This issue's major focus is a group of reports on the treatment of depression. In addition there are a combination reports on a range of topics including self-harm, racial and ethnic differences in psychiatric disorders, a new diagnostic psychosis interview scale, PTSD, anxiety disorders, substance abuse and bulimia nervosa.

Much of the burden of depression and anxiety in the population is attributable to subclinical symptoms. Broadening formal health-care systems to treat subclinical depression and anxiety is not the answer to reducing this burden, because health-care systems lack the resources even to provide optimal care to clinical cases. The solution proposed is the population-wide dissemination of informal self-help strategies that have evidence for effectiveness. These are highly acceptable to the public, easily applied, inexpensive and may avert the development of many clinical cases.

Background. Deficits in the care of depression lead to poor medication adherence, which increases the risk of an unfavourable outcome for this care. This review evaluates effects on symptoms and medication adherence of case management in primary health care.

Method. A systematic literature search was performed. The quality of the studies was rated according to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria. To conduct a subgroup analysis interventions were classified as either ‘standard’ or ‘complex’ case management.

Results. Thirteen studies met the inclusion criteria. In a meta-analysis we calculated a standard mean difference/effect size on symptom severity after 6–12 months of −0·40 (95% CI −0·60 to –0·20). Patients in the intervention groups were more likely to achieve remission after 6–12 months [relative risk (RR) 1·39, 95% CI 1·30–1·48]. The relative risk for clinical response was 1·82 (95% CI 1·68–2·05). Patients in intervention groups had better medication adherence than the control group (RR 1·5, 95% CI 1·28–1·86). We found heterogeneous results when assessing effects of different types of intervention.

Conclusions. We conclude that case management improves management of major depression in primary health-care settings.

Background. Depression is a highly prevalent, often recurring or persistent disorder. The majority of patients are initially seen and treated in primary care. Effective treatments are available, but possibilities for providing adequate follow-up care are often limited in this setting. This study assesses the effectiveness of primary-care-based enhanced treatment modalities on short-term patient outcomes.

Method. In a randomized controlled trial we evaluated a psycho-educational self-management intervention. We included 267 adult patients meeting criteria for a DSM-IV diagnosis of major depressive disorder, assessed by a structured psychiatric interview. Patients were randomly assigned to: the Depression Recurrence Prevention (DRP) program (n=112); a combination of the DRP program with psychiatric consultation (PC+DRP, n=39); a combination with brief cognitive behavior therapy (CBT+DRP, n=44); and care as usual (CAU, n=72). Follow-up assessments were made at 3 months (response 90%) and 6 months (85%).

Results. Patient acceptance of enhanced care was good. The mean duration of the index episode was 11 weeks (S.D.=9·78) and similar in CAU and enhanced care. Recovery rate after 6 months was 67% overall; 17% of all participants remained depressed for the entire 6-month period.

Conclusion. Enhanced care did not result in better short-term outcomes. We found no evidence that the DRP program was more effective than CAU and no indications for added beneficial effects of either the psychiatric evaluation or the CBT treatment to the basic format of the DRP program. Observed depression treatment rates in CAU were high.

Background. Clinicians have questioned the validity of depression criteria in patients with chronic medical illness, but few empirical data address this question.

Method. Computerized records identified two samples of managed care patients beginning depression treatment: 235 with diabetes, ischemic heart disease, or chronic obstructive lung disease and 204 without those conditions. Telephone assessments at baseline, 2 months, and 6 months included the Structured Clinical Interview for DSM-IV and other measures of depression severity and functional status. Item Response Theory analyses compared patterns of depressive symptoms across groups and specifically evaluated somatic symptoms (fatigue, change in weight or appetite, psychomotor agitation/retardation, and sleep disturbance) as indicators of depression. Logistic regression examined how change in somatic symptoms during treatment varied between patient groups.

Results. Overall item response analysis indicated differential item functioning between groups (χ2=33·7, df=18, p=0·017). Two of eight item-level comparisons were statistically significant; one in the predicted direction (patients with co-morbidity reported more fatigue at low levels of depression: χ2=17·9, df=1, p<0·001) and one in the opposite direction from predicted (patients with co-morbidity reported less psychomotor agitation/retardation at low levels of depression: χ2=8·0, df=1, p=0·005). Observed differences were modest: at the midpoint of the depression severity scale, patients with medical co-morbidity had a 54% probability of reporting fatigue compared to 45% in those without co-morbidity. All four somatic symptoms showed robust improvement with treatment, and this improvement did not differ significantly between patients with and without medical co-morbidity.

Conclusions. We find only limited evidence that fatigue, changes in weight or appetite, psychomotor agitation/retardation, and sleep disturbance are less valid indicators of depression in patients with chronic medical illness. DSM-IV criteria for diagnosis of depression do not require significant modification for patients with medical co-morbidity.

Background. There is evidence to indicate that peripheral glucocorticoid receptor (GR) function is reduced in major depression, and a possible molecular explanation for this is the impact of raised pro-inflammatory cytokines. The topical steroid vasoconstriction assay provides a convenient probe of peripheral GR function. The present study sought to assess the sensitivity of peripheral GRs in antidepressant-resistant major depressives and investigate the association between GR sensitivity and circulating plasma cytokines.

Method. Nineteen antidepressant-resistant depressives together with age- and sex-matched healthy controls underwent the steroid vasoconstriction assay using three commercial preparations of corticosteroids containing clobetasol propionate 0·05%, betamethasone valerate 0·1%, and clobetasone butyrate 0·05%, corresponding to very potent, potent, and moderately potent steroid creams respectively. The pro-inflammatory cytokines, tumour necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were measured using enzyme-linked immunosorbent assays. The severity of the depressive episode was assessed using the Hamilton Depression Scale (HAMD).

Results. Depressed subjects had a significantly reduced vasoconstriction response across all three strengths of steroid. They also had significantly higher concentrations of TNF-α and IL-6. There was a significant inverse correlation between TNF-α concentration and vasoconstriction response and also between the HAMD score and vasoconstriction response.

Conclusions. These findings suggest that cutaneous GR function is abnormal in antidepressant-resistant depression, that circulating TNF-α may play a significant role in this abnormality and that the efficacy of topical steroids in antidepressant-resistant depressives is reduced.

Background. While recent studies have found problem-solving impairments in individuals who engage in deliberate self-harm (DSH), few studies have examined repeaters and non-repeaters separately. The aim of the present study was to investigate whether specific types of problem-solving are associated with repeated DSH.

Method. As part of the WHO/EURO Multicentre Study on Suicidal Behaviour, 836 medically treated DSH patients (59% repeaters) from 12 European regions were interviewed using the European Parasuicide Study Interview Schedule (EPSIS II) approximately 1 year after their index episode. The Utrecht Coping List (UCL) assessed habitual responses to problems.

Results. Factor analysis identified five dimensions – Active Handling, Passive-Avoidance, Problem Sharing, Palliative Reactions and Negative Expression. Passive-Avoidance – characterized by a pre-occupation with problems, feeling unable to do anything, worrying about the past and taking a gloomy view of the situation, a greater likelihood of giving in so as to avoid difficult situations, the tendency to resign oneself to the situation, and to try to avoid problems – was the problem-solving dimension most strongly associated with repetition, although this association was attenuated by self-esteem.

Conclusions. The outcomes of the study indicate that treatments for DSH patients with repeated episodes should include problem-solving interventions. The observed passivity and avoidance of problems (coupled with low self-esteem) associated with repetition suggests that intensive therapeutic input and follow-up are required for those with repeated DSH.

Background. Epidemiological studies have found lower than expected prevalence of psychiatric disorders among disadvantaged race-ethnic minority groups in the USA. Recent research shows that this is due entirely to reduced lifetime risk of disorders, as opposed to persistence. Specification of race-ethnic differences with respect to clinical and social characteristics can help identify the protective factors that lead to lower lifetime risk among disadvantaged minority groups.

Method. Data on 5424 Hispanics, non-Hispanic Blacks, and non-Hispanic Whites came from the National Comorbidity Survey Replication, a nationally representative survey conducted with the World Mental Health version of the Composite International Diagnostic Interview. Race-ethnic differences in risk of disorders were compared across specific diagnoses, ages of onset, cohorts and levels of education.

Results. Both minority groups had lower risk for common internalizing disorders: depression, generalized anxiety disorder, and social phobia. In addition, Hispanics had lower risk for dysthymia, oppositional-defiant disorder and attention deficit hyperactivity disorder; non-Hispanic Blacks had lower risk for panic disorder, substance use disorders and early-onset impulse control disorders. Lower risk among Hispanics, relative to non-Hispanic Whites, was found only among the younger cohort (age [les ]43 years). Lower risk among minorities was more pronounced at lower levels of education.

Conclusion. The pattern of race-ethnic differences in risk for psychiatric disorders suggests the presence of protective factors that originate in childhood and have generalized effects on internalizing disorders. For Hispanics, but not for non-Hispanic Blacks, the influence of these protective factors has emerged only recently.

Background. We describe the development, reliability and applications of the Diagnostic Interview for Psychoses (DIP), a comprehensive interview schedule for psychotic disorders.

Method. The DIP is intended for use by interviewers with a clinical background and was designed to occupy the middle ground between fully structured, lay-administered schedules, and semi-structured, psychiatrist-administered interviews. It encompasses four main domains: (a) demographic data; (b) social functioning and disability; (c) a diagnostic module comprising symptoms, signs and past history ratings; and (d) patterns of service utilization and patient-perceived need for services. It generates diagnoses according to several sets of criteria using the OPCRIT computerized diagnostic algorithm and can be administered either on-screen or in a hard-copy format.

Results. The DIP proved easy to use and was well accepted in the field. For the diagnostic module, inter-rater reliability was assessed on 20 cases rated by 24 clinicians: good reliability was demonstrated for both ICD-10 and DSM-III-R diagnoses. Seven cases were interviewed 2–11 weeks apart to determine test–retest reliability, with pairwise agreement of 0·8–1·0 for most items. Diagnostic validity was assessed in 10 cases, interviewed with the DIP and using the SCAN as ‘gold standard’: in nine cases clinical diagnoses were in agreement.

Conclusions. The DIP is suitable for use in large-scale epidemiological studies of psychotic disorders, as well as in smaller studies where time is at a premium. While the diagnostic module stands on its own, the full DIP schedule, covering demography, social functioning and service utilization makes it a versatile multi-purpose tool.

Background. Gender differences in the prevalence of post-traumatic stress disorder were examined by analysing discrepancies between the DSM-IV and ICD-10 diagnostic systems.

Method. Data from the Australian National Survey of Mental Health and Well-Being (n=10641) were analysed at the diagnostic, criterion and symptom level for DSM-IV and ICD-10 PTSD for males versus females.

Results. While there was a significant gender difference in the prevalence of PTSD for ICD-10, no such difference was found for DSM-IV. The pattern of gender difference at the diagnostic level was mirrored in the pattern of gender differences at the criterion level for both DSM-IV and ICD-10. Females only endorsed three symptoms at a significantly higher rate than males. For all other symptoms, endorsement was equal. This apparently small gender difference at the symptom level was sufficient to cause the gender difference at the diagnostic level for ICD-10, but not DSM-IV because of the different manner in which symptoms are configured into criteria in each of the diagnostic systems.

Conclusions. Gender differences in ICD-10 PTSD but not in DSM PTSD diagnoses are attributable in this study to different patterns of endorsement of symptoms by males and females. Possible reasons for the differential endorsement of symptoms and implications for the use of epidemiological instruments are discussed.

Background. The use of strategies to aid performance when undertaking neuropsychological tasks is dependent on intact fronto-striatal circuitry, and growing evidence suggests impaired spontaneous use of strategies in patients with obsessive–compulsive disorder (OCD). However, studies to date have not examined the effects of strategy training on task performance in OCD or in trichotillomania (compulsive hair-pulling, a condition that has been argued to share overlap with OCD in terms of phenomenology and co-morbidity).

Method. The ability to generate novel visuospatial sequences using a computer interface was examined before and after undertaking optimal strategy training in 20 OCD patients, 17 trichotillomania patients, and 20 controls (matched for age, education, and IQ).

Results. OCD patients failed to improve ability to generate novel sequences above baseline despite successfully completing strategy training to the same extent as other groups. In contrast, performance of trichotillomania patients improved significantly after training to the same extent as controls. Groups did not differ on memory span, trial-by-trial action monitoring, or ability to generate novel visuospatial sequences prior to strategy training.

Conclusions. Strategy implementation deficits, suggestive of cognitive inflexibility and fronto-striatal dysfunction, appear integral to the neurocognitive profile of OCD but not trichotillomania. Future research should investigate cognitive flexibility in obsessive–compulsive spectrum disorders using a variety of paradigms, and clarify the contribution of specific neural structures and transmitter systems to deficits reported.

Background. There is a high incidence of panic and somatoform disorders after vestibular neuritis. However, the occurrence of psychiatric disorders has been shown to be unrelated to persistent functional vestibular impairment. The aim of the present study was to examine the role played by cognitions in the development of panic and somatoform disorders.

Method. In a 2-year prospective study, cognitions were recorded at various stages using the Agoraphobic Cognitions Questionnaire and Body Sensations Questionnaire. Our analysis focused on whether body-related anxiety or panic-related thoughts can predict the development of a panic or somatoform disorder.

Results. Fear arising on the first day of an acute vestibular episode did not predict the development of panic or somatoform disorders. One week after the dysfunction, however, the fear of vertigo was a significant predictor, explaining 20% of the variance in the development of either disorder. After 6 weeks, persistent fear of vertigo or vomiting predicted approximately 30% of the variance, and after 6 months panic-related thoughts predicted 40% of the variance and, with the inclusion of body-related fears, as much as 60% of the variance in the development of panic or somatoform disorders.

Conclusion. Our data confirm prospectively a number of fundamental assumptions of cognitive theory concerning the development of anxiety disorders. Subjects who experience vertigo as particularly alarming focus more intensely than other patients on the negative symptoms they perceive as being related to the disorder. Patients with panic-related cognitions were prone to develop panic or somatoform disorders.

Background. Early alcohol use is associated with abuse and dependence of licit and illicit substances later in life. The role of genetic and environmental factors in this association is not conclusive.

Method. In 1992, data on substance use, abuse/dependence and psychiatric disorders were collected from 8169 male twin members of the Vietnam Era Twin Registry. The interview obtained age of onset of regular drinking (one drink/month for 6 or more months). Regression analyses of twin pairs discordant for early alcohol use tested whether the association between early drinking (before age 17) and adult substance use and abuse/dependence remained after controlling for genetic factors, family environment and covariates. Twin models tested for common genetic and/or environmental influences on early drinking and adult alcohol dependence and ever use and abuse/dependence on marijuana and other drugs.

Results. Co-twin analyses suggested the association between early regular alcohol use and adult alcohol dependence, marijuana and other drug use, and marijuana and other drug abuse/dependence could not be entirely explained by common genetic and shared family environmental factors. Genetic contributions to early regular drinking were significantly correlated with those on use of marijuana (rA=0·59), use of other drugs (rA=0·64), alcohol dependence (rA=0·54) and abuse/dependence of marijuana and other drugs (rA=0·63 and 0·66). Small but significant unique environmental correlations (rE range 0·11–0·22) indicated that familial factors could not entirely explain the association between early alcohol use and later substance use, abuse and dependence.

Conclusions. Early regular drinking is associated with later alcohol dependence and use, abuse/dependence on drugs. The association is not entirely explained by genetic or shared family environmental factors. This suggests unique environmental factors contribute to transitions from early regular alcohol drinking to use, abuse and dependence on alcohol and other substances.

Background. Recent epidemiological data suggest a decline in bulimia nervosa (BN) incidence in primary care. We sought to examine BN point prevalence from 1982 to 2002 in a college population.

Method. In 1982, 1992, and 2002, 800 women and 400 men were randomly sampled from a university for a study of health and eating patterns. Participation rates were 72% in women and 63% in men, resulting in n=2491 participants.

Results. BN point prevalence decreased significantly in women over the period of observation. Eating Disorder Inventory Bulimia scores decreased across cohorts, and these decreases remained significant when male and female and Caucasian and non-Caucasian students were analyzed separately.

Conclusion. These data support a decline in BN rates that cannot be attributed to changes in service utilization. Changing socio-cultural factors may explain a true decrease in BN incidence and prevalence.