This issue contains two reviews, one on chronic fatigue syndrome and one on suicide and the menstrual cycle. Other sets of papers examine various aspects of suicide, addictive behaviours, and depression, and three individual papers examine a variety of topics.

Background. One of the many controversies surrounding chronic fatigue syndrome (CFS) is the possible impact of the diagnostic label: is it disabling or enabling? In this paper, we discuss the pros and cons of labelling CFS.

Method. A narrative synthesis of the literature.

Results. Diagnosed CFS patients have a worse prognosis than fatigue syndrome patients without such a label. The ways in which CFS patients perceive themselves, label their symptoms and appraise stressors may perpetuate or exacerbate their symptoms, a process that involves psychological, psychosocial and cultural factors. Labels can also lead to conflicts with doctors who fear diagnosis might lead to worse outcomes. However, on the other hand, finding a label that fits one's condition can provide meaning, emotional relief and recognition, whilst the denial of the diagnosis of CFS in those who have already reached their own conclusion can be very counter productive. The act of diagnosis therefore seems to be a trade-off between empowerment, illness validation and group support, contrasted with the risk of diagnosis as self-fulfilling prophecy of non-recovery.

Conclusions. The answer to the question of ‘to label or not to label’ may turn out to depend not on the label, but on what that label implies. It is acceptable and often beneficial to make diagnoses such as CFS, provided that this is the beginning, and not the end, of the therapeutic encounter.

Background. To investigate the available data regarding possible associations between phases of the menstrual cycle and suicidal behaviour.

Method. A systematic search of major relevant databases was performed using appropriate search terms.

Results. Forty-four relevant studies were identified in total, 13 pertaining to suicide, two pertaining to both attempted and completed suicide, 23 to suicide attempts, three to suicide attempts in those suffering from the premenstrual syndrome (PMS), three to suicidal ideation and two to repetitive self-harming behaviours. A variety of methodologies were used in these studies and there were notable differences in the conclusions reached. Studies with better methodology suggest that a positive relationship exists between aspects of the menstrual cycle and non-fatal suicidal behaviour. Such behaviour appears to be more common in those phases of the menstrual cycle when oestrogen levels are lowest (the late luteal and follicular phases), and in those suffering from PMS.

Conclusions. There appears to be an association between the menstrual cycle and non-fatal suicidal behaviours. Interaction between oestrogen and the serotonergic system may provide a possible mechanism.

Background. Despite voluminous research on the role of hopelessness and depression in suicidality, a systematic examination of various causal models pertaining to these variables is conspicuous in its absence.

Method. The directions of relationships between the three variables were examined by means of a prospective-longitudinal, cross-lagged, three-wave design in a severely suicidal young adults.

Results. Structural Equation Modeling (SEM) analyses revealed synchronous, but not longitudinal, associations between hopelessness, depressive symptoms, and suicidal ideation.

Conclusions. In severely suicidal young adults, the three clinical constructs appear to constitute a single depressive syndrome.

Background. The purpose of the study was to estimate the proportion of alcohol abuse and dependence (AAD) among suicides and controls, and to compare the incidence of AAD documented by clinicians with diagnoses derived from a research protocol.

Method. AAD according to DSM-IV was diagnosed on the basis of interviews with relatives of people who committed suicide and with controls. A total of 427 people who committed suicide during one year were paired by region, gender, age and nationality with controls randomly selected from general practitioners' lists.

Results. Alcohol abuse was found in 10% and alcohol dependence in 51% of suicide cases. The corresponding figures for controls were 7% and 14% respectively. AAD was a statistically significant predictor of completed suicides, while abstinence was a significant predictor for female suicides and former use a significant predictor for older male suicides. AAD was diagnosed in 68% of male and 29% of female suicides. Middle-aged (35–59 years) males who committed suicide had the highest risk of alcohol dependence. Among suicide cases only 29% had received a lifetime diagnosis of AAD, against 23% of controls.

Conclusions. AAD was significantly more prevalent among suicides than controls. Overall, the proportion of male suicides affected by alcohol was the same in the present psychological autopsy study as in our previous findings for Estonia on the aggregate level, while the share of female suicides with an AAD diagnosis was dramatically higher on the individual level. AAD is markedly underdiagnosed by general practitioners and clinicians.

Background. Item response theory (IRT) was used to determine whether the DSM-IV diagnostic criteria for alcohol abuse and dependence are arrayed along a continuum of severity.

Method. Data came from a large nationally representative sample of the US population, 18 years and older. A two-parameter logistic IRT model was used to determine the severity and discrimination of each DSM-IV criterion. Differential criterion functioning (DCF) was also assessed across subgroups of the population defined by sex, age and race-ethnicity.

Results. All DSM-IV alcohol abuse and dependence criteria, except alcohol-related legal problems, formed a continuum of alcohol use disorder severity. Abuse and dependence criteria did not consistently tap the mildest or more severe end of the continuum respectively, and several criteria were identified as potentially redundant. The drinking in larger amounts or for longer than intended dependence criterion had the greatest discrimination and lowest severity than any other criterion. Although several criteria were found to function differentially between subgroups defined in terms of sex and age, there was evidence that the generalizability and validity of the criterion forming the continuum remained intact at the test score level.

Conclusions. DSM-IV diagnostic criteria for alcohol abuse and dependence form a continuum of severity, calling into question the abuse–dependence distinction in the DSM-IV and the interpretation of abuse as a milder disorder than dependence. The criteria tapped the more severe end of the alcohol use disorder continuum, highlighting the need to identify other criteria capturing the mild to intermediate range of the severity. The drinking larger amounts or longer than intended dependence criterion may be a bridging criterion between drinking patterns that incur risk of alcohol use disorder at the milder end of the continuum, with tolerance, withdrawal, impaired control and serious social and occupational dysfunction at the more severe end of the alcohol use disorder continuum. Future IRT and other dimensional analyses hold great promise in informing revisions to categorical classifications and constructing new dimensional classifications of alcohol use disorders based on the DSM and the ICD.

Background. To examine sex differences in DSM-IV subclinical and pathological gambling in nationally representative data of the US population.

Method. Data come from a large (n=43093) representative sample of the adult US population.

Results. The lifetime prevalence rate of DSM-IV pathological gambling was 0·64% (95% CI 0·50–0·78) for men and 0·23% (95% CI 0·17–0·29) for women, whereas the lifetime prevalence of subclinical pathological gambling was 6·79% (95% CI 6·32–7·26) for men and 3·26% (95% CI 2·93–3·59) for women. For subclinical pathological gambling, men were significantly (p<0·01) more likely than women to have smoked more than two packs of cigarettes a day, to be classified as heavy drinkers and to have lifetime diagnoses of alcohol and drug use disorders. Women with subclinical and pathological gambling were significantly more likely than men to have lifetime mood and anxiety disorders. With respect to pathological gambling, women had later ages of onset of the disorder, and were significantly more likely than men to report gambling to relieve depressed mood and to prefer casino gambling. Rates of treatment-seeking for DSM-IV pathological gambling were low for both men and women.

Conclusions. There are important sex differences in the prevalence, symptom pattern, sociodemographic and clinical correlates and course of DSM-IV subclinical and pathological gambling. Results underscore the need to investigate sex differences in the social determinants, neurobiology and treatment response of DSM-IV subclinical and pathological gambling.

Background. Prior population-based twin studies from two Anglophonic countries with relatively high rates of drug use – the USA and Australia – suggest that genetic factors contribute substantially to individual differences in the use, abuse and dependence of illicit psychoactive substances. Would these results replicate in Norway, a Nordic country with a low prevalence of illicit drug use?

Method. Lifetime use, abuse and dependence of five illicit drug categories (cannabis, stimulants, opiates, cocaine and psychedelics) were assessed at personal interview in 1386 complete young adult twin pairs ascertained from the Norwegian Institute of Public Health Twin Panel. Twin model fitting was performed using the Mx statistical package on three phenotypes: any lifetime use, endorsement of at least one DSM-IV symptom of abuse or dependence, and meeting DSM-IV criteria for abuse or dependence.

Results. Significant lifetime use of illicit substances (defined as use 10 or more times) was reported by only 6·4% of the sample. Meaningful analyses were possible for use of any substance and each of the five substances individually, but for symptoms or a diagnosis of abuse/dependence meaningful analyses were possible only for any substance and cannabis. Full twin models uniformly found twin resemblance to be due largely or entirely to genetic factors. Best-fit models for all analyses included only genetic and individual-specific environmental effects with heritability estimates ranging from 58% to 81%.

Conclusion. In accord with prior results from the USA and Australia, genetic factors appear to play an important role in the etiology of use and abuse/dependence of illicit drugs in Norway.

Background. We examined whether there are genetic influences on nicotine withdrawal, and whether there are genetic factors specific to nicotine withdrawal, after controlling for factors responsible for risk of progression beyond experimentation with cigarettes and for quantity smoked (average number of cigarettes per day at peak lifetime use).

Method. Epidemiologic and genetic analyses were conducted using telephone diagnostic interview data from young adult Australian twins reporting any cigarette use (3026 women, 2553 men; mean age 30 years).

Results. Genetic analysis of the eight symptoms of DSM-IV nicotine withdrawal suggests heritability is intermediate for most symptoms (26–43%), and similar in men and women. The exceptions were depressed mood upon withdrawal, which had stronger additive genetic influences in men (53%) compared to women (29%), and decreased heart rate, which had low heritability (9%). Although prevalence rates were substantially lower for DSM-IV nicotine withdrawal syndrome (15·9%), which requires impairment, than for the DSM-IV nicotine dependence withdrawal criterion (43·6%), heritability was similar for both measures: as high as 47%. Genetic modeling of smoking more than 1 or 2 cigarettes lifetime (‘progression’), quantity smoked and nicotine withdrawal found significant genetic overlap across all three components of nicotine use/dependence (genetic correlations=0·53–0·76). Controlling for factors associated with risk of cigarette smoking beyond experimentation and quantity smoked, evidence for genetic influences specific to nicotine withdrawal (up to 23% of total variance) remained.

Conclusions. Our results suggest that at least some individuals become ‘hooked’ or progress in the smoking habit, in part, because of a vulnerability to nicotine withdrawal.

Background. The question of whether unipolar clinical depression differs categorically from limited depressive complaints has important implications for the disorder's assessment, treatment and research. This crucial issue has proven difficult to resolve, in part because many studies to date have relied on self-report measures or on clinically homogeneous samples. We therefore applied Meehl's taxometric method to a large, clinically heterogeneous sample, and examined the latent structure of depressive episodes using both self-report and structured clinical interview data.

Method. Data were derived from the Oregon Adolescent Depression Project, a large longitudinal community study. All analyses involved more than 1400 participants. MAXEIG (MAXimum EIGenvalue) and base rate estimation were performed separately for Beck Depression Inventory (BDI) items and for DSM-IV-based major depressive episode (MDE) symptoms.

Results. MAXEIG analyses of the BDI and MDE indicator sets appeared to converge on a taxonic structure for unipolar depression. Base rate estimates overall implied a latent depressive episode class that occurs more frequently than diagnosable MDEs but less frequently than persistent depressed or anhedonic mood.

Conclusions. These findings provide tentative support for a categorical conceptualization and make it very clear that the continuity controversy regarding unipolar depression has not yet been decided in favor of dimensionality. To reconcile the conflicting reports to date, several data analytic and sampling issues need to be explored systematically.

Background. Very few large national epidemiologic surveys have examined the prevalence of psychiatric disorders among Asians and Native Americans due to small sample sizes. Very little is also known about the co-occurrences between substance use disorders and mood and anxiety disorders among these two minority groups and how their rates compare to Whites, Blacks, and Hispanics.

Method. Analyses were based on a large (n=43093) nationally representative survey of the adult (18+ years), U.S. population supplemented by a group quarters sampling frame. Prevalences and associations of major DSM-IV mood, anxiety and substance use disorders were examined among all major race/ethnic subgroups of the population.

Results. Twelve-month rates of most mood, anxiety and substance use disorders were generally greatest among Native Americans and lowest among Asians. For most race/ethnic subgroups, alcohol and drug dependence, but not abuse, were significantly associated with mood disorders. With few exceptions, there were no significant associations between alcohol and drug abuse and anxiety disorders. In contrast, alcohol dependence was associated with most anxiety disorders among Whites, Blacks and Asians, but not among Native Americans.

Conclusions. The 12-month prevalence of substance use, mood, and anxiety disorders varied greatly across the five major race/ethnic subgroups of the population. Twelve-month co-occurrence of substance use disorders and mood and anxiety disorders was pervasive among all race/ethnic subgroups. Future research is also needed to understand race/ethnic differentials in prevalence and co-occurrence of these disorders with a particular focus on factors that may give rise to them.

Background. Common mental disorder prevalence decreases substantially around the conventional retirement age for men in the UK, but trends for older women are more continuous. Prevalence changes in depression and anxiety around retirement are less clear, as is the role of risk factors. The aim of this study was to establish whether work status, age or other known risk factors account for the reduced prevalence of depressive episode and anxiety disorder around retirement ages for men and for women.

Method. The British Psychiatric Morbidity Survey (BPMS) 2000 was analysed, including 1875 men and 2253 women aged 45–75 years. Diagnoses were from the Revised Clinical Interview Schedule (CIS-R). Logistic models were adjusted for sociodemographic factors, social network, work status, life events, physical illness and disability.

Results. There are marked reductions in the prevalence of depressive episode after 60 years for women [60% lower prevalence, 95% confidence interval (CI) 40–80] and 65 years for men (90% lower prevalence, 95% CI 70–100), compared to the youngest age groups. For anxiety disorder, the reduction in prevalence was 80% (95% CI 60–90) for men and 40% (95% CI 20–60) for women. In fully adjusted multivariate models, the strong association between diagnoses and age groups remained, for both genders. Work status was a significant factor for men but not for women.

Conclusion. There is a discontinuity in the prevalence of depressive episode for both men and women, coinciding with statutory retirement ages. No studied risk factor reduced the associations between age group and disorders. This population scale recovery may provide a model for understanding non-genetic factors.

Background. Effective community-based care for older people requires the integration of assessment approaches by old age psychiatry, geriatric medicine and social services care management. This study examines the value of such collaboration in the assessment of older people at risk of entering care homes.

Method. A randomized controlled trial of integrated assessment (care management with additional clinical assessment by old age psychiatrist or geriatrician) versus care management assessment only, for older people at risk of care-home admission. Older people's characteristics, physical and cognitive functioning, depression, behaviour and quality of care measures were recorded at assessment and 6 months. Differences in clinicians' and care managers' recommendations and placement rates between experimental and control groups were analysed. Logistic regression, examining associations between different needs-related characteristics and the likelihood of care-home admission, was used to characterize placement decisions.

Results. Clinicians recommended fewer older people for placement than did care managers in their usual assessments (a reduction of 85%). This did not, however, translate into a reduction in actual numbers of placements, although placements were delayed in those receiving the integrated assessment. Placements of those receiving the integrated assessment were influenced more by clinical factors, most notably cognitive impairment, which clinicians detected more readily than care managers.

Conclusions. In this at-risk group, integrated assessment offers a means of potentially both delaying care-home admissions and taking account of a wider range of factors in placement decisions. Such an approach is viewed as an important policy goal both in the UK and internationally.

Background. Pregnancy has often been associated with cognitive deficits, but results are equivocal and little is known about how these deficits progress with time.

Method. In the present study, the cognitive performance of 57 pregnant women was compared with that of 50 non-pregnant women matched for age and education, using a well-validated neurocognitive test battery at weeks 14, 17, 29, and 36 of pregnancy, and 32 weeks postpartum in the pregnant group and at comparable times in the non-pregnant group.

Results. Memory encoding and retrieval, as assessed with a word learning task, were significantly lower in the pregnant group than in the control group. This difference was still present at 32 weeks after delivery. The two groups did not differ in complex speed of information processing at any of the test moments; however, general speed of information processing was significantly compromised during early motherhood (week 32 postpartum).

Conclusion. Thus, memory performance is poorer during pregnancy and early motherhood, and general speed of information processing is slower during early motherhood.

Background. Previous cross-sectional studies have found substantial genetic influences on individual variation in subjective well-being (SWB), and evidence for sex-specific genetic effects has been reported. However, the genetic and environmental influences on stability and change in SWB over time are largely unexplored.

Method. Questionnaire data on SWB from a population-based sample of Norwegian twins born 1967 to 1979, initially surveyed in 1992 (T1) and re-surveyed in 1998 (T2), were analysed using structural equation modelling to explore the relative effects of genetic and environmental influences on phenotypic stability and change.

Results. The phenotypic cross-time correlations for SWB were 0·51 and 0·49 for males and females respectively. The best-fitting longitudinal model specified only additive genetic and individual environmental effects with qualitative and quantitative sex-specific genetic influences. For both males and females, the additive genetic factors influencing SWB were largely stable, although some time-specific genetic contributions were indicated. Cross-time correlations for genetic effects were 0·85 and 0·78 for males and females respectively. The individual environmental influences were primarily time-specific. Additive genetic effects explained approximately 80% of the phenotypic cross-time correlation. For females, the magnitude of the additive genetic effects decreased significantly from T1 to T2, whereas for males, the estimates generally remained unchanged.

Conclusions. For both males and females, long-term stability of SWB was mainly attributable to stable additive genetic factors, whereas susceptibility to change was mostly related to individual environmental factors. However, both stable environmental contributions and emerging genetic influences were indicated.