This issue contains three reviews, one on SSRI use in late pregnancy, one on dimensional approaches to psychiatric diagnoses, and one on resource utilization in the short-term management of deliberate self-harm (DSH). Other sets of papers examine various aspects of substance use and dependence, depression, and suicide, and two individual papers examine further topics.

This issue is my last as editor of Psychological Medicine. It is time to wrap up and to say thank you.

Recent pharmaceutical company and regulatory body circulars warning against the use of selective serotonin reuptake inhibitors (SSRIs) in late pregnancy have left clinicians in somewhat of a quandary as to how to manage their more severely depressed patients in pregnancy. Conversely, up to 75% of depressed women ceasing their antidepressants periconceptually will relapse. Studies reporting on adverse neonatal outcomes following exposure to SSRIs in the latter half of pregnancy suggest that the fetus is exposed to significant concentrations of these medications during this time. Adverse neonatal effects affecting the respiratory, gastrointestinal and neurological systems are, however, predominantly mild and self-limiting. One small retrospective case study suggests that SSRI exposure in the latter half of pregnancy may be associated with an increased risk of persistent pulmonary hypertension of the neonate (PPHN), however, the absolute risk of developing PPHN remains very small and these findings will require replication with a prospective study. While the studies to date suggest the need to closely monitor SSRI-exposed neonates in the immediate postnatal period, preferably with a neonatal withdrawal scale and access to neonatology services, there is currently no clear argument for women to be weaned off their SSRI in late pregnancy. The decision to use SSRIs at this time will have to be made on a case-by-case basis in close consultation with the mother and her partner.

Background. It is our contention that both categorical and dimensional approaches to diagnosis are important for clinical work and research alike, and that each approach has its drawbacks and advantages. As the processes toward developing DSM-V and ICD-11 progress, we suggest that another exclusively categorical revision of psychiatric taxonomies will no longer be sufficient and that adding a dimensional component is a necessary step if these taxonomies are to continue serving the future clinical and research needs of psychiatry as they have so effectively done in the past.

Method. We begin the paper with a review of terminology related to categories and dimensions and briefly review literature on advantages and disadvantages of both approaches.

Results. A review of relevant literature supports both the need for and feasibility of augmenting traditional categorical diagnoses with dimensional information.

Conclusion. We conclude with a proposal for preserving traditional categorical diagnostic definitions, but adding a dimensional component that would be reflective of and directly referable back to the categorical definitions. We also offer a specific proposal for adding a dimensional component to official taxonomies such as the DSM and the ICD in a way that fully preserves the traditional categorical approach.

Background. Deliberate self-harm (DSH) is a significant public health problem, representing a major burden in terms of morbidity to the individual and health-service utilization. While clinical guidelines suggest good practice for the short-term hospital management of DSH, there remains considerable variability in the way that services are provided.

Method. A systematic review of the literature was undertaken to examine the current evidence on hospital resource use and costs involved in the short-term hospital management of adults following DSH and to elucidate the factors that influence these differences, in terms of clinical characteristics and service provision.

Results. Twenty-one papers reporting on 17 studies met the inclusion criteria for review. Clinical characteristics associated with an increase in resource use included overdose with tricyclic antidepressants (TCAs) compared with selective serotonin re-uptake inhibitors (SSRIs) (weighted ratio 2·6[ratio ]1) and co-ingestion of alcohol with SSRIs. Variations in service provision, including medical admissions policy and provision of a specialist liaison service, affected resource utilization independently of the clinical needs of patients.

Conclusions. Overdoses of TCAs incur substantially greater hospital costs than overdoses of SSRIs. Variations in the medical seriousness of DSH, and in the structure of service provision, affect the resources used in its short-term hospital management, with little evidence about the impact these differences have on clinical outcome. Research is needed to evaluate the impact of different styles of service provision on outcome, and to incorporate these factors into the trial design of future cost-effectiveness studies of interventions following DSH.

Background. Etiologic research on complex disorders including alcohol dependence requires informative phenotypes. Information is lost when categorical variables represent inherently dimensional conditions. We investigated the validity of DSM-IV alcohol dependence as a dimensional phenotype by examining evidence for linearity and thresholds in associations with validating variables.

Method. Current drinkers in the National Longitudinal Alcohol Epidemiologic Survey (NLAES) (n=18352) and National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) (n=20836) were analyzed. Validating variables included family alcoholism, early-onset drinking, and alcohol treatment. Logistic or Poisson regression modeled the relationships between the validating variables and dependence in categorical, dimensional or hybrid forms, with severity defined as number of current DSM-IV alcohol-dependence criteria. Wald tests assessed differences between models.

Results. No evidence was found for boundaries between categories. Instead, the association of alcohol dependence with the validating variables generally increased in linear fashion as the number of alcohol-dependence criteria increased. For NLAES models of family alcoholism, early-onset drinking and treatment, the lines had zero intercepts, with slopes of 0·18, 0·27, 0·70, respectively. For NESARC models of family history and early-onset drinking, the zero intercept lines had slopes of 0·20, 0·33, and 0·77, respectively. Wald tests indicated that models representing alcohol dependence as a dimensional linear predictor best described the association between dependence criteria and the validating variables.

Conclusions. The sample sizes allowed strong tests. Diagnoses are necessary for clinical decision-making, but a dimensional alcohol-dependence indicator should provide more information for research purposes.

Background. Chronic alcohol abuse is associated with a wide range of cognitive deficits. However, little is known about memory for real-life events (autobiographical memory) in non-amnesic alcoholic patients. The purpose of this study was to investigate (a) non-amnesic alcoholics' ability to recall specific autobiographical memories and (b) their subjective experience when they access specific memories.

Method. Twenty non-amnesic (without Korsakoff syndrome) recently detoxified alcoholics and 20 healthy controls completed the Autobiographical Memory Test (AMT), which assesses the frequency of specific (versus general) memories recalled in response to cue words, and the Memory Characteristics Questionnaire (MCQ), which assesses subjective experience (e.g. the amount of sensory and contextual details experienced) when remembering specific events.

Results. Alcoholic patients recalled specific memories less frequently and general memories more frequently than healthy controls. Nevertheless, when a specific past event was accessed, alcoholic patients subjectively experienced as many sensory and contextual details as controls.

Conclusions. These findings suggest that non-amnesic alcoholics have difficulties strategically accessing event-specific autobiographical knowledge, which might result from changes in frontal lobe function that are associated with alcoholism.

Background. Although caffeine is the most commonly used psychoactive substance and often produces symptoms of toxicity and dependence, little is known, especially in community samples, about the association between caffeine use, toxicity and dependence and risk for common psychiatric and substance use disorders.

Method. Assessments of lifetime maximal caffeine use and symptoms of caffeine toxicity and dependence were available on over 3600 adult twins ascertained from the population-based Virginia Twin Registry. Lifetime histories of major depression (MD), generalized anxiety disorder (GAD) and panic disorder, alcohol dependence, adult antisocial behavior and cannabis and cocaine abuse/dependence were obtained at personal interview. Logistic regression analyses in the entire sample and within monozygotic (MZ) twin pairs were conducted in SAS.

Results. In the entire sample, measures of maximal caffeine use, heavy caffeine use, and caffeine-related toxicity and dependence were significantly and positively associated with all seven psychiatric and substance use disorders. However, within MZ twin pairs, controlling for genetic and family environmental factors, these associations, while positive, were all non-significant. These results were similar when excluding twins who denied regular caffeine use.

Conclusions. Maximal lifetime caffeine intake and caffeine-associated toxicity and dependence are moderately associated with risk for a wide range of psychiatric and substance use disorders. Analyses of these relationships within MZ twin pairs suggest that most of the observed associations are not causal. Rather, familial factors, which are probably in part genetic, predispose to both caffeine intake, toxicity and dependence and the risk for a broad array of internalizing and externalizing disorders.

Background. An ecological analysis found that the docosahexaenoic acid content in mother's milk and seafood intake were inversely correlated with postpartum depression. This prospective study investigated the relationship of consumption of selected high-fat foods and specific types of fatty acids with the risk of postpartum depression.

Method. The subjects were 865 Japanese women. Dietary data were obtained from a self-administered diet history questionnaire during pregnancy. The Edinburgh Postnatal Depression Scale (EPDS) was used for the evaluation of postpartum depression. Adjustment was made for age, gestation, parity, cigarette smoking, family structure, family income, education, changes in diet in the previous month, season when data at baseline were collected, body mass index, time of delivery before the second survey, medical problems in pregnancy, baby's sex and baby's birthweight.

Results. The percentage of women with high depression scores was 14·0%. No evident dose–response associations were observed between intake of fish, meat, eggs, dairy products, total fat, saturated fatty acids, monounsaturated fatty acids, n-3 polyunsaturated fatty acids, n-6 polyunsaturated fatty acids, linoleic acid, α-linolenic acid, arachidonic acid, eicosapentaenoic acid or docosahexaenoic acid and the ratio of n-3 to n-6 polyunsaturated fatty acids and the risk of postpartum depression. However, there was an inverted J-shaped relationship between intake of n-3 polyunsaturated fatty acids and docosahexaenoic acid and the risk of postpartum depression.

Conclusions. This study failed to substantiate a clear inverse relationship between fish and n-3 polyunsaturated fatty acid intake and postpartum depression. Further investigations are needed to determine whether fish and n-3 polyunsaturated fatty acid consumption is preventive against postpartum depression.

Background. Effective internet-based programs for depression usually incorporate a component that provides telephone or email contact. Open access websites, without such contact, show high rates of attrition and poorer outcomes. The present study was designed as an exploratory investigation of the parameters that influence the effectiveness and retention of users on open access websites. We investigated whether brief cognitive behaviour therapy (CBT) was as effective as an extended version, whether add-on components of behaviour therapy or stress management contributed to positive outcomes, and whether longer programs were associated with greater attrition.

Method. An online randomized controlled trial (RCT) was conducted between 13 January 2005 and 26 May 2005 (19 weeks). A total of 2794 registrants (1846 women and 948 men; median age category 35–44 years) with elevated scores on the Goldberg Depression Scale of 5·96 (S.D.=2·09) elected online to be randomized to one of six versions of a CBT website. The versions were compiled consisting of various components of brief CBT, extended CBT, behaviour strategies, stress management and problem solving.

Results. A total of 20·4% of participants completed the assigned intervention. The interaction of measurement occasion and treatment version was significant [F(13,131)=2·20, p=0·01]. A single module of brief introductory CBT was not effective in reducing depression symptoms. However, extended CBT with or without the addition of behaviour strategies resulted in the reduction of depression.

Conclusions. Brief CBT-based interventions are not as effective as extended interventions. However, longer programs are associated with higher rates of dropout.

Background. Clinical judgments about the likelihood of suicide attempt would be aided by an index of risk factors that could be quickly assessed in diverse settings. We sought to develop such a risk index for 12-month suicide attempts among suicide ideators.

Method. The National Comorbidity Survey Replication (NCS-R), a household survey of adults aged 18+, assessed the 12-month occurrence of suicide ideation, plans and attempts in a subsample of 5692 respondents. Retrospectively assessed correlates include history of prior suicidality, sociodemographics, parental psychopathology and 12-month DSM-IV disorders.

Results. Twelve-month prevalence estimates of suicide ideation, plans and attempts are 2·6, 0·7 and 0·4% respectively. Although ideators with a plan are more likely to make an attempt (31·9%) than those without a plan (9·6%), 43% of attempts were described as unplanned. History of prior attempts is the strongest correlate of 12-month attempts. Other significant correlates include shorter duration of ideation, presence of a suicide plan, and several sociodemographic and parental psychopathology variables. Twelve-month disorders are not powerful correlates. A four-category summary index of correlates is strongly related to attempts among ideators [area under the receiver operator characteristic curve (AUC)=0·88]. The distribution (conditional probability of attempt) of the risk index is: 19·0% very low (0·0%), 51·1% low (3·5%), 16·2% intermediate (21·3%), and 13·7% high (78·1%). Two-thirds (67·1%) of attempts were made by ideators in the high-risk category.

Conclusions. A short, preliminary risk index based on retrospectively reported responses to fully structured questions is strongly correlated with 12-month suicide attempts among ideators, with a high concentration of attempts among high-risk ideators.

Background. The global toll of suicide is estimated to be one million lives per year, which exceeded the number of deaths by homicide and war combined. A key step to suicide prevention is to prevent less serious suicidal behaviour to preclude more lethal outcomes. Although 61% of the world's suicides take place in Asia and the suicide rates among middle age groups have been increasing since the economic crisis in many Asian countries, population-based studies of suicidal behaviour among working-age adults in non-western communities are scarce.

Method. Data from a population-based survey with 2015 participants were used to estimate the prevalence of suicidal ideation and behaviour among the working-age population in Hong Kong, and to study the associated socio-economic and psychological correlates. We focused particularly on potential modulating factors between life-event-related factors and suicidal ideation.

Results. Six per cent of the Hong Kong population aged 20–59 years considered suicide in the past year, while 1·4% attempted suicide. Hopelessness, reasons for living, and reluctance to seek help from family and friends had direct association with past-year suicidal ideation. Reasons for living were found to moderate the effect of perceived stress on suicidal ideation.

Conclusions. Suicidality is a multi-faceted problem that calls for a multi-sectored, multi-layered approach to prevention. Prevention programmes can work on modulating factors such as reasons for living to reduce suicidal risk in working-age adults.

Background. Developmental adversities may be risk factors for adult suicidal behavior, but this relationship has rarely been studied prospectively. The present study examined the association between childhood adversities and new onset suicidal ideation and attempts in an adult population-based sample.

Method. The study used a large community mental health survey (the Netherlands Mental Health Survey and Incidence Study; n=7076, age range 18–64 years). Logistic regression analyses were used to evaluate the relationship between childhood adversities and new onset of suicidal ideation and attempts over 3 years of longitudinal follow-up.

Results. During the study period 85 new cases of suicidal ideation and 39 new onset suicide attempts were observed. The incidence rate for new suicide ideation was 0·67% per year and the incidence rate for new suicide attempts was 0·28% per year. Childhood neglect, psychological abuse and physical abuse were strongly associated with new onset suicidal ideation and suicide attempts. Odds ratios (ORs) ranged from 2·80 to 4·66 for new onset suicidal ideation and from 3·60 to 5·43 for new onset suicide attempts. The total number of adversities reported had a strong graded relationship to new onset suicidal ideation and attempts. These associations remained significant after controlling for the effects of mental disorders.

Conclusions. Childhood abuse and multiple adversities are strongly associated with future suicidal behavior and the mental disorders assessed in the present study do not fully account for this effect. A comprehensive understanding of suicidal behavior must take childhood adversities into account.

Background. Impulsiveness, hostility and aggressiveness are traits associated with suicidal behavior, but also with borderline personality disorder (BPD). The presence of large numbers of BPD subjects in past attempter samples may distort the relative importance of each of these traits to predicting suicidal behavior, and lead to prospective, biological and genetic models that systematically misclassify certain subpopulations of suicidal individuals.

Method. Two hundred and seventy-five subjects with major depressive disorder (MDD), including 87 with co-morbid BPD (69 past suicide attempters, 18 non-attempters) and 188 without BPD (76 attempters, 112 non-attempters) completed standard impulsiveness, hostility and aggressiveness ratings. Differences between past suicide attempters and non-attempters were examined with the sample stratified by BPD status.

Results. As expected, BPD subjects scored significantly higher than non-BPD subjects on all three trait measures. Stratifying by BPD status, however, eliminated attempter/non-attempter differences in impulsiveness and hostility in both patient subgroups. Past suicide attempters in each of the two subgroups of patients were only distinguished by higher levels of aggressiveness.

Conclusions. Once BPD is accounted for, a history of aggressive behavior appears to be the distinguishing trait characteristic of suicide attempters with major depression, rather than global personality dimensions such as impulsiveness or hostility. Aggressiveness, and not these related traits, may be the ideal target for behavioral, genetic and biological research on suicidal behavior, as well as for the clinical assessment of suicide risk.

Background. We measured psychopathic traits in boys with autism spectrum disorder (ASD) selected for difficult and aggressive behaviour. We asked (i) whether psychopathic tendencies can be measured in ASD independent of the severity of autistic behaviour; (ii) whether individuals with ASD with callous–unemotional (CU) traits differ in their cognitive profile from those without such traits; and (iii) how the cognitive data from this study compare with previous data of youngsters with psychopathic tendencies.

Method. Twenty-eight ASD boys were rated on psychopathic tendencies, autistic traits and a range of cognitive measures assessing mentalizing ability, executive functions, emotion recognition and ability to make moral–conventional distinction.

Results. Our results indicate that psychopathic tendencies are not related to severity of ASD. In addition, such tendencies do not seem to be related to core autistic cognitive deficits, specifically in ‘mind-reading’ or executive function. Boys with co-occurring ASD and CU tendencies share some behaviours and aspects of cognitive profile with boys who have psychopathic tendencies alone.

Conclusions. Callous/psychopathic acts in a small number of individuals with ASD probably reflect a ‘double hit’ involving an additional impairment of empathic response to distress cues, which is not part and parcel of ASD itself.

Background. Cognitive impairment may be part of the endophenotype of bipolar disorder (BP), but little is known about patterns and severity of impairment in BP subgroups and their relation to depression. The same applies to deficits in emotion processing known to be present in BP.

Method. To explore the relationship between depression and impairment in cognition and emotion processing and the differences between BP subgroups, we assessed 36 (25 BP I and 11 BP II) patients using a cognitive battery and a facial emotion recognition task.

Results. BP patients were impaired compared to published norms on memory, naming and executive measures (Binomial Single Proportion tests, p<0·05). Cognitive performance was largely unrelated to depression ratings. Surprise recognition was the only emotion processing impairment in BP patients compared to controls (patients' recognition score 75% v. controls' 89%, p=0·024). Patients with higher depression ratings were more impaired in recognizing expressions of anger (t23=2·21, p=0·037). BP II patients were more impaired than BP I patients in IQ, memory and executive measures (Mann–Whitney tests, p<0·05). Depression severity or exposure to medication or electroconvulsive therapy (ECT) did not explain these differences.

Conclusions. We confirm cognitive impairment and an isolated facial emotion processing deficit in BP patients and suggest that these deficits are largely unrelated to depressive symptoms. Our study also provides evidence that cognitive deficits are more severe and pervasive in BP II patients, suggesting that recurrent depressive episodes, rather than mania, may have a more detrimental and lasting effect on cognition.