions and attitudes relating to attachment relationship style, drawn directly from the ASI. The VASQ was validated against the ASI for 262 community-based subjects. Test–retest was determined on 38 subjects.

Results. Factor analysis derived two factors, labelled ‘insecurity’ and ‘proximity-seeking’. The VASQ insecurity dimension had highest mean scores for those with interview-based Angry-dismissive and Fearful styles and was significantly correlated with degree of interview-based insecurity. The proximity-seeking VASQ scores had highest mean for those with Enmeshed interview attachment style and was uncorrelated with ASI insecurity. VASQ scores were highly correlated with a well-known self-report measure of insecure attachment (Relationship Questionnaire) and text–retest reliability of the VASQ was satisfactory. The total VASQ score and the insecurity subscale proved highly related to poor support and to depressive disorder. This was not the case for the proximity-seeking subscale.

Conclusion. The VASQ is a brief self-report measure that distinguishes individuals with attachment styles vulnerable for depressive disorder. The use of the measure for screening in research and clinical contexts is discussed.

Background. Depression has been hypothesized to be potentially linked to an increased risk of breast cancer. Few studies have addressed this question using population-based cohorts and prospective designs, adjusting for known biomedical risk factors. This has been done in the present investigation.

Method. Participants were 5191 women from a cohort of women born between 1941 and 1947 and living in the city of Eindhoven, The Netherlands. All women completed questionnaires regarding the presence of depressive symptoms (Edinburgh Depression Scale) and background (demographic, medical and lifestyle) variables. The questionnaire data were linked with the records of the Eindhoven Cancer Registry. These records provided data on breast cancer diagnoses, which took place up to 5 years after the questionnaire screening.

Results. Fifty-eight women (1·1%) were found to have developed breast cancer at least 2 years after the questionnaire screening. After controlling for 15 potential risk factors, of which family history of breast cancer, hypothyroidism and unilateral oophorectomy were significant predictors of breast cancer development, women with depressive symptoms had a lower risk of subsequent breast cancer (OR=0·29, 95% CI=0·09–0·92, P=0·04).

Conclusions. Depressive complaints may be associated with a protective factor involved in the development of breast cancer. Some of the possible candidates for this factor are discussed.

Background. It has been demonstrated that patients experiencing their first-episode of psychosis have social functioning deficits that are equivalent to those seen in patients with a more chronic course of illness. The purpose of this study is to examine social functioning over the course of the first year after admission to an early psychosis programme.

Method. The social functioning of 177 first-episode subjects was assessed on admission and 1 year later and compared with that of 40 non-psychiatric controls. Assessment measures included the Quality of Life Scale (QLS).

Results. At the 1-year follow-up there was significant improvement in quality of life. However, even those first-episode patients experiencing a remission from positive symptoms had lower QLS scores than the non-psychiatric controls.

Conclusions. These results are encouraging and supportive of early intervention. There is room for more improvement in the application and development of psychological interventions for these young patients.