Three statistical models are presented to describe different aspects of the natural history of depression (as recognized by a general practitioner) during a 20-year study of a single general practice. After controlling for age, the prevalence of recognized depression in men increased during the 20 years of the study (1957–76), but there was little change in women. In any given year, however, women are both more likely to become depressed than men, and are less likely to recover. The changes in prevalence are shown to be due to changes in observed incidence and recovery rates. Taking into account attendances over the previous 5 years at which a diagnosis of depression was made, the models enable one to predict, for example, incidence rates for ‘first episodes’ of recognized depression, and recovery rates for ‘chronic’ patients. In all situations there is a significant sex difference (women always being more likely to be recognized as depressed), but this difference is smaller at the end than at the beginning of the 20 years.

Background. The purpose of this study was to demonstrate the influence of several risk factors (particularly physical and mental disorders, loneliness and housing conditions) on the wish to die in the elderly.

Method. Using data from a population-based sample of 516 senior citizens (70 to 103 years of age) in Berlin (Germany), we compared 54 persons with death wishes with 462 persons without death wishes on several psychosocial risk factors, physical health and psychiatric diagnoses. A logistic regression analysis was also conducted.

Results. The data indicate that the wish to die is strongly associated with the presence of a mental disorder, especially major depression, while higher age, female gender, subjective assessment of physical health and negative living conditions were all only moderately related to death wishes.

Conclusions. Our results emphasize the need for very careful diagnosis of death wishes in the very old and question the view that it is a normal and understandable phenomenon in older age.

Background. Biases in the processing of emotional information have been shown to be abnormal in subjects with major depression, both during an episode and after full recovery. However, it is unclear whether these biases are a cause or an effect of the depression. This study set out to explore whether such biases represent a vulnerability factor for depression by looking at unaffected first-degree relatives of those with major depressive disorder. We also measured waking salivary cortisol, as the regulation of the hypothalamo–pituitary–adrenal (HPA) axis is thought to be impaired in depressive disorder.

Method. Twenty-five female relatives and 21 age-matched controls completed a facial expression recognition task, an emotional categorization task with positive and negative personality characteristics, and had their waking salivary cortisol measured on a work day and a non-work day.

Results. The depressed relative group was significantly faster to recognize facial expressions of fear than controls. The depressed relative group also showed significantly increased reaction time to recognize positive versus negative personality characteristics in the categorization task. There was no difference in waking salivary cortisol between groups, although there was an effect of work day versus non-work day.

Conclusions. Subtle biases in the processing of emotional information may exist in the unaffected first-degree relatives of those with depression. As such, this may represent a familial vulnerability factor to developing a depressive illness.

In 17 benzodiazepine (BDZ) dependent in-patients a CT scan was performed before initiation of withdrawal therapy. The evaluation of the ventricular to brain ratio (VBR) by standardized and computerized measurements revealed significantly higher mean VBRs for both high-and low-dose BDZ-dependent patients compared to the mean VBR of an age- and sex-matched control group. In addition, the mean VBR of high-dose BDZ-dependent patients (N = 8) was significantly higher than the mean VBR of low-dose BDZ-dependent patients (N = 9). This difference could not be accounted for by the age of the patients or duration of BDZ-dependency and, therefore, suggests a dose-dependent effect of BDZs on the enlargement of internal CSF-spaces. On the other hand, higher values for the width of external CSF-spaces were found to be related to increasing age of the patients and duration of BDZ-dependency.

Age of onset reports obtained retrospectively for each symptom of DSM-III-R alcohol dependence (AD) are used to study patterns of lifetime symptom progression in a large general-population survey of people in the United States. It is shown that symptom progression among a substantial majority of respondents can be summarized as movement across three clusters. Cluster A is defined by symptoms of role impairment/hazardous use (A4), use despite social, psychological or physical problems (A6), and drinking larger amounts or over a longer period of time than intended (A1). Cluster B is defined by tolerance (A7) and impaired control (A2, A3). Cluster C is defined by withdrawal (A8, A9) and giving up activities in order to drink (A5). Clusters are shown to follow a time sequence, with at least one symptom in Cluster A usually occurring first, followed by symptoms in Clusters B and C. In all, 83·4% of the symptom cluster transitions estimated from retrospective age of onset reports are consistent with this progression. Progression to AD is differentially predicted by symptom profiles reported at the age of first symptom onset, with persons reporting Cluster C symptoms most likely to progress subsequently to AD. Furthermore, profiles of AD defined by the highest symptom cluster present at AD onset are differentially predicted by prior personal and parental histories of psychopathology and, among men, are predictive of diagnosis persistence.

Background. Life events and social problems are common in primary-care attenders and contribute to the high rate of emotional distress observed in this setting but are often not disclosed during the consultation. Physicians' characteristics associated with patients' disclosure of psychosocial problems are well documented, but less empirical evidence is available on the contribution of patients' variables.

Method. Logistic regression analyses were performed on a set of clinical and psychosocial data from 319 primary-care attenders with stressful life events and/or social problems in the presence or absence of emotional distress, in order to identify the variables that predict disclosure of such problems during the consultation.

Results. Two-thirds of patients with stressful life events and social problems had mentioned them to their GP. In both sexes a positive attitude about confiding and emotional distress were the best predictors of confiding. In men they accounted for 76% of correct predictions and, in women, together with past confiding, long-lasting relationship with GP, and coexistence of life events and social problems, for 81%. A positive confiding attitude was related in males to age and severity of medical condition and in females to age and experience of past confiding.

Conclusions. In view of the high prevalence of positive attitude towards confiding the efforts by GPs should focus on the reduction of disclosure thresholds. This would require increased abilities to elicit psychosocial information and show emphatic understanding of patients' life difficulties. By contrast there is a need to promote a positive attitude in confiding that concerns only a minority of primary-care patients. More data are needed for shaping more specific strategies for these patients.

We used cluster analysis to delineate coping subtypes in a sample of 166 men with coronary heart disease who completed the Antwerp out-patient rehabilitation programme. These subtypes were identified on the basis of three well-defined superordinate traits that were selected from a comprehensive taxonomy: negative affectivity, social inhibition, and self-deception. Using Ward's minimum variance method and the cubic clustering criterion, we identified four coping subtypes; low-negative affectivity (N = 48), high-negative affectivity (N = 30), inhibited (N = 62), and repressive (N = 26) individuals. The accuracy of the resulting classification was demonstrated across parallel data sets and was further validated against external, health-related correlates that were not included in the clustering. The identified coping subtypes were significantly related to self-reports of subjective distress/perceived stress, ratings of Type A behaviour and anger-in, return to work, prevalence of chest-pain complaints, and use of minor tranquillizers and sleeping pills. The major findings of this study suggest that (a) male coronary patients represent a heterogeneous population with distinctly different coping subtypes, and that (b) a relatively small number of homogeneous subtypes can account for a substantial amount of variance in subjective well-being, coronary-prone behaviour, and return to work. These findings indicate that psychosomatic research should focus on how superordinate traits interact within individuals and corroborate the appropriateness of a class model to describe coping styles of male coronary patients. It is argued that discrepant findings across studies of Type-A behaviour and hostility may be related to the coping subtypes of the subject sample. Further attempts to cross-validate this classification scheme and to examine its health-related correlates are needed.

Background. Functional MRI studies have begun to identify neural networks implicated in visuospatial working memory in healthy volunteers and patients with schizophrenia. The study of schizotypal personality disorder (SPD) provides regional analysis in unmedicated patients in the schizophrenia spectrum.

Method. Unmedicated patients with SPD by DSM-IV criteria and normal controls were assessed with fMRI while performing a visuospatial working-memory task. It required the subjects to retain the location of three dots located on the circumference of an imaginary circle and then respond to a query display in which one dot was presented and the subject required to press a button to indicate whether the probe dot location was previously displayed. Subject groups did not differ significantly in spatial memory scores. The exact Talairach and Tournoux coordinates of brain areas previously reported to show activation with spatial memory tasks were assessed.

Results. The majority of these locations showed BOLD response activation significantly less in patients during the memory retention period, including the left ventral prefrontal cortex, superior frontal gyrus, intraparietal cortex and posterior inferior gyrus. Regions in the right middle prefrontal and prestriate cortex showed greater activation at a trend level for patients with SPD than for normal controls. In addition, we replicated the findings of increased activation with the task in healthy volunteers in the premotor areas, ventral prefrontal cortex and parietal cortex.

Conclusions. SPD patients show decreased activation compared to healthy volunteers in key frontal regions and we also provided a partial replication of findings reported in healthy subjects.

Background. There is controversy surrounding the factor structure of the Parental Bonding Instrument (PBI), a widely used instrument for assessing perceived parental rearing behaviours. Recent studies have proposed five different factor structures, including Parker et al.'s original two-factor model.

Methods. Four hundred and eighteen employed Japanese adults filled out the PBI. Maximum likelihood confirmatory factor analyses were performed to compare the five different factor structures in terms of model-fit.

Results. Parker's original two-factor structure fitted the data poorly. In general, three-factor structures showed better fit. Among the three-factor structures, Murphy's model and Kendler's model were superior (the adjusted goodness-of-fit index >0·8), with the latter providing the best fit to the data (the goodness-of-fit index >0·9). When considering invariance of factor structure across gender subgroups and across age subgroups, only Kendler's model was acceptable.

Conclusions. Parker's two-factor structure of the PBI may not be appropriate for assessing perceived parental rearing behaviours in a Japanese population. Three-factor structures, in particular Murphy's model and Kendler's model, are preferable. Kendler's model provided the best fit to the data and was relatively invariant across the subgroups in this study. Thus, Kendler's model might prove to be very important for obtaining a factor structure invariant across different cultures.

Background. Chronic fatigue greatly affects quality of life and is a common reason for consulting a physician. Since conventional therapy is often of limited help, fatigued patients may use herbal treatments. This randomized controlled trial evaluated the effectiveness of Siberian ginseng.

Method. Subjects were recruited from advertisements in Iowa (82%) and members of chronic fatigue syndrome support groups (18%). Potential subjects were required to have substantial fatigue [ges ]6 months with no identifiable cause. The mean change in a fatigue measure was compared for placebo and Siberian ginseng at 1 and 2 months. Comparisons were for all subjects and for subjects with characteristics previously identified in the literature as important for categorizing chronic fatigue.

Results. Ninety-six subjects were randomized to treatment groups, and 76 provided information at 2 months of follow-up. Fatigue among subjects assigned to either placebo or Siberian ginseng was substantially reduced during the study, but differences between treatment groups were not statistically significant in the full sample. Fatigue severity and duration had a statistically significant interaction with response to Siberian ginseng at the P<0·05 level. Treatment was effective at 2 months for 45 subjects with less severe fatigue (P=0·04 unadjusted for multiple comparisons) and for 41 subjects with fatigue for [ges ]5 years (P=0·09 unadjusted for multiple comparisons).

Conclusion. Overall efficacy was not demonstrated. However, the findings of possible efficacy for patients with moderate fatigue suggests that further research may be of value.

Background. Current mental health legislation in the UK makes provision for the use of certain treatments in severely ill patients who are unable, or unwilling, to give informed consent. Under the terms of this legislation, electroconvulsive therapy (ECT) may be used, usually to treat severely depressed patients. A number of organizations have challenged this practice, stating that ECT should only be given with fully informed consent: it has been implied that patients receiving compulsory ECT (given without the patient's consent, under the terms of mental health legislation) find the treatment damaging and unhelpful.

Methods. A series of 150 patients receiving ECT in Aberdeen was studied. A proportion of the series (approximately 7%) received compulsory ECT. The views and treatment outcomes of compulsory patients were compared with those of patients giving informed consent for treatment.

Results. More than 80% of patients in both consenting and compulsory groups considered ECT to have helped them. Clinical outcome did not differ between the groups. Patients' views showed marked concordance with independent medical evaluation of outcome.

Conclusions. Outcome following ECT in non-consenting patients is equivalent to that seen in consenting patients whether rated by the patients themselves or by clinicians. Overall outcome is good, with more than 80% of patients benefiting from treatment. A ban on compulsory ECT would deny the access of seriously ill patients to an effective and acceptable treatment.

Plasma levels of chlorpromazine (CPZ) and prolactin were measured repeatedly in 14 psychiatric patients throughout CPZ treatment. Mean prolactin level was elevated in 11 subjects (all six women and five of eight men). Mean plasma prolactin correlated significantly with mean plasma CPZ but not with the dose of the drug. Only patients with mean plasma prolactin above 35 ng/ml developed Parkinsonian side-effects.