This issue contains a review on child-onset bipolar disorder. Other sets of papers examine various aspects of bipolar disorder, depression and suicide, anxiety, and chronic fatigue, and four individual papers examine a variety of topics.

Background. The diagnosis of bipolar disorder in pre-pubertal populations remains difficult and often controversial. Consequently, the clinical and neuropsychological characteristics of mania in the child and adolescent years remain poorly defined. This review provides a clinical account of childhood and adolescent bipolar disorder and compares the neuropsychology and neuroanatomy of young BPD patients compared with adult BPD and childhood syndromes of attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD).

Method. Literature review based on Pubmed searches.

Results. Early- and adult-onset mania and BPD may share a common pattern of neurobiological characteristics despite developmental variations in the clinical presentation. In contrast, important distinctions are apparent between the child-onset syndromes of BPD, ADHD and CD, specifically at the neural level.

Conclusions. Disorders of affect dysregulation in childhood deserve closer neuroscientific and phenotypic scrutiny than given hitherto.

Background. Demonstrating differences between euthymic bipolar subjects and healthy controls in response to positive (happy) mood induction may help elucidate how mania evolves. This pilot study evaluates the Go task in a reward paradigm as a method for inducing a happy mood state and compares the response of euthymic bipolar subjects and healthy controls.

Method. The Sense of Hyperpositive Self Scale, the Tellegen positive and negative adjectives, the Global-Local task and a visual analogue scale for measuring positive affect were administered to 15 euthymic bipolar subjects and 19 age-and-sex-matched healthy control subjects before and after they had performed the Go task in a reward paradigm.

Results. Significant differences were found between subjects and controls on several measures at each time-point but there were no differences across the groups across time except for the visual analogue scales, where subjects had a more sustained duration in self-reported happiness compared with controls.

Conclusions. This pilot study has shown that a positive affect can be induced in bipolar subjects and controls which can be demonstrated by changes in scores on several tasks. However, only the visual analogue scales showed a significant difference between cases and controls over time. Such tests may prove valuable in furthering understanding about the evolution of manic mood states.

Background. Several studies have found an association between indicators of fetal growth and/or obstetric complications and schizophrenia but only a few studies have investigated the possible association between these factors and bipolar disorder. Furthermore, the results of these studies have been contradictory. The aim of this study was to investigate whether the risk of bipolar disorder is associated with exposure to indicators of fetal growth.

Method. A national population nested case-control study based on Danish longitudinal register databases was carried out. Conditional logistic regression was used, controlling for potential confounding factors such as parental age at birth, socio-economic indicators and psychiatric history. We identified 196 cases, and each case was time-, age- and sex-matched with 25 normal population-based controls. All cases were between the ages of 12 and 26 years at the time of diagnosis, were born between 1973 and 1983 and were admitted and diagnosed between 1987 and 1999.

Results. During the study period 1973–1983, none of the individual variables available for analyses (birthweight, birth length, gestational age and number of previous pregnancies in the mother) was associated with receiving a diagnosis of bipolar disorder.

Conclusions. None of the indicators of fetal growth under study could be identified as risk factors for bipolar disorder, suggesting that the etiologies of schizophrenia and bipolar disorder, at least in part, are different.

Background. The global burden and large diagnostic and therapeutic deficits associated with depressive disorders call for intervention programs. The aim of the Nuremberg Alliance against Depression (NAD) is to establish and to assess the effectiveness of a four-level intervention program for improving the care of patients with depression.

Method. A 2-year intervention program was performed in Nuremberg (480000 inhabitants) at four levels: training of family doctors and support through different methods; a public relations campaign informing about depression; cooperation with community facilitators (teachers, priests, local media, etc.); and support for self-help activities as well as for high-risk groups. The effects of the 2-year intervention on the number of suicidal acts (completed suicides plus suicide attempts, main outcome criterion) were evaluated with respect to a 1-year baseline and a control region (Wuerzburg, 270000 inhabitants).

Results. Compared to the control region, a reduction in frequency of suicidal acts was observed in Nuremberg during the 2-year intervention (2001 v. 2000: −19·4%; p[les ]0·082; 2002 v. 2000: −24%, p[les ]0·004). Considering suicide attempts only (secondary outcome criterion), the same effect was found (2001 v. 2000: −18·3%, p[les ]0·023; 2002 v. 2000: −26·5%, p<0·001). The reduction was most noticeable for high-risk methods (e.g. hanging, jumping, shooting). Concerning completed suicides, there were no significant differences compared to the control region.

Conclusions. The NAD appeared to be effective in reducing suicidality. It provides a concept as well as many methods that are currently being implemented in several other intervention regions in Germany and in other countries.

Background. Few studies have focused on factors that uniquely distinguish suicide attempters from suicide ideators. This study assesses prevalence of suicide attempts among suicide ideators within a community sample; explores demographics, employment status, mental and physical health conditions, personality, life stresses and social environment as factors that may distinguish these groups; examines effects of age and gender upon suicide attempts and associated factors; and investigates the increase in suicide attempts when multiple factors related to this behaviour are present.

Method. Data were drawn from the PATH Through Life Project, a community survey of 7485 people in Canberra, Australia. A subsample of 522 suicide ideators were used for this study.

Results. Logistic regression was used to identify factors associated with suicide attempts. Physical medical conditions (OR 1·95) and negative interactions with friends (OR 1·20) were associated with an increased likelihood of suicide attempts among suicide ideators. Age and gender interaction effects for suicide attempts were found involving physical medical condition and mastery among men (OR 3·78 and 0·83 respectively) and not being employed for those aged 40–44 years (OR 8·94). A cumulative effect was found when multiple factors associated with suicide attempts were present, and the probability of an attempt was significantly elevated.

Conclusions. Factors distinguishing those who attempt suicide from suicide ideators involve being unemployed, physical ill health and relationship difficulties. Contrary to expectation, this study found that ideators and attempters experience comparable levels of depression and anxiety.

Background. Recently accumulated evidence has demonstrated that bright-light therapy in combination with antidepressants is effective in patients with non-seasonal major depression. Whether bright light has a sustained effect after discontinuation is, however, poorly investigated.

Method. In this double-blind randomized study we report the results from a 4-week follow-up period in patients with major non-seasonal depression who had been treated for 5 weeks with sertraline combined with bright-light therapy or sertraline combined with dim-light therapy. At the beginning of the follow-up period the light therapy was stopped while sertraline treatment continued for 4 weeks.

Results. Depression scores decreased substantially in both groups, resulting in high response and remission rates in both groups after 9 weeks of treatment. The difference in depression scores at week 5, favouring the bright-light-treated group, disappeared gradually in the 4-week follow-up period, resulting in similar end-point scores.

Conclusions. Bright light did not have a sustained effect after discontinuation. The offset of effect was complete after 4 weeks.

Background. Bright light and high-density negative air ion exposure are efficacious for winter and non-seasonal depression compared with a low-density negative ion placebo. Similarly, auditory stimuli improve mood in clinical populations. This study compared the short-term effects of bright light, an auditory stimulus, and high- and low-density negative ions on mood and alertness in mildly depressed and non-depressed adults.

Method. One hundred and eighteen subjects, 69 women and 49 men (mean age±S.D., 19·4±1·7 years), participated once across the year. Subjects were randomly assigned to one of four conditions: bright light (10000 lux; n=29), auditory stimuli (60 dB; n=30), or high-density (4·5×1014 ions/s flow rate; n=29) or low-density (1·7×1011 ions/s; n=30; placebo control) negative ions. Exposure was for 30 min on three consecutive evenings between 1900 and 2100 hours. Mood and alertness assessments, using standardized scales, occurred before, and 15 and 30 min during exposure. The Beck Depression Inventory classified subjects as depressed ([ges ]10; n=35) or non-depressed (<10; n=83).

Results. The three active stimuli, but not the low-density placebo, reduced depression, total mood disturbance (a global affect measure) and/or anger within 15–30 min. Neither testing season nor degree of depressive symptoms affected response to stimuli.

Conclusions. The auditory stimulus, bright light and high-density ions all produced rapid mood changes – with small to medium effect sizes – in depressed and non-depressed subjects, compared with the low-density placebo, despite equivalent pre-study expectations. Thus, these stimuli improve mood acutely in a student sample, including a subset with depressive symptoms.

Background. The role of physical illness and life problems in contributing to suicide in older people is potentially important with regard to suicide prevention.

Method. The aim of the study was to determine the life problems other than psychiatric illness contributing to suicide in older people. Semi-structured psychological autopsy interviews, covering life problems and physical illness prior to death, were conducted with informants for 100 people aged 60 years old and over who died through suicide in five English counties. Interviews were completed with informants for 54 age- and sex-matched control subjects who died through natural causes.

Results. The three most frequent life problems associated with suicide were physical illness, interpersonal problems, and bereavement. Physical health problems were present in 82% and felt to be contributory to death in 62%. Pain, breathlessness and functional limitation were the most frequent symptoms. Interpersonal problems were present in 55% of the sample and contributory in 31%. The corresponding figures for bereavement-related problems were 47% and 25%. In the case-control analysis, the problems found to be risk factors for suicide were problems related to a bereavement over 1 year before death (OR 3·5, 95% CI 1·2–10·6), and problems with accommodation (OR 5·0, 95% CI 1·1–22·8), finances (p=0·01), and retirement (p=0·02).

Conclusion. Physical illness, interpersonal problems and bereavement are commonly associated with suicide in older people, but financial, accommodation, retirement and long- term bereavement-related problems may be more specific risk factors.

Background. A recent meta-analysis provides evidence that generalized anxiety disorder (GAD) is familial. However, two of the key studies relied on subjects who were self-selected or recruited from the clinic setting, thereby limiting generalizability.

Method. We conducted a family study of GAD in which probands and controls came from a community sample originally enrolled in a prevalence study in Edmonton, Canada. One hundred and sixty probands, 764 controls and 2386 first-degree relatives (FDRs) were interviewed using the Diagnostic Interview Schedule (DIS); lifetime diagnoses were made according to DSM-III criteria without exclusions. Logistic regression analysis was performed with GAD (in a proband) as the ‘exposure’, and GAD in an FDR as the ‘outcome’. Several analytic strategies were used to control for potential confounding by major depressive disorder (MDD) and several anxiety disorders (panic disorder, phobic disorders, obsessive–compulsive disorder, and post-traumatic stress disorder).

Results. The odds ratios for the association between GAD in a proband and GAD in an FDR were in the range 1·4–1·8 when the entire FDR sample was analysed, and in the range 2·1–2·8 when we restricted to FDRs who were children of probands and controls.

Conclusion. In the community setting, GAD exhibits mild to moderate familial aggregation.

Background. This study questions the 6-month duration criterion for generalized anxiety disorder (GAD) used in DSM-III-R and DSM-IV.

Method. In adults from age 20/21 to 40/41 in the prospective Zurich Cohort Study, four groups of generalized anxiety syndromes defined by varying duration (2 weeks, 1 month, 3 months and 6 months) were compared.

Results. Applying DSM-III (1979–1999) and DSM-III-R (1986–1999) criteria, there were no significant differences between the four groups in terms of family history of anxiety, work impairment, distress, treatment rates or co-morbidity with major depressive episodes (MDEs), bipolar disorder or suicide attempts. Only social impairment related to the length of episodes. The 6-month criterion of DSM-III-R and DSM-IV GAD would preclude this diagnosis in about half of the subjects treated for generalized anxiety syndromes.

Conclusions. In this epidemiological sample, the 6-month duration criterion for GAD could not be confirmed as clinically meaningful. GAD syndromes of varying duration form a continuum with comparable clinical relevance.

Background. Persistent fatigue is strongly associated with functional status and can lead to absenteeism and work disability. Despite several prognostic studies on chronic fatigue, little attention has been paid to occupational outcomes.

Method. A total of 127 fatigued employees on sick leave were followed-up after 4 years to determine long-term predictors of work disability, fatigue caseness and chronic fatigue syndrome (CFS)-like caseness. Measures included fatigue, physical functioning, illness attributions, psychological problems and emotional exhaustion.

Results. Thirty-three participants (26%) were receiving work disability benefits at the 4-year follow-up. Older age and lower levels of physical functioning predicted work disability. Weaker psychological attributions and lower levels of physical functioning were predictors of fatigue caseness. CFS-like caseness was predicted by female gender and lower levels of physical functioning. Self-reported physical functioning remained a strong and statistically significant determinant of work disability [odds ratio (OR) 0·45, 95% confidence interval (CI) 0·24–0·87] and CFS-like caseness (OR 0·20, 95% CI 0·09–0·43) after controlling for confounders.

Conclusions. This study suggests that physical functioning plays an important role in the persistence of fatigue complaints and work disability in employees on sick leave. The course of fatigue is a complex process, and exploring temporal relationships between fatigue, functional status and work status in future research could provide valuable information for the improvement of fatigue management.

Background. Comprehensive studies of mortality among patients with chronic fatigue (CF) and chronic fatigue syndrome (CFS) have not been published, but several sources suggest that CFS is associated with an elevated risk for suicide.

Method. Data on 1201 chronically fatigued patients followed in a university-affiliated tertiary-care clinic for up to 14 years were submitted to the Center for Disease Control and Prevention (CDC) National Death Index (NDI) to evaluate all-cause and suicide-caused death rates against standardized mortality rates (SMRs). We used Life Table Analysis to examine the influence of sex and diagnoses of CFS and depression.

Results. All-cause mortality in chronically fatigued patients was no higher than expected, but suicide-caused death rates were more than eight times higher than in the US general population. The significant elevation in the SMR of suicide was restricted to those who did not meet criteria for CFS [SMRCF=14·2, 95% confidence interval (CI) 5·7–29·3 versus SMRCFS=3·6, 95% CI 0·4–12·9]. Among chronically fatigued patients who did not meet CFS criteria, those with a lifetime history of major depression (MD) had higher suicide-caused death rates than among their non-depressed counterparts (SMRMD=19·1, 95% CI 7·0–41·5 versus SMRNMD=5·6, 95% CI 0·1–31·4), although the difference was not significant.

Conclusions. CFS does not appear to be associated with increased all-cause mortality or suicide rates. Clinicians, however, should carefully evaluate patients with CF for depression and suicidality.

Background. Jacobs and Bovasso reported (Psychological Medicine 2000, 30, 669–678) that maternal death in childhood and chronic severe depression in adulthood were associated with subsequent breast cancer. We have examined the effects of parental loss in childhood and psychiatric disorder in adult life on breast cancer risk using a national birth cohort study.

Method. Eighty-three cases of breast cancer were diagnosed in a study of 2253 women followed from birth to age 59 years. Cox proportional hazards models were used to test whether breast cancer rates were higher in women who experienced parental death and divorce before age 16, psychiatric disorders between 15 and 32 years, symptoms of anxiety and depression at 36 years, or use of antidepressant medication at 31 or 36 years than in women who did not have these experiences.

Results. There was no overall association between parental death, parental divorce or psychiatric disorder and the incidence of breast cancer. There was some evidence that women with more severe psychiatric disorders between the ages of 15 and 32 years were more likely to develop breast cancer early. The interaction between parental divorce and severe psychiatric disorder was non-significant (p=0·1); however, the group who experienced both these events had an increased breast cancer risk compared with those who experienced neither [hazard ratio (HR) 2·64, 95% confidence interval (CI) 1·13–6·19].

Conclusions. Our study does not provide strong support for the hypothesis that early loss or adult psychiatric disorders are associated with breast cancer. A meta-analysis is needed that uses data from all available cohort studies and investigates possible interactive effects on breast cancer risk.

Background. Evidence for the effects of marital status and marital status change on physical health is equivocal.

Method. Structural equation models examined whether marital status predicted physical health. Six groups were examined simultaneously: married (M); widowed (W); divorced (D); never married (NM); newly widowed (NW); and newly divorced (ND). There were four annual measures (T1–T4). Both NW and ND were married at T1, but had lost their partners by T2. Four physical health variables were examined: Problems, Limitations, Service use, and Self-rated health (SRH). Age and gender were included.

Results. Previous health predicted future for all measures and for all groups. However, the specific strengths and time-courses varied between marital status groups and between health measures. The most marked patterns were associated with marital status change. Service use was influenced most strongly by NW, whilst Limitations was influenced by ND. Problems distinguished NW and ND from stable marital status groups but also from each other. SRH was influenced by W and not by recent marital status change. The effects of age and gender were modest and restricted to specific health variables and specific marital statuses.

Conclusions. The results demonstrate that marital status and marital status change, in particular, influence health longitudinally. The impact of a change to divorced or to widowed status is not the same. No two health variables responded in the same way, suggesting that marital status has a differential effect on health.

Background. Oculomotor studies have found saccadic abnormalities in obsessive–compulsive disorder (OCD), lending support for models postulating a central role for inhibition in OCD. Saccadic abnormalities in OCD may also be potential candidates for a biological marker, important for more endophenotype-oriented research. Saccadic abnormalities have not been examined in psychotropic-naive patients with OCD without co-morbidity.

Method. We compared the error rates and latencies of 14 carefully selected adult psychotropic-naive patients with OCD with no co-morbid diagnosis and 14 pairwise matched healthy controls on a fixation task, on a prosaccade task and on an antisaccade task.

Results. Patients with OCD showed normal error rates on all tasks, but latencies on the antisaccade task were significantly increased.

Conclusions. Our results indicate that patients with OCD have no gross impairment of oculomotor inhibitory capacities, but may have a disturbed capacity to deliberately initiate a saccade to an imagined target.

Background. Abnormal perceptions of food and shape underpin the cognitive behavioural model of eating disorders (EDs). The aim of this study was to investigate motivational processing of disorder-specific and standard emotional cues in anorexia (AN) and bulimia nervosa (BN) using startle eyeblink modulation (SEM). SEM was used because it is sensitive to motivational states of approach (appetitive response) and withdrawal (aversive response), which are independent of conscious intentional control.

Method. Acoustically elicited SEM and subjective anxiety ratings were measured in 30 female patients with an ED (n=15 AN, n=15 BN) and 30 female control subjects while they viewed ED-relevant stimuli (food, female bodies) and standardized emotional pictures.

Results. BN subjects showed an appetitive response (startle inhibition) to food relative to neutral cues that differed significantly from AN subjects. By contrast, self-reports indicated significantly increased anxiety related to food cues across both ED groups. To female body picture (relative to neutral) cues, no significant between-group differences were found for SEM. ED subjects unexpectedly showed an aversive response (startle potentiation) to positive cues, in contrast to controls, who showed the established startle attenuation.

Conclusions. These preliminary results suggest that BN patients demonstrated an exaggerated appetitive response to food but not to standardized positive cues, whereas SEM in AN patients points to a generalized failure to activate the appetitive motivational system. Differences in motivational salience to food cues are in line with distinctions between AN and BN in eating behaviour and food consumption and support differential treatment requirements.

In the interest of clarity the authors wish to amend the title of the above paper to read as follows:

The lack of sustained effect of bright light, after discontinuation, in non-seasonal major depression