Background. We describe the epidemiology of suicide pacts in England and Wales and assess the health, circumstances and motivation of those who died in pacts; the first such account for 35 years.

Methods. We have analysed the death certificates, coroners' records and medical notes of all people who died in suicide pacts in England and Wales between 1 January 1988 and 31 December 1992.

Results. The 124 suicides in 62 pacts accounted for 0·6% of all suicides giving a rate of 0·6 per million. The average age was 56 years. Poisoning by car exhaust or medicines caused 95% of deaths, both members of each pair using the same method. Forty-eight pacts were between married couples, five between blood relatives. Mental disorder was present in half and medical illness in one-third. Motives were avoiding loss of a partner from ill-health in 26 pacts, euthanasia in nine, thwarted love in four.

Conclusions. The findings are similar to those of 35 years ago except the incidence of pacts is less. Improved management of illness might avoid some pacts especially when partners in an enduring, affectionate relationship, with few social ties, are both ill.

Background. Familial factors, which are partly genetic, influence risk for phobias. Prior family and twin studies, however, were based on a single lifetime assessment, which may be only moderately reliable.

Methods. We obtained, 8 years apart, two assessments of lifetime history of five unreasonable fears and phobias (agoraphobia and social, situational, animal and blood-injury phobia) from face-to-face and telephone interviews from 1708 individual female twins from a population-based registry. We also obtained, 1 month apart, test–retest reliability on 192 twins. We fitted, using the program Mx, a measurement model that estimates the role of genetic and environmental risk factors correcting for measurement error.

Results. Short-term reliability of the five phobias was modest (mean κ=0·46), but higher than long-term stability (mean κ=0·30). Unreliability occurred both for subject recall of unreasonable fears and for interviewer assessment of which fears constituted phobias. Examining fears and phobias together, in a multiple threshold model, results suggested that twin resemblance was due solely to genetic factors, with estimated total heritabilities, corrected for unreliability, of: any 43%, agoraphobia 67%, animal 47%, blood/injury 59%, situational 46% and social 51%. With the exception of animal phobia, similar results were obtained analysing phobias alone.

Conclusions. Lifetime histories of unreasonable fears and phobias assessed at personal interview have substantial unreliability. Correcting for unreliability, the liability to fears and their associated phobias is moderately heritable. Individual-specific environmental experiences play an important role in the development of phobias, while familial–environmental factors appear to be of little aetiological significance.

Background. It has been suggested that giving people the opportunity talk about a traumatic experience may prevent the development of later disorder. We tested the efficacy of two brief interventions, education and psychological debriefing, designed to prevent adverse psychological reactions to criminal victimization.

Methods. Individuals who had been the victims of a violent crime within the past month were written to and invited to take part in a study of their attitudes to crime and punishment: 2161 were contacted and 243 replied, of whom 157 were eligible and were randomly assigned either to an education condition, to a psychological debriefing plus education condition, or to an assessment only condition. Education involved providing information about normal post-traumatic reactions. Debriefing involved in-depth probing about events, thoughts and feelings experienced during the crime. Subjects were recruited from police and hospital sources and interviewed in their own homes: 138 were followed up at 6 months, and 92 at 11 months.

Results. Outcome was assessed using a DSM-III-R diagnosis of PTSD, the Post-traumatic Symptom Scale, the Impact of Event Scale and the Beck Depression Inventory. All groups improved over time but there were no between-group differences.

Conclusions. No evidence was found to support the efficacy of brief one-session interventions for preventing post-traumatic symptoms in individual victims of violent crime.

Background. The aim of the study was to identify sociodemographic and clinical risk factors for death from suicide and undetermined injury in residents of one health district.

Method. Data were collected on all cases of suicide (ICD-9 E950–959) and undetermined injury (ICD-9 E980–989) for residents in North Staffordshire Health District between 1991 and 1995. Controls, identified from the Coroner's inquest register, who died from other causes, were matched for age and sex.

Results. Two hundred and twelve pairs of cases and matched controls were identified. Multivariate analysis (conditional logistic regression) showed that the risk of death due to suicide and undetermined death was associated with: recent separation, relationship difficulties, experience of financial difficulties, history of past criminal charges or contact with the police, a past history of deliberate self-harm, being on psychotropic medication at the time of death and a diagnosis of bipolar affective disorder. For sociodemographic variables, a univariate analysis found associations between the cases and being separated, living alone, having a past history of criminal charges and unemployment. Cases were more likely to have a psychiatric disorder, past history of deliberate self-harm and a past history of psychiatric contact for themselves or a family member. Controls were more likely to have a current medical disorder. Cases were more likely than controls to be on any form of medication at the time of death and to have received a prescription for psychotropic or non-psychotropic medication in the week and month before death. Cases were more likely than controls to have had contact with medical services in the week and month before death, with the general practitioner in the week before death and with psychiatric services at any time in the year before death. Strong associations were found between suicide and undetermined injury and life events such as recent separation and bereavement, and financial and relationship difficulties.

Conclusions. The study provides an analytical investigation utilizing a dead control group, data gathered from several sources and adequate numbers of cases. It confirms many of the risk factors identified in other studies and highlights the high proportion of suicides who have been in recent contact with the criminal justice system or have been prescribed medication shortly before death.

Background. Expressed emotion (EE) is a measure that has been used to assess the quality of the relationship between patient and their key relative. It has been shown to be strongly predictive of clinical outcome in a range of psychiatric and medical disorders. This study investigated the effect of EE on treatment outcome in chronic post-traumatic stress disorder (PTSD).

Methods. A prospective design was adopted. The key relatives of 31 PTSD patients participating in a treatment trial comparing imaginal exposure with cognitive therapy were interviewed and rated on EE prior to treatment allocation. The effect of EE on post-treatment clinical outcomes was assessed.

Results. Sixteen patients (52%) had high EE and 15 (48%) low EE relatives. Patients with high EE relatives showed lesser change scores on the main outcome variable of the trial, the total CAPS score, and on all the secondary outcome variables than those with low EE relatives. Using different multiple regression models the EE scales of criticism and hostility predicted just under 20% of the outcome variance. These two scales were highly correlated and criticism marginally predicted the greatest variance (19·7%).

Conclusions. The results highlight the importance of the quality of the patient's social environment in influencing their response to cognitive and behavioural treatments.

Background. General population data were used to study co-morbidities between lifetime social phobia and mood disorders.

Methods. Data come from the US National Comorbidity Survey (NCS).

Results. Strong associations exist between lifetime social phobia and major depressive disorder (odds ratio 2·9), dysthymia (2·7) and bipolar disorder (5·9). Odds ratios increase in magnitude with number of social fears. Reported age of onset is earlier for social phobia than mood disorders in the vast majority of co-morbid cases. Temporally-primary social phobia predicts subsequent onset of mood disorders, with population attributable risk proportions of 10–15%. Social phobia is also associated with severity and persistence of co-morbid mood disorders.

Conclusions. Social phobia is a commonly occurring, chronic and seriously impairing disorder that is seldom treated unless it occurs in conjunction with another co-morbid condition. The adverse consequences of social phobia include increased risk of onset, severity and course of subsequent mood disorders. Early outreach and treatment of primary social phobia might not only reduce the prevalence of this disorder itself, but also the subsequent onset of mood disorders.

Background. Lower cognitive ability, higher neuroticism and symptoms of anxiety and depression in childhood predict non-psychotic disorder in adulthood. This study examined whether these early risk factors act by modifying relationships with life events close to disease onset in adulthood.

Methods. Childhood measures of neuroticism (N) (including maternal N), cognitive ability (CA) and symptoms of anxiety and depression were measured in a national British birth cohort of 5362 individuals born in the week 3–9 March, 1946. At ages 36 and 43 years, mental state examinations were carried out by trained interviewers, and subjects were asked about the occurrence of stressful life events in the previous year (SLE).

Results. The effect of aggregated SLEs on mental health was greater in women, in individuals with higher childhood N and poorer childhood mental health. Higher maternal N was also associated with greater sensitivity to SLEs, independent of subject's N, suggesting possible familial transmission of vulnerability. In addition, higher childhood N predicted, independent of later mental health, greater likelihood of reported exposure to SLEs. In general, individuals with higher childhood CA also reported more SLEs.

Conclusions. The results suggest that early risk factors for affective disorder exert effects by modifying person–environment relationships close to onset of adult symptoms. Sensitivity to life events may be transmitted from parents to offspring; psychopathological continuity over the life-span may be explained in part by continuity of altered stress sensitivity.

Background. Chronic fatigue syndrome (CFS) patients often complain that they are more susceptible to acute mental fatigue. It is important to determine whether this is observed using objective tests of sustained attention and responding.

Methods. Sixty-seven patients who fulfilled the criteria for CFS proposed by Sharpe et al. (1991) were compared with 126 matched healthy controls. Acute fatigue was assessed by comparing performance at the start and end of a lengthy test session and by examining changes over the course of individual tasks.

Results. CFS patients showed impaired performance compared to the controls and these differences increased as the volunteers developed acute fatigue. In addition, differences between the two groups were larger at the end of the test session.

Conclusions. The present results show that CFS patients are more susceptible to acute fatigue than healthy controls. This could reflect motor fatigue or an inability to compensate for fatigue with increased effort. This profile is consistent with previous research on fatigue and suggests that interpretation of certain aspects of CFS may be helped by considering it as the end point of a continuum of fatigue rather than a distinct disease.

Background. Despite markedly different clinical presentations, few studies have reported differences in neuropsychological functioning between mania and depression. The disinhibited behaviour characteristic of mania and evidence that subgenual prefrontal cortex is differentially activated in mania and depression both suggest that dissociable deficits will emerge on tasks that require inhibitory control and are subserved by ventromedial prefrontal cortex.

Methods. Manic patients and controls undertook computerized neuropsychological tests of memory and planning ability. In addition, manic and depressed patients were directly compared with controls on a novel affective shifting task that requires inhibitory control over different components of cognitive and emotional processing.

Results. Manic patients were impaired on tests of memory and planning. Importantly, affective shifting performance of manic patients differed from that of depressed patients. Manic patients were impaired in their ability to inhibit behavioural responses and focus attention, but depressed patients were impaired in their ability to shift the focus of attention. Depressed patients exhibited an affective bias for negative stimuli, and we believe this to be the first demonstration of an affective bias for positive stimuli in manic patients.

Conclusions. Observed impairments on tests of memory and planning suggest a global pathology for mania consistent with previous profiles for this disorder and similar to established profiles for depression. The results on the affective shifting task demonstrate the presence of mood-congruent bias and dissociable components of inhibitory control in mania and depression. Against a background of memory and planning impairments in the two groups, these findings are consistent with a role for the ventromedial prefrontal cortex in mediating mood–cognition relationships.

Background. Acute tryptophan depletion (ATD), a means of reducing brain serotonin synthesis, lowers mood in normal males with a multi-generational family history of major affective disorder (MAD) and in normal women devoid of any family history of psychiatric illness. As both a family history of MAD and female sex are factors predisposing to depression, the hypothesis that a mood lowering response to ATD may reflect a susceptibility to depression was further investigated in young women with an extensive, multi-generational family history of MAD. In addition, the temporal stability of mood change following repeated trials of ATD was also assessed in this study.

Methods. To deplete tryptophan, a tryptophan deficient amino acid mixture was ingested on two separate occasions. The control treatment, administered on a third occasion, was a nutritionally balanced amino acid mixture containing tryptophan.

Results. A marked lowering of plasma tryptophan (85–90%) was achieved by both depletions. In comparison to the balanced condition, family history positive (FH+) women showed no lowering of mood to either the first or second ATD (N=13) and N=12, respectively). Mood change between the two ATD trials (N=13) exhibited poor temporal stability.

Conclusions. These results may indicate that serotonin responsiveness is not an important characteristic of vulnerability to depression in these women. Alternately, these negative results may be due to the exclusion of a large number of FH+ women who had already experienced an episode of depression, resulting in the selection of a biased FH+ sample who are resistant to the mood lowering effects of ATD.

Background. The response styles theory suggests that rumination in response to depressed mood exacerbates and prolongs depression, while distraction ameliorates and shortens it. Gender differences in response styles are said to contribute to the observed gender differences in the prevalence of unipolar depression. While empirical support for the theory has been found from a variety of non-clinical studies, its generalizability to clinically depressed patient populations remains unclear.

Methods. A cohort of 52 unipolar depressed in-patients was assessed with the Response Styles Questionnaire during in-patient stay (T1) and 4 weeks after discharge (T2). The patients were followed up 4 months after discharge (T3). Clinical assessment included the SCAN-PSE-10.

Results. Moderate and statistically significant retest-stabilities for rumination and distraction were found, comparable for patients with stable and changing depression status from T1 to T2. A cross-sectional diagnosis of a major depressive episode was associated with rumination, while gender was not. Post-discharge baseline rumination (T2), adjusted for concurrent depression, predicted follow-up levels of depression (T3), and, in patients who were non-remitted at post-discharge baseline, it predicted presence of a major depressive episode at follow-up (T3). Results on distraction were more ambiguous.

Conclusions. Our results suggest that rumination is likely to have a deteriorating impact on the course of clinical episodes of depression in unipolar depressed patients. Larger longitudinal patient studies are needed to validate these findings.

Background. The aim of this review was to survey the available literature on prodromal and residual symptoms of unipolar major depression and bipolar disorder.

Methods. Both a computerized (Medline) and a manual search of the literature were performed.

Results. In a substantial proportion of patients with affective disorders a prodromal phase can be identified. Most patients report residual symptoms despite successful treatment. Residual symptoms upon remission have a strong prognostic value. There appears to be a relationship between residual and prodromal symptomatology (the rollback phenomenon).

Conclusions. Appraisal of subclinical symptomatology in mood disorders has important implications for pathophysiological models of disease and relapse prevention. In depression, specific treatment of residual symptoms may improve long-term outcome, by acting on those residual symptoms that progress to become prodromes of relapse. In bipolar disorder, decrease of subclinical fluctuations and improvement of level of functioning by specific therapeutic strategies may add to the benefits provided by lithium prophylaxis.

Background. We examine potential sources of the sex differences in post-traumatic stress disorder (PTSD) in the community.

Methods. Data were obtained from a representative sample of 2181 persons aged 18–45 years in the Detroit primary metropolitan statistical area, which is a six-county area containing more than four million residents. A random digit dialling method was used to select the sample and a computer-assisted telephone interview was used to obtain the data. DSM-IV PTSD was assessed with respect to a randomly selected trauma from the list of qualifying traumas reported by each respondent.

Results. The lifetime prevalence of exposure and the mean number of traumas were lower in females than males. The overall conditional risk of PTSD (i.e. the probability of PTSD among those exposed to a trauma) was approximately twofold higher in females than males, adjusting for the sex difference in the distribution of trauma types. The sex difference was due primarily to females' greater risk following assaultive violence. The sex difference in the avoidance and numbing symptom group following assaultive violence exceeded the sex differences in other symptom groups.

Conclusions. Future research should focus on sex differences in the response to assaultive violence, including potential explanations for females' greater probability to experience avoidance and numbing.

Background. This study reports antecedents of recovery from DSM-III-R social phobia.

Methods. Retrospective data were obtained from 1116 individuals age 15 to 64 participating in a large population health survey in the province of Ontario, Canada.

Results. Approximately 50% of the sample recovered from their illness. Survival analysis revealed a median length of illness of 25 years with peak periods of risk of recovery occurring between 30 and 45 years duration. Using discrete time multivariate hazard regression analysis, statistically significant predictors of recovery from social phobia included: childhood social contextual factors (one or no childhood siblings, a small town childhood place of residence), characteristics of the disorder (onset past the age of 7, less than three disorder symptoms), an absence of co-morbid health-related conditions and psychiatric disorders (chronic health problems and major depression), and the occurrence of co-morbid chronic health problems and major depression prior to the onset of the disorder.

Conclusions. Our data indicate that social phobia in the general population is a chronic and unremittent disorder. Determinants of recovery are rooted in distal childhood circumstances, disorder attributes, and the physical and mental health status of individuals over the life course.

Background. Infectious diseases are accompanied by behavioural and psychological changes that suggest the implication of the central nervous system. Among them, cognitive alterations have been reported, but their specificity and implication in everyday life are still largely unclear. The purpose of the present study was to evaluate and specify the everyday memory disturbances in sick human subjects and to determinate the role of fever in the appearance of these alterations.

Methods. The study was carried out in a military training centre for naval recruits. Ninety-one volunteer subjects, healthy (N=30) or suffering from flu-like syndrome, with (N=29) or without fever (N=32), participated in this experiment and were administered a cognitive test (the ERBMT) according to a cross-sectional design for assessing various aspects of everyday memory.

Results. Sick subjects were specifically impaired in daily memory tasks that require the temporary management of a large amount of information. This impairment was similar for the feverish and apyretic sick subjects who both differed from the controls.

Conclusion. These findings suggest that infectious disease disturbs the complex cognitive processes that might be associated with attentional functions. Moreover, these results show that fever is not a necessary condition for the appearance of these cognitive disturbances.

Background. Substantial evidence exists for an important genetic contribution to alcohol dependence risk in women and men. It has been suggested that genetically determined differences in alcohol sensitivity may represent one pathway by which an increase in alcohol dependence risk occurs.

Methods. Telephone interview follow-up data were obtained on twins from male, female and unlike-sex twin pairs who had participated in an alcohol challenge study in 1979–81, as well as other pairs from the same Australian twin panel surveyed by mail in 1980–82.

Results. At follow-up, alcohol challenge men did not differ from other male twins from the same age cohort on measures of lifetime psychopathology or drinking habits; but alcohol challenge women were on average heavier drinkers than other women. Acomposite alcohol sensitivity measure, combining subjective intoxication and increase in body-sway after alcohol challenge in 1979–81, exhibited high heritability (60%). Parental alcoholism history was weakly associated with decreased alcohol sensitivity in women, but not after adjustment for baseline drinking history, or in men. High alcohol sensitivity in men was associated with substantially reduced alcohol dependence risk (OR=0·05, 95% CI 0·01–0·39). Furthermore, significantly decreased (i.e. low) alcohol sensitivity was observed in non-alcoholic males whose MZ co-twin had a history of alcohol dependence, compared to other non-alcoholics. These associations remained significant in conservative analyses that controlled for respondents' alcohol consumption levels and alcohol problems in 1979–81.

Conclusions. Men (but not women) at increased genetic risk of alcohol dependence (assessed by MZ co-twin's history of alcohol dependence) exhibited reduced alcohol sensitivity. Associations with parental alcoholism were inconsistent.

Background. Recent studies have suggested that subjects with depression suffer a diagnosis-specific motivational deficit, characterized by an abnormal response to negative feedback that endures beyond clinical recovery. Furthermore, it has been suggested that negative feedback may motivate non-depressed controls, but not depressed patients, to improve their performance in neuropsychological tests.

Methods. We describe two studies. The first compared performance on the simultaneous and delayed match to sample (SDMS) task from the CANTAB neuropsychological test battery, in 20 patients with severe depression with 20 with acute schizophrenia, 40 with chronic schizophrenia and 40 healthy controls. The second examined the performance of depressed patients with diurnal variation in symptoms and cognitive function.

Results. All patients groups showed impairments on the simultaneous and delayed match to sample task compared to controls. Depressed patients did not show an abnormal response to negative feedback. Controls did not show a motivational effect of negative feedback. Depressed patients with diurnal variation showed no variation in their response to perceived failure. There was no evidence of abnormal response to negative feedback in any patient group using the ‘runs test’ or of a motivational effect in controls. Conditional probability analysis was not independent of the total number of errors made in the SDMS task.

Conclusions. Further studies are suggested to examine whether an abnormal response to negative feedback characterizes particular subgroups of patients suffering from depression.

Background. The development of drug dependence requires prior initiation. What is the relationship between the risk factors for initiation and dependence?

Methods. Using smoking as a model addiction, we assessed smoking initiation (SI) and nicotine dependence (ND) by personal interview in 1898 female twins from the population-based Virginia Twin Registry. We developed a twin structural equation model that estimates the correlation between the liability to SI and the liability to ND, given SI.

Results. The liabilities to SI and ND were substantially correlated but not identical. Heritable factors played an important aetiological role in SI and in ND. While the majority of genetic risk factors for ND were shared with SI, a distinct set of familial factors, which were probably partly genetic, solely influenced the risk for ND. SI was associated with low levels of education and religiosity, high levels of neuroticism and extroversion and a history of a wide range of psychiatric disorders. ND was associated with low levels of education, extroversion, mastery, and self-esteem, high levels of neuroticism and dependency and a history of mood and alcohol use disorders.

Conclusions. The aetiological factors that influence SI and ND, while overlapping, are not perfectly correlated. One set of genetic factors plays a significant aetiological role in both SI and ND, while another set of familial factors, probably in part genetic, solely influences ND. Some risk factors for SI and ND impact similarly on both stages, some act at only one stage and others impact differently and even in opposite directions at the two stages. The pathway to substance dependence is complex and involves multiple genetic and environmental risk factors.

Background. Although anxiety is quite prevalent in late life, its impact on disability, well-being, and health care utilization of older persons has not been studied. Older persons are a highly relevant age group for studying the consequences of anxiety, since their increasing numbers put an extra strain on already limited health care resources.

Methods. Data of a large community-based random probability sample (N=659) of older subjects (55–85 year) in the Netherlands were used to select three groups: subjects with a diagnosed anxiety disorder, subjects with merely anxiety symptoms and a reference group without anxiety. These groups were compared with regard to their functioning, subjective well-being, and use of health care services, while controlling for potentially confounding variables.

Results. Anxiety was associated with increased disability and diminished well-being. Older persons with a diagnosed anxiety disorder were equally affected in their functioning as those with merely anxiety symptoms. Although use of health services was increased in anxiety sufferers, their use of appropriate care was generally low.

Conclusions. Anxiety has a clear negative impact on the functioning and well-being of older subjects. The similarity of participants with an anxiety disorder and those having merely anxiety symptoms regarding quality of life variables and health care use was quite striking. Finally, in spite of its grave consequences for the quality of life, appropriate care for anxiety is seldom received. Efforts to improve recognition, disseminate effective treatments in primary care, and referring to specialized care may have positive effects on the management of anxiety in late life.

Background. Assessment of adjustment of patients in cancer treatment trials is becoming more common and increasingly regarded as a useful outcome measure. The widely used Mental Adjustment to Cancer (MAC) Scale was designed to measure Fighting Spirit (FS), Anxious Preoccupation (AP), Helpless–hopelessness (HH) and Fatalism.

Methods. Questionnaire responses from 632 breast cancer patients were randomly divided into two groups, one for exploratory analyses and possible scale refinement, and the other for validation purposes.

Results. Estimates of reliability (Cronbach's α) were satisfactory for two scales, FS (α = 0·85) and HH (α = 0·81), but lower for AP (α = 0·65) and Fatalism (α = 0·64). Exploratory factor analysis suggested that the MAC Scale might be measuring six independent constructs including two related to Fighting Spirit (Positive Orientation to the Illness, Minimizing the Illness), two related to Fatalism (Fatalism-revised, Loss of Control), a construct we have named Angst, and an unchanged HH construct. Scales developed to measure these constructs were satisfactorily replicated in confirmatory analyses but some reliabilities were lower than desirable. The general structure of the MAC Scale remained little changed despite the division of two scales and the suggested removal of six items. The refined scales correlated with the Hospital Anxiety and Depression scale and the Medical Coping Modes Questionnaire, indicating good concurrent validity.

Conclusions. While reasonable reliability of the original scales persists through analyses of the MAC Scale, the original factor structure could not be reproduced. Six refined constructs with strong construct validity were identified within the overall domain of mental adjustment to cancer.