This issue features groups of papers on life stress, neuropsychology of psychiatric disorders, substance use disorders.

It is more than 40 years since a burst of studies in the late 1960s started what has become a substantial corpus of work, establishing the role of life events in psychiatric disorders (Brown & Birley, 1968; Paykel et al. 1969). Findings depended on advances in methodology. First, came development of a life events questionnaire and a scaling of their stress magnitude (Holmes & Rahe, 1967); then, replacement by more reliable and valid interview methods and better ways of distinguishing major and minor events (Brown & Harris, 1978; Paykel, 1996).

Background. Studies that assess the rates of psychotic patients who fail to adhere to treatment programmes have generated heterogeneous results, with estimates ranging from 24 to 90%. This paper presents findings from a systematic review on adherence to treatment by patients with psychosis. Its purpose is to provide an overall estimate of treatment non-adherence in community psychiatric services, and to analyse and study patient characteristics explaining the between-study heterogeneity in rates of non-adherence.

Method. A systematic review of published studies that report rates of non-adherence with medication and scheduled appointments by psychotic patients in community settings has been undertaken.

Results. A total of 103 studies were included in this systematic review. Eighty-six of these studies were suitable for data re-analysis. The overall weighted mean rate of non-adherence, calculated in a sample of 23796 patients, was 25·78%. A linear regression analysis of non-adherence rates on background characteristics showed that sample size was negatively associated with non-adherence rates, while first-contact cases and low-adherence cases, in comparison with ongoing cases, were associated with higher non-adherence rates. Factors associated with poor compliance included: lack of insight; positive symptoms; younger age; male gender; history of substance abuse; unemployment; and low social functioning.

Conclusions. Approximately one in four patients with psychosis fails to adhere with treatment programmes. Preventive evidence-based clinical interventions should be routinely implemented in community settings to reduce patient non-adherence.

Background. High rates of depression associated with childbirth have been reported in many parts of the developing world. However, the prevalence and associations of antenatal and post-natal depression in the rural population remain unknown. Disability associated with depression and its impact on infant health and development could have important public health implications for many developing countries where large proportions of the population are rural.

Method. All women living in southern Kahuta, Pakistan, in their third trimester of pregnancy were interviewed at 6 weeks before delivery (N=632) and again at 10–12 weeks after delivery (N=541), using WHO Schedule for Clinical Assessment in Neuropsychiatry (SCAN), Personal Information Questionnaire (PIQ) and Brief Disability Questionnaire (BDQ).

Results. The point prevalence of ICD-10 depressive disorder was 25% in the antenatal period and 28% in the post-natal period. Depressed mothers were significantly more disabled, had more threatening life events, and poorer social and family support than non-depressed mothers. Vulnerable mothers were more likely to be depressed during pregnancy, rather than have an onset in the post-natal period.

Conclusion. Over one-quarter of mothers in a rural sub-district of Pakistan suffer from depression shortly before and after childbirth. Rapidly changing traditional family structures and practices may be increasing the risk of depression in many women. Recognizing and treating depression should be initiated during the antenatal, rather than post-natal period.

Background. It has been proposed that adverse life events involving loss or humiliation are particularly potent in provoking depressive episodes. We have also previously suggested that experiencing high rates of non-severe events may play a role in the development of resilience to the impact of severe threatening events when these occur.

Method. The Life Events and Difficulties Schedule (LEDS) (Brown & Harris, 1978) was used to record the life events experienced by 108 depressed probands and their nearest aged siblings as well as 105 healthy control subjects and their nearest aged siblings. All subjects were interviewed using the Schedule for the Clinical Assessment of Neuropsychiatry (SCAN) (Wing et al. 1990).

Results. Depressed probands were significantly more likely to have experienced a severe threatening event, loss event, or a humiliation event compared to the other subjects. These events also made up a greater proportion of the total number of events, in the depressed probands. Humiliation events were more frequent in depressed men than depressed women. There were no differences between the four groups for experiencing a non-severe event, although depressed probands also experienced more difficulties than the other three groups. Fifty-six healthy subjects who had not become depressed despite having experienced at least one severe and threatening event, had significantly more non-severe events, than the 116 subjects who were depressed at the time of interview.

Conclusions. The findings support the hypothesis that loss and humiliation events are particularly depressogenic. Experiencing a high rate of non-severe events may be associated with resilience to becoming depressed in the face of a threatening event.

Background. It is unclear whether there is an interaction of ageing on the association between major life events and onset of depression.

Method. This was a population-based nested case–control study with linkage of the Danish Psychiatric Central Research Register and the Integrated Database for Longitudinal Labour Market Research. The study includes data on all admissions at psychiatric wards in Denmark from 1981 to 1998 and data on sociodemographic variables and death/suicide of first-degree relatives.

Results. A total of 13006 patients who received a diagnosis of depression at the first ever admission at a psychiatric ward and a gender- and age-matched control group of 260108 subjects were identified. A recent divorce and recent unemployment and suicide of a relative (mother, father, sibling, child, spouse) were associated with increased risk of being admitted for the first time ever at a psychiatric ward with a diagnosis of depression whereas death of a relative by causes other than suicide years had no significant effect. In general, no interaction was found with age with any of the variables, totally, or for men or women, separately.

Conclusions. The susceptibility to major life stressors does not seem to change throughout life.

Background. The role of stress in the onset of chronic fatigue syndrome is unclear. Our objectives in this study were first, to determine the relation between the onset of chronic fatigue syndrome and stressful life events and difficulties. Secondly, we examined the role of a particular type of problem, dilemmas, in the onset of chronic fatigue syndrome.

Method. We used a case–control design with 64 consecutive referrals from an Infectious Diseases/Liaison Psychiatry Fatigue clinic and 64 age- and sex-matched controls from a general practice population control group in Leeds. We had two main outcome measures; the odds ratios of the risk of developing chronic fatigue syndrome after experiencing a severe life event, severe difficulties or both in the year and 3 months preceding onset; and the proportion of subjects in each group who experienced a dilemma prior to onset.

Results. Patients with chronic fatigue syndrome were more likely to experience severe events and difficulties in the 3 months (OR=9, 95% CI 3·2 to 25·1) and year (OR=4·3, 95% CI 1·8 to 10·2) prior to onset of their illness than population controls. In the 3 months prior to onset 19 of the 64 patients (30%) experienced a dilemma compared to none of the controls.

Conclusions. Chronic fatigue syndrome is associated with stressful events and difficulties prior to onset. Those events and difficulties characterized as being dilemmas seem to be particularly important.

Background. While psychiatric epidemiology often focuses on the causal relationship between environmental adversity and the individual (e.g. environment to person), individuals probably make important contributions to the quality of their environments (person to environment).

Method. In a population based sample of >7000 male and female adult twins, we examined the relationship between the personality trait of neuroticism (N) and the occurrence of stressful life events (SLEs) and the quality of interpersonal relationships (IPR). We compared the magnitude of the prediction of twin 1's self-reported SLEs and IPR from: (i) twin 1's self-reported N; (ii) twin 2's report of twin 1's N; and (iii) twin 2's report of twin 2's N in monozygotic pairs.

Results. In our entire sample, self-report N significantly predicted the occurrence of most SLEs and all dimensions of IPR. Using the co-twin's report of N produced associations that were of the same magnitude for SLEs and modestly weaker for IPR. In monozygotic pairs, the level of N in one twin predicted SLEs and IPR in the co-twin at levels similar to those found for the co-twin's report of N. Repeating these analyses with a prospective subsample produced similar results.

Conclusion. An individual's personality in adulthood plays a significant role in influencing exposure to some forms of environmental adversity and this association is not the result of reporting bias. Furthermore, this relationship is largely mediated by a common set of familial factors that predispose both to a ‘difficult’ temperament and to environmental adversity. Developmental models of psychiatric illness should adopt an interactionist view of individuals and their environment (person and environment).

Background. Adverse life events prior to episodes of depression are assumed to play a causal role. Earlier studies have, however, not adequately controlled for the potential confounding effects of previous depression.

Method. A two-phase study was nested within a six-wave population based cohort study of 1947 adolescents. Interviews at two assessment phases with the CIS-R and CIDI were used to generate ICD-10 diagnoses of depressive disorder. Life events with longer-term contextual threat were reported for the 6 months before first diagnosis and categorized on the basis of participant appraisal as negative and neutral/positive in effects. Previous depressive and anxiety symptoms were measured 6 months earlier.

Results. Pre-existing depressive and anxiety symptoms predicted later events, increasing three-fold the risks for both neutral/positive and negative events in females and increased seven-fold the risk of negative events in males. Life events in turn predicted the onset of depressive disorder independently of previous symptoms. Single negative events held an over five-fold elevated risk and multiple events an almost eight-fold higher risk. Personal threat and loss were associated with disorder in females but not males.

Conclusions. The findings are consistent with a causal role for life events in early episodes of depression. The association also reflects a reciprocal relationship in which earlier symptoms predict later events, perhaps as a result of an individual's attempts to change unfavourable social circumstances.

Background. Cross-sectional findings in community surveys of adults suggest that adolescent anxiety disorders are strong predictors of the subsequent onset of alcohol use, abuse and dependence. However, prospective data that follow a sample of adolescents into adulthood are needed to confirm these associations.

Method. Baseline and 4-year follow-up data from the EDSP-Study, a prospective community survey of 3021 (2548 at follow-up) adolescents and young adults aged 14 to 24 years at baseline carried out in Munich, were used. DSM-IV anxiety disorders, alcohol use and alcohol use disorders were assessed with the Munich-Composite-International-Diagnostic-Interview (M-CIDI). Multiple logistic regression analysis, controlling for age, gender, other mental disorders, substance use disorders and antisocial behaviour was used to study the associations of baseline anxiety disorders with the subsequent onset and course of alcohol use and alcohol disorders.

Results. Baseline social phobia significantly predicts the onsets of regular use and hazardous use and the persistence of dependence. Panic attacks significantly predict the onsets of hazardous use and abuse as well as the persistence of combined abuse/dependence. Panic disorder significantly predicts the persistence of combined abuse/dependence. Other anxiety disorders do not significantly predict any of the outcomes.

Conclusions. Panic and social phobia are predictors of subsequent alcohol problems among adolescents and young adults. Further studies are needed to investigate the underlying mechanisms and the potential value of targeted early treatment of primary panic and social phobia to prevent secondary alcohol use disorders.

Background. Older adults are the main recipients of repeat prescriptions for benzodiazepine (BZD) hypnotics. BZDs can impair cognitive function and may not aid sleep when taken continuously for years. This study therefore aimed to determine if withdrawing from BZDs leads to changes in patients' cognitive function, quality of life, mood and sleep.

Method. One hundred and ninety-two long-term users of BZD hypnotics, aged [ges ]65 years, were identified in 25 general practices. One hundred and four who wished to withdraw were randomly allocated to one of two groups under double-blind, placebo controlled conditions: group A's BZD dose was tapered from week 1 of the trial; group B were given their usual dose for 12 weeks and then it was tapered. An additional group (C) of 35 patients who did not wish to withdraw from BZDs participated as ‘continuers’. All patients were assessed at 0, 12 and 24 weeks and 50% were re-assessed at 52 weeks.

Results. Sixty per cent of patients had taken BZDs continuously for >10 years; 27% for >20 years. Of all patients beginning the trial, 80% had successfully withdrawn 6 months later. There was little difference between groups A and B, but these groups differed from continuers (C) in that the performance of the withdrawers on several cognitive/psychomotor tasks showed relative improvements at 24 or 52 weeks. Withdrawers and continuers did not differ in sleep or BZD withdrawal symptoms.

Conclusions. These results have clear implications for clinical practice. Withdrawal from BZDs produces some subtle cognitive advantages for older people, yet little in the way of withdrawal symptoms or emergent sleep difficulties. These findings also suggest that, taken long-term, BZDs do not aid sleep.

Background. Working memory has been identified as a core cognitive deficit in schizophrenia that is associated with negative symptoms, but it is unclear whether it is impaired prior to onset of psychosis in symptomatic patients.

Method. Thirty-eight young people at ultra high-risk (UHR) of developing psychosis (of whom nine later became psychotic) were compared with 49 healthy controls on tests of spatial working memory (SWM) and delayed matching-to-sample (DMTS).

Results. Both SWM and DMTS performance was significantly poorer in the UHR groups. Those who later became psychotic generally performed more poorly than those who did not, although this did not reach significance for any measure. A significant association between SWM errors and negative symptoms was seen in the later-psychotic group only (P=0·02).

Conclusions. Spatial working memory abilities are impaired in those at high-risk for psychosis. The relationship between working memory and negative symptoms may be useful as a predictive tool.

Background. The ability to encode time cues underlies many cognitive processes. In the light of schizophrenic patients' compromised cognitive abilities in a variety of domains, it is noteworthy that there are numerous reports of these patients displaying impaired timing abilities. However, the timing intervals that patients have been evaluated on in prior studies vary considerably in magnitude (e.g. 1 s, 1 min, 1 h etc.).

Method. In order to obviate differences in abilities in chronometric counting and place minimal demands on cognitive processing, we chose tasks that involve making judgements about brief durations of time (<1 s).

Results. On a temporal generalization task, patients were less accurate than controls at recognizing a standard duration. The performance of patients was also significantly different from controls on a temporal bisection task, in which participants categorized durations as short or long. Although time estimation may be closely intertwined with working memory, patients' working memory as measured by the digit span task did not correlate significantly with their performance on the duration judgement tasks. Moreover, lowered intelligence scores could not completely account for the findings.

Conclusions. We take these results to suggest that patients with schizophrenia are less accurate at estimating brief time periods. These deficits may reflect dysfunction of biopsychological timing processes.

Background. Previous research has yielded conflicting evidence regarding the long-term cognitive outcome of depression. Some studies have found evidence for a higher incidence of subsequent cognitive impairment or dementia, while others have refuted this.

Method. Depression, neuropsychological performance, functional ability and clinical variables were assessed in a sample of patients who had been hospitalized for depression 25 years previously.

Results. Data were available on 71 depressed patients (10 of whom were deceased) and 50 surgical controls. No significant differences were found between depressed subjects and controls on any neuropsychological measure. Ten depressed patients but no controls were found to have dementia at follow-up (continuity corrected χ2=5·93, P<0·01). Presence of dementia was predicted by older age at baseline. Vascular dementia was the most common type.

Conclusions. We conclude that this study did not find evidence that early onset depression is a risk factor for Alzheimer's disease, but that for a small subgroup there appears to be a link with vascular dementia. Several plausible explanations for this link, such as lifestyle factors, require further investigation.

Background. The dorsolateral prefrontal cortex (DLPFC) is involved in the pathophysiology of major depression. In particular, metabolic (functional hypometabolism) and structural alterations have been described. In this study metabolic changes within the DLPFC of severely depressed patients before and after electroconvulsive therapy (ECT) were evaluated by proton STEAM spectroscopy (1H-MRS).

Method. Twelve severely depressed patients with a diagnosis of major depressive episode, unipolar with melancholic features (DSM-IV), were enrolled, and the left dorsolateral prefrontal cortex (DLPFC) was investigated before and after unilateral ECT by 1H-MRS. Three of the four non-responding patients were remeasured a third time after a combined ECT/antidepressant pharmacotherapy. The results were compared with 12 age- and gender-matched controls.

Results. In depressed patients reduced glutamate/glutamine (Glx) levels were measured pre-ECT; Glx concentrations correlated negatively with severity of depression. After successful treatment, Glx increased significantly and levels no longer differed from those of age-matched controls.

Conclusions. Our results indicate that major depressive disorder is accompanied by state-dependent metabolic alterations, especially in glutamate/glutamine metabolism, which can be reversed by successful ECT.

Background. This paper examines the emergence of ‘moral treatment’ in British psychiatry.

Method. Re-examining a range of largely well-known sources, this article begins by outlining the social and intellectual shifts entailed by the secularization of madness at around 1660. The boundaries of various schools of psychiatric treatment are distinguished according to: (a) how much moral autonomy they accord the insane patient; and (b) whether they promote ‘body’ or ‘mind’ first (are ‘somatopsychic’ or ‘psychosomatic’). I have also incorporated newly-discovered material that proves the existence of ‘classical moral treatment’, or therapeutic argumentation.

Results. The paper outlines four distinct models of psychiatric treatment: ‘classical moral treatment’; the ‘pious fraud’; ‘charismatic stewardship’; and ‘moral treatment’. Neither the ‘pious fraud’ nor ‘charismatic stewardship’ allowed that the patient was morally autonomous – rather, lunatics were stereotyped as animals. After the 1780s, some psychiatrists began practising in ways that understood the patient as being capable of some rationality. But none of these practitioners saw ‘moral’ therapies to be independent of the body's workings – they used: (a) psychological methods to ease the administration of physic; and/or (b) psychological and medical remedies interchangeably. The Tukes, who developed the famous asylum ‘The Retreat’ at York, were the first to find successful ways to make psychological means predominate in therapy.

Conclusion. The Tukes of York are reinstalled in their position as founders of moral treatment as a therapy aimed at the autonomous human mind.

Background. Psychiatric co-morbidity is thought to be an important problem in suicide, but it has been little investigated. This study aims to investigate patterns of co-morbidity in a group of male suicide completers.

Method. One hundred and fifteen male suicide completers from the Greater Montreal Area and 82 matched community controls were assessed using proxy-based diagnostic interviews. Patterns of co-morbidity were investigated using latent class analysis.

Results. Three subgroups of male suicide completers were identified (L2=171·62, df=2012, P<0·05), they differed significantly in the amount of co-morbidity (Kruskal–Wallis χ2=71·227, df=2, P<0·000) and exhibited different diagnostic profiles. Co-morbidity was particularly found in subjects with disorders characterized by impulsive and impulsive–aggressive traits, whereas subjects without those traits had levels of co-morbidity which were not significantly different from those of controls (χ2=8·17, df=4, P=0·086).

Conclusions. Suicide completers can be divided into at least three subgroups according to co-morbidity: a low co-morbidity group, a substance-dependent group and a group exhibiting childhood onset of psychopathology.

Background. There are numerous reports of personality disorder pathology in different eating disorders. However, few studies have directly compared personality pathology in bulimia nervosa, binge eating disorder and obesity. The present study examines group differences in DSM-IV personality pathology, considering the potential utility of understanding personality disorders in terms of diagnosis and dimensional scores.

Method. Eating disorder diagnoses were established using the Eating Disorder Examination interview. Thirty-five bulimia nervosa patients, 15 binge eating disorder patients and 37 obese patients were assessed and compared on the International Personality Disorder Examination using categorical and dimensional personality disorder scores.

Results. For most personality disorders, there was a dichotomy of binge eaters versus non-binge eaters. In contrast, there was a continuum of severity in borderline personality disorder pathology between the groups. The dimensional system of measurement of personality pathology allowed for clearer differentiation between the groups.

Conclusion. The study strongly indicates that personality disorder difficulties are present in patients who binge eat, while obese patients who do not binge eat display significantly less personality disorder pathology. Assessment of bulimia nervosa, binge eating disorder and obesity needs to address personality disorders and pathology. Dimensional markers of personality pathology can be used to supplement categorical diagnoses, providing information about the traits that underlie diagnosis.

Background. Family studies have suggested that eating disorders and mood disorders may coaggregate in families. To study further this question, data from a family interview study of probands with and without major depressive disorder was examined.

Method. A bivariate proband predictive logistic regression model was applied to data from a family interview study, conducted in Innsbruck, Austria, of probands with (N=64) and without (N=58) major depressive disorder, together with 330 of their first-degree relatives.

Results. The estimated odds ratio (OR) for the familial aggregation of eating disorders (anorexia nervosa, bulimia nervosa and binge-eating disorder) was 7·0 (95% CI 1·4, 28; P=0·006); the OR for the familial aggregation of mood disorders (major depression and bipolar disorder) was 2·2 (0·92, 5·4; P=0·076); and for the familial coaggregation of eating disorders with mood disorders the OR was 2·2 (1·1, 4·6; P=0·035).

Conclusions. The familial coaggregation of eating disorders with mood disorders was significant and of the same magnitude as the aggregation of mood disorders alone – suggesting that eating disorders and mood disorders have common familial causal factors.