The severe depressive disorders of late life are associated with high rates of medical morbidity and mortality, cognitive impairment, suicide, disability, complex treatment regimens, institutionalization and high costs to the community (Murphy, 1983; Murphy et al. 1988; Bruce & Leaf, 1989; NIH Consensus Development Panel, 1992; Alexopoulos et al. 1993a, b; Brodaty et al. 1993; Bruce et al. 1994; Forsell et al. 1994; Hickie et al. 1995; Blazer, 1996). Those disorders that are accompanied by cognitive impairment and/or concurrent medical morbidity have a particularly poor outcome (Bruce & Leaf, 1989; Alexopoulos et al. 1993b; Hickie et al. 1995, 1997a). Although psychosocial models of late-life depression place considerable importance on age-related psychological and social risk factors, those who survive into later life may actually be characterized by psychological resilience (Henderson, 1994; Blazer, 1997).

Current aetiological research in late-life depression, therefore, places particular emphasis on the potential role of biological risk factors. The potential importance of vascular risk factors is receiving renewed attention and may provide opportunities for specific prevention and intervention strategies in high-risk populations. This emphasis on possible vascular risk factors, and the wider importance of vascular pathologies in late-life neuropsychiatric disorders, mirrors the emphasis of much earlier clinico-pathological studies (Binswanger, 1894; Alzheimer, 1895). The specific focus on the importance of small progressive changes within the subcortical white matter, as distinct from more discrete cortical infarcts (Olszewski, 1962), is now supported by the emerging neuroimaging literature and theoretical constructs in late-life depression (Krishnan, 1991, 1993; Hickie et al. 1996, 1997b; Krishnan et al. 1997).

Numerous studies conducted in clinical and community settings by researchers from different countries over a period of almost five decades, have conclusively shown protracted and disabling psychiatric effects among World War II Holocaust victims, formerly known as the concentration camp syndrome (e.g. Matussek, 1975; Eitinger & Krell, 1985; Eitinger & Major, 1993; Levav, 1998). The multiple and brutal trauma endured by the survivors during the war years were further compounded by earlier systematic discrimination, and by exhausting socio-political events and pogroms that followed liberation by the Allies. In this latter period survivors had to learn the fate of their spouses, children, parents, other relatives and friends. Hastily contracted post-war marriages were likely intended both to cope with feelings of extreme loneliness and to recreate a social support group that would buttress survival.

Given the above, many observers hypothesized that, among other impaired abilities, survivors would evidence a deficit in their parenting functions. As one author noted 25 years ago: ‘Survivors are now beginning to bring their children to our clinics. In retrospect one should not be surprised at this because of the nature and severity of the psychological effects of the persecution, and because the emotional state of the parents has some bearing on the development of the child …’ (Sigal, 1971). Several mediating mechanisms that affected the survivors' family as a functioning unit were postulated by the examining clinicians, such as over-involvement, withdrawal, inability to exert control, parental affective unavailability, undue degree of preoccupation with past experiences, and an inability to cope with mourning and bereavement (Klein, 1973; Levine, 1982; Sigal & Weinfeld, 1989). Other imputed mechanisms referred to psychological processes taking place during child development, such as difficulties in the individuation-separation phase (Freyberg, 1980).

Background. The reform of mental health services needs to be guided by an overall conceptual framework. Such a framework is important to avoid many risks, including extrapolating from a specific service site to other services, without taking into account local and regional variables.

Methods. A conceptual framework, the ‘matrix model’, is proposed. This model has been developed using the most relevant information that is necessary for describing and interpreting mental health services data as well as patient-based information.

Results. The ‘matrix model’ has two dimensions: the geographical, which refers to three levels (country, local and patient) and the temporal, which refers to three phases (inputs, processes and outcomes). Using these two dimensions a nine-cell matrix is constructed to bring into focus critical issues for mental health services. The relevance of each level and each phase is briefly presented.

Conclusions. The matrix is intended to assist clinicians, planners and researchers to deal with clinical phenomena, organizational issues, and research questions that share a degree of complexity that render inadequate analyses and the interventions made only at one level. The matrix model applies particularly to mental health systems of care that are provided with a public health framework, and is less useful for contexts that consist of clinicians offering only one-to-one treatments, within fragmented programmes of care.

This issue of Psychological Medicine carries a number of papers on the neurobiology of major depression. Those acquainted with the field will recognize some familiar topics and while familiarity can be comforting, it can also raise a sense of unease; as the millennium approaches should we still be enquiring about the role of decreased serotonin and increased cortisol in the pathophysiology of depressive disorders?

In our defence we can maintain that there is, in fact good evidence that serotonin and cortisol are implicated in the biology of depression. Our failure to tie down exactly how they are involved in the manifestation of the depressive syndrome does not reflect their lack of importance but rather the problems we have in asking the right questions and the technical difficulties we have answering them. So how far do the papers in this issue take us into this difficult territory ?

Sex differences in rates of depressive disorder have not been convincingly explained, and this reflects a more general failure of research to provide a comprehensive aetiological account of depression. The difference can be used as a probe for evaluating the research base of integrative models of depressive disorder (e.g. Akiskal & McKinney, 1975). It is particularly likely to be illuminating if the causes of the sex difference do not overlap completely the causes of depression itself. While there have been many reviews in the area (Weissman & Klerman, 1977; Kessler & McRae, 1981; Wolk & Weissman, 1995; Bebbington, 1996), this point has not been adequately expressed.

Several lines of investigation are necessary for assessing the relative importance of social, psychological and biological influences: the epidemiological study of macrosocial variables and of age effects; temperament, personality, and attributional and coping styles; the experience of psychosocial adversity; and the possibility of increased susceptibility to some forms of stress in women. Both the tendency to affiliation and the requirement for social support may differ by sex. The particular strains of the roles available to women may increase their risk of depression. Possible genetic explanations of the sex difference are of special relevance because of their implications for biological differences. The latter can also be studied directly: hormonal theories in particular must be evaluated.

Foolish as the theory of Durkeim may be in confusing what is religious with what is social, it yet contains an element of truth; that is to say that the social feeling is so much like the religious as to be mistaken for it. (Simone Weil, 1951).

Psychiatrists concern themselves with human mental suffering. Behind the consulting room door they reflect with their patients on questions of meaning and existence, issues that concern philosophy and religion as much as psychiatry. It is striking, therefore, that psychiatrists regard spirituality and religion as, at best, cultural noise to be respected but not addressed directly, or at worst pathological thinking that requires modification (Larson et al. 1993).

Despite two millennia of debate we are little nearer a consensus on the meanings of spirituality and religion. The word ‘religion’ has as many definitions as writers. Spirituality and religion are often used interchangeably. Spilka (1985) doubts that a single definition is even possible. Dittes (1969) argues that religion contains so many unrelated variables that it cannot be considered as a unidimensional concept in research. We would argue that religion is the outward practice of a spiritual system of beliefs, values, codes of conduct and rituals (Speck, 1988). Religious groups may function like any other with codes of behaviour, political alliances and ‘in’ and ‘out’ group member ideology (Sherif et al. 1966).

Unfortunately, a concentration on the religious variable has led to a failure to appreciate the broader concept of spiritual and the presumption that if someone does not profess a recognized, religious faith, they have no spiritual discernment or need (Speck, 1988). We propose a definition of ‘spiritual’ as a person's experience of, or a belief in, a power apart from their own existence. It may exist within them but is ultimately apart. It is the sense of relationship or connection with a power or force. It is more specific than a search for meaning or a feeling of unity with others. People may use the word ‘spiritual’ to describe intense emotional pleasure when moved by natural beauty or by an important relationship. Spiritual belief is more specific than that. Some people may use the word ‘God’ to describe this power; others may be less specific. Spirituality differs from belief in other powers, such as nuclear power or magnetism, in its ‘set apart’ quality and the degree to which it is revered and ritualized, the quality which Durkheim (1915) refers to as the sacred.

Background. This study seeks to identify the genetic and environmental risk factors for the overvalued ideas that are characteristic of bulimia nervosa, using a biometrical model fitting approach with twin data.

Methods. The Eating Disorder Examination (EDE), which can be used to gain continuous measures of dietary restraint, eating concern, weight concern and shape concern, was administered to 325 female twins, both monozygotic (MZ) and dizygotic (DZ). For each subscale, questions were asked concerning the month prior to interview and lifetime prevalence (‘ever’).

Results. Model fitting indicated that there is a powerful role of the environment in shaping women's attitude towards weight, shape, eating and food, ranging from 38% to 100% of the variance. For all subscales, with the exception of weight concern, the best explanation for individual variation was one that incorporated additive genetic and non-shared environmental influences. In contrast, model fitting indicated that non-shared and shared environmental influences best explained the variance of weight concern.

Conclusions. With the exception of the Shape Concern subscale, environmental factors make a greater contribution than genetic factors to the development of the overvalued ideas that are seen to be one of the triggers for the development of bulimia nervosa. Given this substantial role of the environment influences, it seems likely that environmental manipulation can be effective in the prevention of bulimia nervosa.

Background. We examine a ‘lock and key’ (‘L–K’) hypothesis to depression which posits that early adverse experiences establish locks that are activated by keys mirroring the earlier adverse experience to induce depression.

Methods. Two-hundred and seventy clinically depressed patients were examined with open-ended and pre-coded interview questions to ascertain both early adverse experiences and precipitating life events. Qualitative and quantitative data analyses examined for any associations between developmental ‘locks’ and precipitating ‘keys’.

Results. Qualitative assessment suggested ‘L–K’ links in almost one-third of the sample, and examples are provided. While quantitative analyses indicated significant associations between several identical ‘lock’ and ‘key’ constructs, evidence of specificity was rare. When individual ‘locks’ and ‘keys’ were consolidated into three higher-order constructs, variable models were suggested, including a non-specific link, a specific link and absence of any link. ‘L–K’ links appeared more likely in those with ‘non-melancholic’ (versus ‘melancholic’) depression, with the seemingly greater relevance to ‘reactive’ (versus ‘neurotic’) depression in the quantitative analyses inviting speculation that that ‘disorder’ may be more a reaction to a salient rather than a severe stressor.

Conclusions. This exploratory study suggests that early adverse experiences may variably establish specific and non-specific patterns of vulnerability to having depression triggered by exposure to salient mirroring life event stressors.

Background. Deficiencies in brain serotonin function are believed to play an important role in the pathophysiology of seasonal affective disorder/winter type (SAD). However, no direct evidence has been reported so far that lowered brain serotonin activity causes the symptoms of SAD.

Methods. We studied 11 SAD patients who had suffered recurrent winter depressive episodes of SAD and were fully recovered and off treatment during the summer. In a randomized, balanced, double-blind crossover design patients received two amino acid beverages, one containing tryptophan and the other containing no tryptophan but otherwise identical. Behavioural ratings and plasma total and free tryptophan concentrations were assessed at baseline before administration of the amino acid beverages and at several time points afterwards.

Results. The tryptophan-free amino acid beverage induced significant decreases of plasma total and free tryptophan levels and both levels increased during sham depletion (condition×time interaction: P<0·001). Tryptophan depletion, but not sham depletion caused a transient return of depressive symptoms (condition×time interaction: P<0·001).

Conclusions. The present study demonstrates that SAD patients in remission during the summer are vulnerable to a return of depression when depleted of tryptophan. This finding supports the importance of serotonergic mechanisms in the pathophysiology of SAD.

Background. Women are consistently reported to have a greater prevalence of depressive disorders than men. The reason for this is unclear, and is as likely to be social as biological. There is some evidence that the excess of depression is greater during women's reproductive lives. Data from the National Survey of Psychiatric Morbidity were used to test the hypothesis that the excess disappeared in the post-menopausal years and that obvious social explanations for this were inadequate.

Method. Subjects (N=9792) from a random sample of the British population provided data for the analysis. Psychiatric assessment was carried out by lay interviewers using the CIS-R. Subjects with ICD-10 depressive episode or mixed anxiety/depression were compared with the remainder. Social variables that were likely to contribute to a post-menopausal decline in depressive disorders were controlled in logistic regression analyses.

Results. There was a clear reversal of the sex difference in prevalence of depression in those over age 55. This could not be explained in terms of differential effects of marital status, child care, or employment status.

Conclusions. This large and representative survey adds considerably to the increasingly held view that the sex difference in prevalence of depression is less apparent in later middle age. This may be linked to the menopause, and our attempts to explain it in terms of obvious conditions among social variables were not successful. More specific studies are required to clarify the finding.

Background. The purpose of this analysis was to examine: (1) the prevalence of psychiatric disorders among disabled people, using seven different measures of disability; (2) variation in disability between and within psychiatric diagnostic categories; and (3) relationship of diagnosis and disability to health service utilization.

Method. Data were drawn from Phase I and Phase II of the Eastern Baltimore Mental Health Survey, part of the Epidemiologic Catchment Area Program (ECA) conducted in 1980–1 to survey mental morbidity within the adult population. A total of 810 individuals received both a household interview and a standardized clinical psychiatric evaluation. Estimated prevalence rates were computed using appropriate survey sampling weights.

Results. Prevalence of disability ranged from 2·5 to 19·5%, varying with specific disability measure. Among those classified as disabled by any of the measures examined, 56 to 92% had a psychiatric disorder and serious chronic medical conditions were present in the majority of these cases (54 to 78%). Disability was expressed differently among the various diagnostic groups. Diagnostic category and disability were significant independent predictors of medical service utilization and receipt of disability payments.

Conclusions. The majority of disabled adults living in the community have diagnosable psychiatric disorders, with the majority of these individuals suffering from significant chronic medical conditions as well, thus making co-morbidity the norm.

Background. Late-life depression is associated with increased subcortical white matter hyper-intensities. There is some evidence that they are associated with a poorer response to acute treatment. Neurological signs and neuropsychological dysfunction are further evidence of abnormalities in the brain, but they have not been studied in relation to therapy resistance.

Methods. A prospective study of 24 normal controls and 75 consecutive elderly (aged 65 to 85) patients with DSM-III-R major depression entered a naturalistic study of treatment. Assessment of response to monotherapy and then lithium augmentation or ECT created three outcome groups. Investigations included magnetic resonance brain imaging, neuropsychological and neurological examination.

Results. Response to monotherapy within 12 weeks was shown by 42·7%, a further 37·3% responded to lithium augmentation or ECT within 24 weeks and 20% had responded poorly to all treatments at 24 weeks. Subcortical hyperintensities were significantly increased in the more resistant patients. These included confluent deep white matter, multiple (>5) basal ganglia lesions and pontine reticular formation lesions. Most of the neuropsychological impairment was restricted to the resistant groups and was of a subcortico-frontal type. Extrapyramidal, frontal and pyramidal neurological signs characterized the resistant groups. The combination of extrapyramidal signs, pyramidal tract signs and impairment of motor hand sequencing strongly predicted resistance to 12 weeks of antidepressant monotherapy with 89% sensitivity and 95% specificity.

Conclusion. In late-life depression a poor response to antidepressant monotherapy can be expected in those patients with a frontal lobe syndrome, extrapyramidal signs or if MRI T2-weighted lesions are present in both the basal ganglia and the pontine reticular formation.

Background. Elderly residents of public housing have high rates of psychiatric disorders, but most of those in need of care do not use any mental health service. This study examines the use of formal and alternative informal sources of mental health care in a sample of elderly African-American public-housing residents.

Method. Data from an epidemiological survey of six Baltimore public-housing developments for the elderly (weighted N=818) were analysed to examine the utilization of mental health services by older African-American residents. Logistic regression analyses were used to determine correlates of using formal and informal sources by those needing mental health care.

Results. Thirty-five per cent of subjects needed mental health care. Less than half (47%) of those in need received any mental health care in the previous 6 months. Residents in need were more likely to use formal (38·5%) than informal sources (18·6%) for care. The strongest correlates of using formal providers were substance use disorder (OR=15·62), Medicare insurance (OR=10·31) and psychological distress (OR=10·27). The strongest correlates of using informal sources were perceiving little or no support from religious/spiritual beliefs (OR=21·65), cognitive disorder (OR=19·71) and having a confidant (OR=15·07).

Conclusions. Contrary to elderly African-Americans in general, those in public housing rely more on formal than informal sources for mental health problems. Nevertheless, both sources fail to fill the gap between need and met need. Interventions to increase identification, referral and treatment of elderly public-housing residents in need should target general medical providers and clergy and include assertive outreach by mental health specialists.

Background. A review of studies of cognition in the euthymic phase of unipolar and bipolar affective disorder reveals diverging results.

Methods. The study was designed as a controlled cohort study, with the Danish psychiatric case register of admissions used to identify patients and the Danish civil register to identify controls. Patients who were hospitalized between 19 and 25 years ago with an affective diagnosis and who at interviews fulfilled criteria for a primary affective unipolar or bipolar disorder, according to ICD-10, were compared with age- and gender-matched controls. Interviews and assessment of the cognitive function were made in the euthymic phase of the disorder. In all, 118 unipolar patients, 28 bipolar patients and 58 controls were included. Analyses were adjusted for differences in the level of education and for subclinical depressive and anxiety symptoms.

Results. Patients with recurrent episodes were significantly more impaired than patients with a single episode and more impaired than controls. Also, within patients the number of prior episodes seemed to be associated with cognitive outcome. There was no difference in the severity of the dysfunction between unipolar and bipolar patients.

Conclusions. Cognitive impairment in out-patients with unipolar and bipolar disorder appears to be associated with the number of affective episodes.

Background. In the present paper, sex differences in the association between adult depression and childhood experiences were examined.

Methods. The study series of the Finnish UKKI Study consisted of a population sample of 501 men and 499 women. Information concerning childhood experiences was gathered retrospectively in a baseline survey carried out in 1969–72. After the initial phase, the mental health of the subjects was evaluated by interviews, questionnaires and register data at the 5-year follow-up (1974–6) and at the 16-year follow-up (1985–7).

Results. Twelve per cent of men and 21% of women had suffered from depression during the 16-year follow-up period. A disturbed mother–child relationship and neurotic symptoms in childhood were associated with depression in women but not in men in the logistic model that included gender interaction. In separate analyses by gender several childhood factors showed statistically significant associations with depression in women but only a few in men.

Conclusions. The finding suggests that childhood experiences are more highly predisposing factors to depression in women than in men.

Background. This study examined the patterns of familial aggregation and co-morbidity of alcoholism and anxiety disorders in the relatives of 165 probands selected for alcoholism and/or anxiety disorders compared to those of 61 unaffected controls.

Methods. Probands were either selected from treatment settings or at random from the community. DSM-III-R diagnoses were obtained for all probands and their 1053 first-degree relatives, based on direct interview or family history information.

Results. The findings indicate that: (1) alcoholism was associated with anxiety disorders in the relatives, particularly among females; (2) both alcoholism and anxiety disorders were highly familial; (3) the familial aggregation of alcoholism was attributable to alcohol dependence rather than to alcohol abuse, particularly among male relatives; and (4) the pattern of co-aggregation of alcohol dependence and anxiety disorders in families differed according to the subtype of anxiety disorder; there was evidence of a partly shared diathesis underlying panic and alcoholism, whereas social phobia and alcoholism tended to aggregate independently.

Conclusions. The finding that the onset of social phobia tended to precede that of alcoholism, when taken together with the independence of familial aggregation of social phobia and alcoholism support a self-medication hypothesis as the explanation for the co-occurrence of social phobia and alcoholism. In contrast, the lack of a systematic pattern in the order of onset of panic and alcoholism among subjects with both disorders as well as evidence for shared underlying familial risk factors suggests that co-morbidity between panic disorder and alcoholism is not a consequence of self-medication of panic symptoms. The results of this study emphasize the importance of examining co-morbid disorders and subtypes thereof in identifying sources of heterogeneity in the pathogenesis of alcoholism.

Background. A new interview measure of life events and post-traumatic stress disorder (PTSD) has been developed for children and adolescents aged 9 through 17, for use in both epidemiological and clinical studies. It includes ‘high magnitude’ events associated with PTSD as well as other ‘low magnitude’ events.

Method. The interview is designed as a module of the Child and Adolescent Psychiatric Assessment, an interviewer-based interview conducted with parent and child separately by trained lay interviewers. The module includes: (1) questions about a wide range of events; (2) a screen for key PTSD symptoms (painful recall, avoidance, hypervigilance); and (3) a detailed interview on all PTSD symptoms, including onset, duration, severity and co-morbidity. A test–retest reliability study was conducted with 58 parents and children, who were interviewed twice by different interviewers.

Results. Intraclass correlations were 0·72 (child) and 0·83 (parent) for high magnitude events, and 0·62 (child) and 0·58 (parent) for low magnitude events. Kappa coefficients ranged from high for violence and sexual abuse to low for child reports of serious accidents and natural disasters. The reliability of the PTSD screen symptoms was fair to excellent (κ=0·40–0·79), and reliability of PTSD symptoms in those who passed the screen was excellent (ICC=0·94–0·99). Compared with a general population sample (N=1015), the clinic-referred subjects and their parents were twice as likely to report a traumatic event and, depending on the event, up to 25 times as likely to report symptoms of PTSD.

Conclusions. The results support the reliability and discriminant validity of the measure.

Background. An investigation of the association between diurnal changes in cortisol and DHEA levels, or in the cortisol/DHEA ratio at five different time points at presentation, and the occurrence of undesirable life events (losses, dangers to self and others, disappointments) during follow-up, and the outcome of major depression at 36 weeks were investigated.

Methods. Psychosocial and endocrine assessment of a consecutive cohort (N=68) of 8- to 16-year-old subjects with first episode major depression reassessed 12 months after presentation using a repeat measures design.

Results. Higher cortisol/DHEA ratios at 20.00 or 24.00 h predicted persistent major depression. Basal levels of either hormone alone or cortisol/DHEA ratios at the other three time points (08.00, 12.00 or 16.00 h) did not. High cortisol/DHEA ratios (i.e. values greater than the 60th percentile) at both evening points (20.00 and 24.00 h) also predicted the occurrence of subsequent disappointing life events but no other category of undesirable event. Both high evening cortisol/DHEA ratio at 20.00 h and one or more severely disappointing life events between presentation and follow-up predicted persistent major depression: 86% of subjects with both of these factors were still depressed at 36 weeks whereas 81% with neither factor were not.

Conclusions. The finding that it is depressed subjects with high cortisol/DHEA ratios at presentation who are specifically at risk for subsequent disappointing life events suggests a putative role for these adrenal steroids in abnormal cognitive or emotional processes associated with disturbed interpersonal behaviour.

Background. The methodology for measuring the needs of patients with severe mental illness is now well established through the MRC Needs for Care Assessment Schedule and its modification in the form of the Cardinal Needs Assessment. This paper reports the rationale and construction of a relatives' version of the Cardinal Needs Schedule and looks at preliminary data reporting on reliability and validity.

Methods. Potential problem areas for relatives were identified from the literature. The criteria determining Cardinal Needs for each problem included objective threshold, carer concern, and carer cooperation. The reliability of the Schedule was assessed in a study whereby 27 relatives of patients with established schizophrenic illness completed two Schedules administered by two independent raters within a short time period.

Results. The Schedule was acceptably reliable for most areas of need although there were some difficulties associated with the cooperation criteria. Concurrent measures of relatives and patients including EE, relative distress and patient psychopathology indicated that the Relatives' Cardinal Needs Schedule shows acceptable validity when used with a sample of 45 relatives.

Conclusions. The paper suggests that the Schedule may prove to be a useful tool for both clinicians and researchers interested in establishing and evaluating family interventions.

Background. A previous paper (Abas & Broadhead, 1997) reported that among 172 women randomly selected from a Zimbabwean township 30·8% had a depressive or anxiety disorder during the previous year. Compared with London, the higher annual prevalence of disorders in Harare could mostly be accounted for by an excess of onset cases in the study year (annual incidence of depression 18%). This paper reports on the role of life events and difficulties in the aetiology of depression among these women.

Method. Randomly selected women (N=172) from a township in Harare were interviewed with a Zimbabwean modification of the Bedford College Life Events and Difficulties Schedule (LEDS).

Results. Events and difficulties proved critical in provoking the onset of depression in Harare. Far more events occurring in Harare were severe or disruptive. Furthermore, a proportion of the Harare severe events were more threatening than have been described in London. As in London, certain types of severe event were particularly depressogenic, i.e. those involving the woman's humiliation, her entrapment in an ongoing difficult situation, or bereavement. However, more severe events in Harare involved these specific dimensions.

Conclusions. Results indicate a common mechanism for the development of depression, as defined by international criteria, between Zimbabwe and London. The high frequency of severe events, and their especially adverse qualities, offer an explanation for the high incidence of depression in Harare.