Psychiatric epidemiology is becalmed. Since mid-century, there has been substantial progress in finding risk factors for the common mental disorders of anxiety and depression. This has been almost entirely within a social paradigm. Much has been learned about the effects of interpersonal and other social exposures across the lifespan in contributing to these disorders (Brown & Harris, 1978, 1989; Paykel, 1992; Blazer, 1995; Henderson, 1988, 1999). But the range of possibly causal variables has been narrow: demography, socio-economic status, childhood experiences, recent exposure to adversity and the availability of social support. The dominant paradigm has been environmental exposure, examining how experiences that arise outside the individual may have an enduring impact on mental health. The environment in question has been interpersonal or social. Within this paradigm, no new hypotheses of major significance have emerged in recent years.

Epidemiologists have known that the biological domain might be important in aetiology, but for the common mental disorders it has been largely passed over. Properties of the adult brain, whether innate or moulded by environmental exposures, have only rarely been accessible. With the advances in molecular genetics, this is changing (Rutter & Plomin, 1997). For epidemiology, there is now the possibility of bringing molecular genetics into studies of aetiology. Because of the significance of this development, we present a critical assessment of the prospects for population-based research using molecular genetics, the work already reaching publication and the methodological issues that are arising.

Background. Dysthymia is a common mental disorder, associated with considerable disability and high co-morbidity. This review assessed the role of pharmacological treatment.

Methods. All randomized-controlled trials that compared active drug versus placebo for dysthymic patients were included. Pooled relative risks (RR) and 95% confidence intervals (CI) were calculated with the Random Effect Model method. Where possible, number needed to treat and number needed to harm were estimated.

Results. Fifteen trials were included for the main comparisons. Similar results were obtained in terms of efficacy for different groups of drugs, such as tricyclic (TCA), selective serotonin reuptake inhibitors (SSRI), monoamine oxidase inhibitors (MAOI) and other drugs (sulpiride, amineptine, and ritanserin). The pooled RR treatment response was 0·68 (95% CI 0·59–0·78) for TCA, 0·64 (95% CI 0·55–0·74) for SSRIs, 0·59 (95% CI 0·48–0·71) for MAOIs. Other drugs (amisulpride, amineptine and ritanserin) showed similar results. Patients treated on TCA were more likely to report adverse events, compared with placebo. There were no differences in response to active treatment when dysthymia was compared to either dysthymia plus major depression or briefer non-major depressive states.

Conclusions. Drug treatment appears to be effective in the short-term management of dysthymic disorder. The choice of drug should take into account specific side-effects profile of each drug.

Background. A unique way of determining patterns of parent–offspring transmission of risk to affective disorders is to focus on aggregation within sibling pairs. We attempt to extend our previous finding that sibling aggregation is notable for anxiety disorders in a 10-year follow-up of siblings at high and low risk for depression, by virtue of parental diagnosis.

Methods. The sample, which included 173 unique sibling pairs in the high risk cohort, and 83 pairs in the low risk cohort, had been assessed using semi-structured clinical interviews three times over a 10-year period, spanning from childhood to adulthood. Sibling aggregation was quantified using pairwise odds ratios.

Results. Sibling aggregation in the high risk cohort was greater than aggregation in the low risk cohort for anxiety disorders, especially those that emerged in childhood, and later co-morbid disorders, especially major depressive disorder and suicide attempts.

Conclusions. Familial liability to affective disorders may be reflected most strongly by a developmental sequence of anxiety disorders in childhood followed by later depressive and suicidal behaviour in adolescence and adulthood.

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. 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. 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. 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.

Background. The reasons for high use of primary care, and in particular the role of psychosocial factors, remain unclear.

Methods. We identified and interviewed 236 frequent attenders and 420 normal users, matched by age and sex, of a public Health Centre in Granada, Spain. Users were questioned about mental health (GHQ-28), social support (Duke-UNC-11), family dysfunction (family APGAR) and health beliefs (health belief model, locus of health control and medical care expectations). We also measured a set of individual, social and illness variables.

Results. Multiple logistic regression analyses showed that mental health was the main factor associated with frequent attender status (odds ratio = 3·1; 2·4–3·9). The association was stronger than that between frequent attender status and perceived illness, and between the former and reported chronic illness. Family dysfunction and perceived susceptibility to and severity of disease were also significantly but more weakly associated with frequent attender status. Affective support was more strongly associated with FA status than was confidant support, but both associations disappeared when mental health and family function were controlled for.

Conclusions. Our findings document the association of psychosocial factors and primary health care use. We suggest that the effective management of mental health problems from a family-based approach may reduce primary health care high use.

Background. A majority of patients with asthma believe that psychological factors (particularly stress) can induce asthma attacks, but empirical support for actual stress-induced airways obstruction is controversial. This study tested the hypothesis that stress induces breathlessness and not airways obstruction.

Methods. Stress was induced by a frustrating computer task in 30 adolescents with asthma and 20 normal controls, aged 14–19 years. Stress measures were self-reported emotions, heart rate, blood pressure. Respiratory measures were respiratory rate (RR), end tidal CO2, deep inspirations and sighs. Asthma measures were lung function, wheeze, cough, breathlessness.

Results. All measures confirmed high levels of negative emotions and stress. None of the participants developed airways obstruction; they had no reduction in lung function, wheeze was absent and cough negligible. However, breathlessness increased in all participants with asthma and excessively in many. The mean breathlessness was higher than during induction of actual airways obstruction with provocative agents in previous studies. End tidal CO2 showed that breathlessness could not be explained by hypocapnia.

Conclusion. Stress can be sufficient to induce breathlessness in patients with asthma.

Background. People with a learning disability are increasingly being encouraged to take a more active role in decisions about their psychological and medical treatment, raising complex questions concerning their ability to consent. This study investigates the capacity of people with a learning disability to consent in the context of three treatment vignettes, and the influence of verbal and memory ability on this capacity.

Methods. Measures of verbal ability, memory ability and ability to consent to treatment (ACQ) were administered to 40 people with a learning disability. The ACQ consisted of three vignettes depicting a restraint, psychiatric or surgical intervention. These were followed by questions addressing people's ability to understand the presenting problem; the nature of the proposed intervention; the alternatives, risks and benefits; their involvement in the decision-making process; and their ability to express a clear decision with a rationale for treatment.

Results. Five people (12·5%) could be construed as able to consent to all three vignettes; 26 (65%) could be construed as able to consent to at least one. The questions that were most difficult to answer concerned a participants' rights, options and the impact of their choices. Verbal and memory ability both influenced ability to consent.

Conclusions. This study introduces a measure that may enable clinicians to make more systematic assessments of people's capacity to consent. A number of issues surrounding the complex area of consent to treatment are also raised.

Background. We aimed to utilize tests of saccadic function to investigate whether cognitive abnormalities in obsessive–compulsive disorder (OCD) arise from a dysfunction of inhibitory processes or whether they reflect a more general difficulty in guiding behaviour on the basis of an internal representation of task goal.

Methods. Twelve patients with OCD and 12 matched controls performed a visually-guided saccade task, a volitional prosaccade task and an antisaccade task. The latency and gain of saccades was compared between groups for the three saccade tasks. The number of antisaccade errors was also calculated and compared between groups.

Results. There was no difference for antisaccade error rates between the groups. The latency of visually guided saccades did not differ between groups, however the latency of both volitional prosaccades and antisaccades was significantly slower in the patients with OCD than in controls. The difference in latency between volitional prosacades and antisaccades, however, was equal between groups.

Conclusions. These results suggest that patients with OCD have an abnormality in guiding behaviour on the basis of an internal representation of the task goal, rather than a problem with inhibiting reflexive behaviour.

Background. This paper reports prevalences, sociodemographic correlates and psychiatric co-morbidity of substance use disorders (SUDs) among adolescents in Taiwan.

Methods. A random sample of ninth grade students (N=774) was selected from an urban, a suburban and a rural community. Two-stage case identification was employed with a brief screening tool and a modified Chinese version of the Kiddie-SADS conducted by child psychiatrists.

Results. The overall prevalence of any SUD was 11·0%, with nicotine (96·0%) as the most prevalent substance. The prevalences of SUDs were significantly higher in boys, rural community and classes with poor academic performance. Sixty-two per cent of all SUD cases suffered from other concurrent psychiatric disorders. The most common co-morbid conditions were conduct disorder, attention deficit hyperactivity disorder and mood disorders.

Conclusions. High prevalences of SUDs were found among adolescent school children in Taiwan. Effects of urbanization, selective migration and the availability of substances are possible explanations for the urban-rural difference on the risk for SUDs. Psychiatric co-morbid conditions for SUD among adolescents in Taiwan were similar to those in Western societies.

Background. This study investigated whether individuals with borderline personality disorder (BPD) tend to be overgeneral in their autobiographical recall and whether the extent of their overgeneral recall covaries with their susceptibilities to dissociative experiences, as expected on theoretical grounds.

Methods. Twenty-three patients with BPD and 23 matched controls completed the Autobiographical Memory Test (AMT) and self-report measures of depression, anxiety, trait anger and dissociative experiences.

Results. Participants with BPD scored significantly higher than the control group on the measures of depression, anxiety, trait anger, and dissociative experiences and also retrieved significantly more general memories on the AMT. The number of general memories retrieved by the BPD group correlated significantly with their dissociation scores but not with their scores on mood measures.

Conclusions. Patients with BPD have difficulties in recalling specific autobiographical memories. These difficulties are related to their tendency to dissociate and may help them to avoid episodic information that would evoke acutely negative affect.

Background. Children with autistic spectrum disorders typically show impairments in processing affective information within social and interpersonal domains. It has yet to be established whether such difficulties persist in the area of music; a domain which is characteristically rich in emotional content.

Methods. Fourteen children with autism and Asperger syndrome and their age and intelligence matched controls were tested for their ability to identify the affective connotations of melodies in the major or minor musical mode. They were required to match musical fragments with schematic representations of happy and sad faces.

Results. The groups did not differ in their ability to ascribe the musical examples to the two affective categories.

Conclusions. In contrast to their performance within social and interpersonal domains, children with autistic disorders showed no deficits in processing affect in musical stimuli.

Background. This study examined the association between job strain and psychiatric morbidity using interview-based assessments of mental health. We assessed the prevalence of neurotic disorder in high job strain (high demand, low control) and low job strain (low demand, high control) school teachers, and compared these rates with data from individuals with similar educational qualifications from the National Psychiatric Morbidity Survey of Great Britain.

Methods. One hundred and sixty primary and secondary school teachers were selected from a larger survey on the basis of high or low job strain, and were assessed for psychiatric morbidity using the Revised Clinical Interview Schedule (CIS-R). The prevalence of neurotic symptoms and a total psychiatric morbidity score were calculated.

Results. After adjusting for age, gender and occupational grade, the prevalence of psychiatric morbidity was greater in high job strain than low job strain individuals. The prevalence of severe anxiety, worry and fatigue symptoms was significantly greater in the high job strain teachers. In comparison with the British psychiatric morbidity survey, the prevalence of neurotic disorders was greater in the high job strain, but not in low job strain teachers. Individuals in the low job strain group were more likely to report severe anxiety, irritability and fatigue in the week prior to interview, than comparably educated individuals in the national survey.

Conclusion. Job strain is associated with psychiatric morbidity. The high levels of neurotic psychopathology among teachers is consistent with previous research that has found teaching to be a highly stressful occupation.

Background. The outcome of electroconvulsive therapy (ECT) is affected by the placement and dose of the stimulus. In general, the ECT dose can be selected either by the dose-titration method (on which the measured seizure threshold level is based), or the method of predetermined dose (e.g. the age-based dosing and the fixed high dose method).

Methods. Seizure thresholds were measured in 50 patients with right unilateral (RUL) and in 30 patients with experimental bifrontal (BF) ECT stimulus. The ECT dose (mC) of the age-based dosing was calculated by multiplying the age (years) by 5·0 (age method) or 2·5 (half-age method). The fixed high dose was set to 378 mC.

Results. The seizure thresholds had only a moderate correlation with the age of the patients. The methods based on the predetermined dose would have led us to give patients with the lowest seizure thresholds in the RUL ECT group very high stimulus doses, up to 12 (age method) or 15 (fixed high dose method) times the individual seizure threshold. In contrast, the RUL ECT patients with the highest seizure thresholds would have received low stimulus doses down to 1·5 times (half-age method) the initial seizure threshold. In the BF ECT group the-age based dose would have been similarly dependent on the initial seizure threshold level.

Conclusion. The use of the dose-titration method is recommended, because it is the only method that allows for the individual selection of ECT stimulus dose relative to the seizure threshold.

Background. There have been six randomized controlled trials of psychological therapy with generalized anxiety disorder (GAD) using DSM-III-R and DSM-IV. All have used the Trait version of the Spielberger State–Trait Anxiety Inventory (STAI-T) as one of several outcome measures. Each study, however, employed different methods of calculating the clinical significance of outcomes making it difficult to reach a balanced appraisal of the efficacy of psychological treatment.

Methods. Raw data on STAI-T scores at pre-, post- and follow-up were obtained for each of the six studies (total N=404). Jacobson methodology for defining clinically significant change (criterion c, reliable change index = 8, cut-off point = 46) was used to allocate each patient to one of four outcomes: worse, unchanged, improved and recovered. The proportion of patients in each category was calculated for treatment conditions in each study and also for aggregate data across types of treatment.

Results. A recovery rate of 40% was found for the sample as a whole with 12 of the 20 treatment conditions obtaining very modest recovery rates of 30% or less. Two treatment approaches – individual cognitive behavioural therapy and applied relaxation – do relatively well with overall recovery rates at 6-month follow-up of 50–60%.

Conclusions. Jacobson methodology, in distinguishing between improvement and recovery on a standardized measure of general vulnerability to anxiety, provides a stringent but clinically more meaningful evaluation of the efficacy of psychological therapies with GAD than has been available hitherto. Systematic focus on either excessive worry or physiological arousal gives worthwhile results.

Background. Recent studies have suggested that major depressive disorders are associated with a breakdown in the organization of ultradian rhythm in sleep EEG. The present study used cross-spectral analysis of sleep EEG to confirm this finding, in a larger-scale study, evaluating the influence of gender and age on ultradian rhythms in depression.

Methods. Temporal coherence of ultradian (80–120 min) rhythms in beta, theta and delta, recorded from central and parietal sites, were compared in 120 symptomatic, unmedicated, depressed out-patients and 59 healthy normal controls.

Results. Few macro-architectural differences were noted between patients and controls. However, interhemispheric beta and theta coherence and intrahemispheric coherence between beta and delta rhythms were significantly lower in depressed patients. Coherence measures were lowest in women with depression and highest in men in the control group, but were not strongly influenced by age. Over 65% of depressed patients were [ges ]2 standard deviations below normal on at least one coherence measure, in sharp contrast to less than 10% of patients on macro-architectural variables.

Conclusions. It was concluded that dysregulation of ultradian rhythms characterizes the majority of depressed out-patients, primarily women, even when macro-architecture did not differentiate groups. The outcome of this study supports the view that the pathophysiology of depression is strongly influenced by gender. It was suggested that low temporal coherence in depression reflects a breakdown in the organization of sleep EEG rhythms within and between the two hemispheres.

Background. Linkage and association studies have suggested genetic susceptibility to bipolar affective disorder in a region of chromosome 11 around the tyrosine hydroxylase locus. We attempted to test the hypothesis that there was allelic association between polymorphisms around the tyrosine hydroxylase locus and bipolar affective disorder.

Methods. A case–control association study was employed using four polymorphic markers, which span a region of approximately 2 cM across the tyrosine hydroxylase locus.

Results. No evidence for allelic association between bipolar affective disorder and any of these markers was found. However, linkage disequilibrium between the markers was detected.

Conclusions. This finding diminishes the probability that genes in this region influence susceptibility to bipolar affective disorder, at least in our sample.

Background. In the assessment of stressful life events (SLEs), researchers have often tried to evaluate whether individual events are dependent or independent of the respondent's behaviour. We sought to validate this evaluation using a twin methodology. We predicted that dependent SLEs would be more heritable than independent SLEs.

Methods. We explored, by twin modelling, the resemblance in two pairs of past-year personal and network SLEs rated individually, by trained interviewers, on a four-point dependence–independence scale. We examined results from two waves of interviews with 785 female–female twin pairs ascertained from a population based registry.

Results. Twin model-fitting found no evidence for genetic effects on personal or network independent SLEs. However, familial–environmental factors played an important role in the aetiology of network independent SLEs. For personal and network dependent SLEs, by contrast, three of four analyses suggested a significant aetiological role for genetic factors with estimated heritabilities ranging from 19 to 51%.

Conclusions. Our results support the validity of interviewer assessments of dependence versus independence of SLEs. As predicted, these assessments were relatively successful at distinguishing SLEs that were influenced by genetic factors from those that were not.