Depression has a profound impact on parameters of interpersonal behaviour (Lewinsohn et al. 1970; Libert & Lewinsohn, 1973; Teasdale et al. 1980). Studies of healthy mother–infant dyads have demonstrated that infants are highly sensitive to their interpersonal environment (Murray, 1988). It is, therefore, likely that postpartum depression, by virtue of its impact on maternal interpersonal functioning, will disrupt normal infant engagements with the mother and, as a consequence, impair infant developmental progress. In recent years a considerable body of research surrounding this question has accumulated.

Background. The authors examined data from a follow-up study of first admission schizophrenic patients treated with and without antipsychotic medications, who were discharged from the hospital within 6 months. It was predicted that patients who did not require antipsychotic medications for discharge would have a more favourable long-term outcome.

Methods. The subjects were part of the Camarillo State Hospital study conducted by May and colleagues in the late 1950s and early 1960s. Patients had been randomly assigned to treatment with and without antipsychotic medications. The number of rehospitalization days and total prescribed chlorpromazine equivalents were calculated for each patient for the 2 years following discharge. In order to assess patients' continuing ability to function, 11 patients from each group who met DSM-IV criteria for schizophrenia were matched for age, educational status at first admission, race, and gender; their Global Assessment of Functioning Scale (GAF) score was estimated across a period of 6–7 years following discharge.

Results. During the second year following discharge, patients initially treated with antipsychotic medications required fewer rehospitalization days than the initially non-medicated patients. Furthermore, 6–7 years following initial discharge, those patients initially treated with medications were functioning at a higher level, as measured by GAF scores, than patients not initially treated with antipsychotic medications.

Conclusions. The results of this study suggest that, at least for this subgroup of patients, early treatment with antipsychotic medications both decreases the immediate morbidity associated with schizophrenia, and prevents detrimental changes possibly related to prolonged untreated psychosis.

Background. Patients with anorexia nervosa (AN) run a high risk of becoming chronically ill and of dying. In the acute phase of their illness they present with numerous physical and laboratory abnormalities. However, little is known about the long-term prognostic value of these findings or about the medical morbidity in large samples of consecutively treated patients in the long-term.

Methods. We evaluated 84 consecutive female patients with AN who were studied again an average of 11·9 years later. The ability of some of the laboratory data obtained at the initial examination to predict a fatal or chronic course was analysed by discriminant and multiple regression analyses.

Results. Abnormally low serum albumin levels ([les ] 36 g/l) and a low weight ([les ] 60% of average body weight) at the initial examination were variables best able to predict a lethal course. In addition, high serum creatinine and uric acid levels predicted a chronic course. Most of the initial abnormal laboratory findings were reversible with a normal food intake. At a 12-year follow-up 67% of the chronic anorexic patients and 27% of those in the good/intermediate outcome group (compared to 8% morbidity in normal controls) presented with medical co-morbidity, in particular osteoporosis and renal disease. The standardized mortality ratio was 9·6.

Conclusions. Laboratory findings obtained at the initial examination may be helpful in predicting a fatal or chronic course of AN. An evaluation of the long-term outcome of eating disorders should include an assessment of the medical co-morbidity.

Background. Though previous studies have clearly shown that lithium affords prophylaxis in bipolar affective disorder, these studies have not demonstrated the persistence of this prophylactic effect beyond the first year of recovery.

Methods. One hundred and eighty-one patients with bipolar affective disorder recovered during 5 years of semi-annual follow-up. After 8 weeks of recovery, 139 were taking lithium prophylaxis and 42 were not. Analyses used drug status (lithium v. no-lithium) as a censoring variable to compare these two groups by interval-specific probabilities of recurrence.

Results. Recurrence was initially less likely in the lithium group but interval-specific probabilities of recurrence did not consistently favour either group after the first 32 weeks of recovery.

Conclusions. Biases in treatment decisions may have both reduced the size and altered the specificity of the lithium effects seen here. Nevertheless, the apparent transience of lithium prophylactic effects is unexplained and may reflect important, physiological differences between relapse and recurrence. This possibility invites a controlled lithium discontinuation study, with gradual taper, of patients who have had at least 8 months of sustained euthymia.

Background. An obstacle to the successful classification of attention deficit hyperactivity disorder (ADHD) is the frequently reported co-morbidity between ADHD and conduct disorder (CD). Prior work suggested that from a familial perspective, ADHD children with CD may be aetiologically distinct from those without CD.

Methods. Using family study methodology and three longitudinal assessments over 4 years, we tested hypotheses about patterns of familial association between ADHD, CD, oppositional defiant disorder (ODD) and adult antisocial personality disorder (ASPD).

Results. At the 4-year follow-up, there were 34 childrenwith lifetime diagnoses of ADHD + CD, 59 with ADHD + ODD and 33 withADHD only. These were compared with 92 non-ADHD, non-CD, non-ODDcontrol probands. Familial risk analysis revealed the following: (1)relatives of each ADHD proband subgroup were at significantly greaterrisk for ADHD and ODD than relatives of normal controls; (2) ratesof CD and ASPD were elevated among relatives of ADHD + CD probandsonly; (3) the co-aggregation of ADHD and the antisocial disorders couldnot be accounted for by marriages between ADHD and antisocial spouses;and (4) both ADHD and antisocial disorders occurred in the samerelatives more often than expected by chance alone.

Conclusions. These findings suggest that ADHD with and without antisocial disorders may be aetiologically distinct disorders and provide evidence for the nosologic validity of ICD-10 hyperkinetic conduct disorder.

Background. This paper summarizes work with the Interview for Recent Life Events (IRLE), an instrument that has been used extensively but not previously reported in detail.

Methods. Rationale, development, organization, content, reliability, validity and applications are reviewed in full.

Results. The instrument covers a comprehensive range of recent life events, their timing and other important qualities. It has been found reliable and valid, and has been translated into a number of languages. It has been used by many research groups in different countries, in studies of psychiatric patients, medical patients and subjects in the general population.

Conclusions. The instrument is useful, has been widely applied and has the necessary qualities for ascertainment of life events in research studies.

Background. An association between disablement and late-life depression is often reported in cross-sectional studies. However, many lack effect sizes, and do not control for confounding. Therefore, it is difficult both to quantify the overall impact of poor health on depression and to understand which aspects are most salient.

Methods. A catchment area survey of all over 65-year-old residents of an electoral district in London, UK, using a population register derived from a door-to-door census was undertaken. Depression was measured using SHORT-CARE, and the consequences of disease classified according to the WHO International Classification of Impairments, Disabilities and Handicaps.

Results. Six hundred and fifty-four subjects were interviewed out of an older population of 889. The prevalence of SHORT-CARE pervasive depression was 17%. Impairment, disability and, particularly, handicap were strongly associated with depression. The adjusted odds ratio for depression in the most handicapped quartile compared with the least was 24·2 (8·8–66·6). The population attributable fraction (PAF) for depression attributable to handicap was 0·78. The PAFs for recent life events and female gender were much lower. Handicap explained most of the depression associated with individual impairments and disabilities. Adjusting for handicap abolished or weakened the associations between depression and social support, income, older age, female gender and living alone.

Conclusions. Even given some uncertainty in distinguishing handicap and depression as constructs, and the impossibility of deciding direction of causality, it seems likely that handicap is of central significance to late-life depression. Handicap may be more amenable to intervention than either impairment or disability.

Background. A companion paper reported a very strong cross-sectional association between handicap and late-life depression. Adjusting for handicap weakened associations between sociodemographic variables and depression. It was unclear whether handicap was a confounder, or a useful summary variable, mediating the effect of a range of sociodemographic disadvantages. This paper focusses on the cross-sectional relationship between depression and demographic variables, social support, and life events.

Method. A community survey of all residents over the age of 65 years of an electoral district in London, UK.

Results. There was a moderate association between SHORT-CARE pervasive depression and the number of life events experienced over the previous year. Personal illness, bereavement and theft were the most salient events. There was a stronger, graded, relationship between the number of social support deficits (SSDs) and depression. Number of SSDs also related to age, handicap, loneliness and use of homecare services. Loneliness was itself strongly associated with depression; odds ratio 12·4 (7·6–20·0).

Conclusions. Problems of collinearity, and the cross-sectional design of the study limited interpretation of the exact nature of the relationship between social support, loneliness, handicap and depression. However, the clustering of these four factors can be used to define a large part of the elderly population with a poor quality of life. An important avenue for future research will be the development and implementation of population intervention strategies designed to address some or all of these problems among older people in general.

Background. The Parental Bonding Instrument (PBI) is a widely used measure of parenting, and is usually used to measure two parenting dimensions, care and over-protection. However, there is disagreement in the research literature about whether the PBI is best used as a two-factor or a three-factor measure.

Method. PBI scores from 583 US and 236 UK students were factor analysed to assess whether a three-factor solution was more satisfactory than a two-factor solution.

Results. A three-factor (care, denial of psychological autonomy and encouragement of behavioural freedom) solution was found to be more satisfactory than a two-factor solution. Using the three-factor solution, group differences that were not apparent with the two-factor solution were identified and it was found that the parenting behaviours associated with depression could be more accurately identified.

Conclusion. The authors suggest that with modifications, the PBI could be used to measure three parenting variables (care, denial of psychological autonomy and encouragement of behavioural freedom), which would allow greater accuracy of prediction and a greater understanding of underlying processes.

Background. Most research on syndromes of chronic fatigue has been conducted in clinical settings and is therefore subject to selection biases. We report a population-based incidence study of chronic fatigue (CF) and chronic fatigue syndrome (CFS).

Methods. Questionnaires assessing fatigue and emotional morbidity were sent to 695 adult men and women who had replied to a postal questionnaire survey 1 year earlier. Possible CFS cases, subjects with probable psychiatric disorder and normal controls were interviewed.

Results. Baseline fatigue score, the level of emotional morbidity and a physical attribution for fatigue were risk factors for developing CF. However, after adjusting for confounding, pre-morbid fatigue score was the only significant predictor. A minority of CF subjects, all female, had consulted their general practitioner; higher levels of both fatigue and emotional morbidity were associated with consultation. Possible CFS cases reported similar rates of current and past psychiatric disorder to psychiatric controls, but after controlling for fatigue or a diagnosis of neurasthenia the current rates were more similar to those of normal controls. Two new cases of CFS were confirmed.

Conclusions. Both fatigue and emotional morbidity are integral components of chronic fatigue syndromes. The demographic and psychiatric associations of CFS in clinical studies are at least partly determined by selection biases. Given that triggering and perpetuating factors may differ in CFS, studies that examine the similarities and differences between chronic fatigue syndromes and psychiatric disorder should consider both the stage of the illness and the research setting.

Background. Recent observations indicate that a certain pre-morbid personality profile (‘autonomic lability’, i.e. elevated neuroticism, frequent somatic complaints and increased inter-personal sensitivity) appears to be a valid antecedent of major depression. However, most of these prospective studies used samples drawn from the general population, which limits the power of any observed differences between subjects who developed a depressive disorder during the follow-up period and those who did not.

Methods. We investigated the psychometric profile of 54 high-risk probands (aged between 18 years and 45 years) without a current or lifetime diagnosis of any psychiatric disorder, but who had first-degree relatives with an affective disorder according to DSM-III-R criteria. Twenty-two control probands, matched for age and gender and without any personal or family history of psychiatric disorders, served as the reference group.

Results. As a group, the high-risk probands scored higher than the controls on scales that assessed neuroticism, rigidity, depressive cognitions, vegetative lability and stress. With an individual-orientated approach (cluster analysis), 30 high-risk probands were identified as conspicuous, characterized by elevated rigidity and increased ‘autonomic lability’. The remaining 24 high-risk probands showed a psychometric profile very similar to that of the controls.

Conclusions. The present findings in 54 probands at high risk for affective disorders not only strongly underline the assumption that the personality trait ‘autonomic lability’ is a valid antecedent of at least major depression, but also add the personality trait ‘rigidity’ as a further and potential candidate for a true vulnerability marker for affective disorders.

Background. Research on the dimensional structure and reliability of the Hospital Anxiety and Depression Scale (HADS) and its relationship with age is scarce. Moreover, its efficacy in determining the presence of depression in different patient groups has been questioned.

Methods. Psychometric properties of the HADS were assessed in six different groups of Dutch subjects (N = 6165): (1) a random sample of younger adults (age 18–65 years) (N = 199); (2) a random sample of elderly subjects of 57 to 65 years of age (N = 1901); (3) a random sample of elderly subjects of 66 years or older (N = 3293); (4) a sample of consecutive general practice patients (N = 112); (5) a sample of consecutive general medical out-patients with unexplained somatic symptoms (N = 169); and (6) a sample of consecutive psychiatric out-patients (N = 491).

Results. Evidence for a two-factor solution corresponding to the original two subscales of the HADS was found, although anxiety and depression subscales were strongly correlated. Homogeneity and test–retest reliability of the total scale and the subscales were good. The dimensional structure and reliability of the HADS was stable across medical settings and age groups. The correlations between HADS scores and age were small. The total HADS scale showed a better balance between sensitivity and positive predictive value (PPV) in identifying cases of psychiatric disorder as defined by the Present State Examination than the depression subscale in identifying cases of unipolar depression as defined by ICD-8.

Conclusions. The moderate PPV suggests that the HADS is best used as a screening questionnaire and not as a ‘case-identifier’ for psychiatric disorder or depression.

Background. The aims of this study were to examine the associations between exposure to unemployment following school leaving and rates of psychiatric disorder using data gathered on a birth cohort of New Zealand young people studied up to the age of 18.

Methods. At age 18 cohort members were assessed on: (a) duration of exposure to unemployment from age 16; (b) DSM-IV diagnostic criteria for major depression, anxiety disorders, conduct disorder, nicotine dependence, other substance abuse/dependence and attempted suicide. This information was integrated into longitudinal data gathered on the social circumstances, family background and adjustment of the cohort up to the age of 18.

Results. Increasing exposure to unemployment was associated with increasing risks of psychiatric disorder in adolescence. Those exposed to 6 months or more unemployment had rates of disorder that were 1·5 to 5·4 times higher than those not exposed to unemployment. However, most of the elevated risk of disorder among those unemployed was explained by family and personal factors that were present prior to school leaving age. Nonetheless, even after control for these factors those exposed to unemployment had significantly higher rates of anxiety disorder and substance use disorders.

Conclusions. To a large extent the relationships between unemployment and psychiatric disorder seen in this cohort were explained by social, family and personal factors that were present before school leaving age. Nonetheless, young people exposed to unemployment had higher rates of substance use and anxiety disorder.

Background. The purpose of this experiment was to investigate mechanisms underlying commonly-observed verbal memory impairments in schizophrenia, and especially the hypothesized encoding deficit.

Methods. A verbal memory task was administered to 38 patients with schizophrenia and 38 normal controls. Three functions involved in long-term memory – encoding, early phase of storage, retrieval – were investigated. First, non-organizable lists were compared to semantically-organizable lists in a free recall task, in order to vary encoding conditions. Superficial encoding (measured by a ‘sequence’ index) and deep encoding (measured by a categorization index) were assessed. Secondly, early storage was investigated by varying the delay between learning and recall. Lastly, cues were provided for organizable lists (semantic cues) and non-organizable lists (recognition sheet), in order to vary retrieval conditions.

Results. An analysis of variance revealed an interaction between type of list (organizable, non-organizable) and group, showing that patients used organization less than controls. A further analysis showed that deep encoding was impaired. Also, although the propensity to use superficial encoding was unimpaired, its efficiency was less. The analysis of variance revealed no interaction with delay or with either type of cue. A correlation was found between deep processing and memory performance in both groups.

Conclusions. A major deficit in encoding appeared in the patient group, with a lesser use of deep encoding and a lesser efficiency of superficial encoding. On the other hand, the early phase of storage and the retrieval function seemed unaffected. Overall memory performance appeared to be related to the depth of encoding.

Background. There is little agreement on whether the prevalence of psychiatric disorder is elevated in HIV-seropositive (HIV +) populations compared with uninfected persons. However, evaluation of this issue has been limited by difficulties of sampling, study design and failure to control for other risk factors for disorder.

Methods. Prevalence and clinical characteristics of DSM-III-R major depressive disorder (MDD), generalized anxiety disorder, adjustment disorder, and alcohol and substance abuse/dependence were evaluated in a representative sample of HIV + men attending primary care physicians' offices in a defined geographical area. Lifetime prevalence at baseline and 1-year rates during longitudinal follow-up were determined for the 113 HIV + men, as well as 57 HIV – men, via standardized interview. Multivariate analyses considered unique and combined effects of HIV serostatus and other risk factors on likelihood of disorder.

Results. Although there were no differences in lifetime rates prior to baseline, HIV + men were at greater risk for disorders during the prospective study period. For MDD, this effect was maintained even after controlling for other risk factors. Several of these other factors bore their own effects: regardless of HIV serostatus, men were susceptible to psychopathology if at baseline they were younger, had a lifetime psychiatric history, or had poor social supports or a low sense of personal mastery.

Conclusions. The risk of certain psychiatric disorders appears uniquely elevated in HIV + men. Since other factors also influence risk, interventions designed to minimize psychopathology during HIV infection should attend to both HIV-related and non-HIV-related risk factors.

Background. Although replication is the heart of science, psychiatric geneticists rarely have the opportunity to replicate findings, especially more than once.

Methods. This article reviews results from three independent family studies of schizophrenia on which one of us conducted diagnostic reviews: the Danish Adoption Study (DAS), the Iowa 500 non-500 family study (IFS), and the Roscommon Family Study (RFS). We utilized DSM-III or DSM-III-R criteria and meta-analysis techniques.

Results. The odds ratios (OR) in personally interviewed, first degree biological relatives of schizophrenic and matched control probands for schizophrenia, other non-affective psychoses (ONAP), schizotypal personality disorder (SPD), unipolar affective illness (UPAI), bipolar affective illness (BPAI), and anxiety disorders were homogeneous across studies. For alcoholism, ORs were significantly heterogeneous. Schizophrenia, SPD and ONAP strongly aggregated in relatives of schizophrenic probands with decreasing common OR estimates of 16·2, 5·0 and 4·0, respectively. The common OR for anxiety disorders was 1·1, indicating no familial co-aggregation. For UPAI and BPAI, the common ORs exceeded unity (1·3 and 1·9, respectively), although only the former was statistically significant.

Conclusions. Schizophrenia strongly aggregates in families and shares familial factors with SPD and ONAP but not anxiety disorders. The familial factors of aetiological importance for schizophrenia and affective illness may be weakly related. With the exception of alcoholism, the patterns of psychiatric disorders in relatives of schizophrenic and control probands in these three studies were sufficiently similar that, despite their methodological differences, they can probably be viewed as replications of one another.

Background. Several clinical and neuroimaging investigations support the notion that underlying brain changes may relate to depression in older patients, especially those with a later-age initial episode. However uncertainty still exists about diagnostic and pathogenic significance of structural brain abnormalities in aged depressives, in part because many studies lack all-elderly and age-similar normal comparison populations.

Methods. Brain morphology of elderly depressives (N = 30) and normal controls (N = 36) was compared by assessing magnetic resonance imaging (MRI) brain scans with qualitative criteria-based scales. Ratings included lateral and third ventricle enlargement, and cortical, medial temporal, and caudate atrophy.

Results. Significant differences between depressed and control groups were not demonstrated. Later-onset depressives had significantly more left medial temporal and left caudate atrophy than early-onset counterparts of similar age. Medial temporal atrophy significantly correlated with cognitive impairment and was not related to physical illness. Depressives with medial temporal atrophy (N = 7) were older and had later age at onset of depression than those without such changes. Cerebrovascular disease risk factors did not predict MRI abnormalities.

Conclusions. Results indicate non-specificity and lack of homogeneity of qualitatively measured structural brain changes in geriatric depression, but suggest that pathology of specific, lateralized brain regions may be implicated in some later-onset patients. The relationship between medial temporal atrophy and late-onset depression raises the possibility that such patients may suffer from as-yet undeclared Alzheimer's disease. Lack of association between cerebrovascular disease risk factors and brain changes suggests other pathophysiological contributions.

Background. Gender and cross-cultural differences in the association between somatic symptoms and emotional distress were investigated, using data from the World Health Organization Collaborative Project on Psychological Problems in General Health Care.

Methods. Data were collected at 15 centres in 14 countries around the world. At each centre, a stratified random sample of primary care attenders aged 15–65 years was assessed using, among other instruments, the 28-item General Health Questionnaire and the Composite International Diagnostic Interview-Primary Health Care Version.

Results. Females reported higher levels of somatic symptoms and emotional distress than males. A strong correlation between somatic symptoms and emotional distress was found in both sexes, with females reporting more somatic symptoms at each level of emotional distress. However, linear regression analysis showed that gender had no significant effect on level of somatic symptoms, when the effects of centre and emotional distress were controlled for. In both sexes, no specific pattern of association emerged between somatic symptom clusters and either anxiety or depression. Primary care attenders from less developed centres reported more somatic symptoms and showed greater gender differences than individuals from more developed centres, but inter-centre differences were small. Finally, gender was not a significant predictor of reason for consultation (somatic versus mental/behavioural symptoms), after controlling for levels of somatic symptoms and emotional distress as well as for centre effect.

Conclusions. These data do not support the common belief that females somatize more than males or the traditional view that somatization is a basic orientation prevailing in developing countries. Instead, somatic symptoms and emotional distress are strongly associated in primary care attenders, with few differences between the two sexes and across cultures.

Background. The DSM-IV criteria for melancholia include the clinical feature ‘distinct quality’, defined as a mood state differing from that experienced in bereavement. Both propositions – its specificity to melancholia and its definition – remain problematical.

Methods. We examine both propositions by analysing an adjective checklist completed by melancholic and non-melancholic depressed subjects, as well as by a bereaved sample. The checklist was refined by a principal components analysis to four scales – one assessing a general ‘mood’ severity or dysphoric dimension, and the other three assessing dimensions of ‘fatigue’, ‘numbness’ and ‘guilt’.

Results. If the concept of ‘distinct quality’ has validity, we would require specificity of the refined qualitative constructs to melancholic depression. The ‘numbness’ component met that requirement, but only to a degree. While bereaved subjects did differ from those with melancholic depression on a number of our refined qualitative mood domains, such differences appeared more related to lower levels of depression in the bereaved sample.

Conclusions. We argue for deleting the ‘distinct quality’ criterion from diagnostic checklists of melancholia until its definition has been improved, its utility demonstrated and its specificity to any depressive subtype established as having clinical significance.

Background. Research indicates that deluded patients ‘jump to conclusions’ on probabilistic reasoning tasks. Two experiments were carried out with patients suffering from persecutory delusions and depressed and normal controls in order to determine whether this response bias is affected by task difficulty and the meaningfulness of the materials.

Methods. Tasks were variants of those employed by Huq et al. (1988) and Garety et al. (1991). In Experiment 1, subjects judged which of two bags a sequence of coloured beads had been taken from. Difficulty was manipulated by varying the ratios of coloured beads in the bags. In Experiment 2, a neutral condition required judgements about coloured beads drawn whereas, in meaningful conditions, subjects had to judge whether personality characteristics described one of two individuals.

Results. In Experiment 1, estimates of certainty varied with task difficulty, and there was no evidence of ‘jumping to conclusions’ in the deluded group. In Experiment 2, all groups reached an initial level of certainty and reduced their estimates of certainty following disconfirmatory evidence more quickly in the meaningful conditions. Both clinical groups expressed higher certainty levels in early trials, and a greater magnitude of reduction in certainty following disconfirmatory information. These group differences were more evident in the meaningful conditions than in the neutral conditions.

Conclusions. Probabilistic reasoning is affected by task difficulty and meaningfulness of materials in both deluded and depressed subjects. Observed reasoning abnormalities were not specific to the deluded group.