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.

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.

Background. Neuropsychological and imaging studies suggest that frontal dysfunction may occur in apparently normal chronic alcoholic subjects.

Methods. To investigate this issue further, we performed neuropsychological and fluorodeoxy-glucose-PET studies in 17 chronic alcoholics without patent neurological and psychiatric complications.

Results. Metabolic abnormalities were found in the mediofrontal and in the left dorsolateral prefrontal cortex, but not in the orbitofrontal cortex. Neuropsychological testing revealed significantly reduced verbal fluency and impaired performance on the Stroop test. The mediofrontal hypometabolism correlated with the reduction in verbal fluency and the time necessary to perform the interference condition of the Stroop test. The left dorsolateral prefrontal hypometabolism correlated with the number of errors on the Stroop test.

Conclusion. These data indicate that circumscribed frontal dysfunctions may occur in chronic alcoholic subjects before clinically obvious neurological complications, and may account for some of the alcohol-related neuropsychological and behavioural impairments.

Background. The aim of the study was to search for the existence of, and define, a possible relationship between performance in neuropsychological tests and baseline concentrations of plasma cortisol, vasopressin and oxytocin in medication-free patients with a major depressive episode.

Methods. Measures of depression and anxiety were obtained and a neuropsychological battery was presented. Blood for neuropeptide analysis was drawn by venepuncture at 8.00, 16.00 and 23.00 h.

Results. The melancholic patients performed less well on the neuropsychological battery than did the non-melancholic patients, but these differences could be accounted for by the severity of the illness. Global intellectual functioning was negatively correlated with mean baseline plasma concentrations of cortisol. Patients with high mean plasma vasopressin concentrations remembered more auditory presented words in the delayed recall test and produced more intrusions in the visual word learning list than did patients with low or normal mean plasma vasopressin concentrations. No association was found between neuropsychological performance and plasma concentrations of oxytocin.

Conclusions. Our findings support the hypothesis that elevated baseline plasma cortisol concentrations are related to cognitive impairment in depressed patients and the hypothesis that the neuropeptide vasopressin independently enhances memory, directly or indirectly through increasing arousal and attention.

Background. Staff and severely mentally ill patients differ in their assessments of need. This study compares staff and patient assessments of need for people suffering from psychotic disorders.

Method. The needs of an epidemiologically representative sample of 137 patients from a catchment area psychiatric service in South London who had an ICD-10 diagnosis of a functional psychotic disorder were assessed cross-sectionally by patients and staff, using the Camberwell Assessment of Need.

Results. Staff rated patients to have on average 6·1 needs, and patients rated 6·7 needs (t=2·58, df=136, P=0·011). This difference was accounted for by the staff rating of 1·2 unmet needs and the patient rating of 1·8 unmet needs (t=3·58, df=136, P<0·001). There was no difference in rating of total number of met needs. There was no difference in ratings in relation to any patient sociodemographic characteristics. There was moderate or better agreement on the presence of a need for 13 of the 22 domains in the Camberwell Assessment of Need.

Conclusions. Staff and patients moderately agree about met needs, but agree less often on unmet needs.

Background. Alcoholism is clinically heterogeneous. We have attempted to identify and validate subtypes of broadly defined alcoholism.

Methods. Latent class analysis (LCA) was applied to data on the number, age at onset and reasons for temperance board registration (TBR) in all male–male twin pairs of known zygosity born in Sweden from 1902–1949.

Results. Of the five classes identified, two were relatively common: single-cause registrant – drunk (SCR-D); and early-onset multiple-cause registrant (EO-MCR). In contrast to the SCR-D class, the EO-MCR class was characterized by: (i) earlier age at first TBR; (ii) higher number of TBRs; (iii) TBRs for drunk driving and alcohol-related crimes; (iv) much higher risk for alcohol-related imprisonment and hospitalization; (v) higher levels of neuroticism and novelty-seeking; and (vi) much greater risk for TBR in co-twins. In twin pairs concordant for TBR, concordance for LCA-derived class assignment far exceeded chance expectation, more so in monozygotic than in dizygotic pairs.

Conclusions. Alcoholism is aetiologically as well as clinically heterogeneous. The two most common subtypes identified in these analyses bear substantial but imperfect resemblance to previously proposed typologies.

Background. This study examines the effects of distress and three types of social relationships (family, friends, and confidantes) on the use of out-patient health services in an adult sample from a community survey of 3481 persons in Baltimore, Maryland.

Methods. Independent effects of predisposing (age, education, marital status, race and sex), enabling (employment, income and insurance) and need (physical health) factors are adjusted for in estimating the odds of using health care services.

Results. Illness, being female, and having insurance were positively related to use of services, while being aged was inversely related. After adjustment for the above factors, social support interacted with psychological distress to effect the use of medical care: the combination of high distress and low social support by a confidante results in a fourfold increase of medical utilization.

Conclusions. Our findings support the inclusion of psychological distress and social network variables in addition to physical health status in models attempting to explain the use of health services. Despite an inability to analyse change over time, our data suggest an understanding of the interrelationship between psychosocial factors, distress and health care use would benefit health providers and their patients.

Background. Opioidergic pathways have an inhibitory regulatory influence on the hypothalamic–pituitary–adrenal axis (HPA) in man. Previous studies have suggested impairment of pituitary–adrenal activation in chronic fatigue syndrome (CFS). We, therefore, decided to investigate the extent of opioid inhibition of HPA activity in CFS as a possible explanation for the reputed HPA hypofunctioning in patients with CFS.

Method. Thirteen patients with CFS, diagnosed according to CDC criteria, were compared with thirteen healthy subjects. Adrenocorticotropin (ACTH) and cortisol (CORT) responses were measured following the administration of the opiate antagonist naloxone.

Results. Baseline ACTH and cortisol levels did not differ between the two groups. The release of ACTH (but not cortisol) was significantly blunted in the CFS subjects compared with controls.

Conclusions. Naloxone mediated activation of the HPA is attenuated in CFS. Excessive opioid inhibition of the HPA is thus an unlikely explanation for the HPA dysregulation in this disorder.

Background. The aim of this study was to investigate mnemonic strategic deficits in schizophrenic patients.

Methods. Analogous tasks were used that required the self-generation of an efficient strategy and its implementation in two domains: visuospatial and verbal. The tasks were given to 20 IQ preserved schizophrenics and 20 matched normal controls. A number of different scores was derived from each task including strategy, short-term memory capacity and perseveration.

Results. Overall, the schizophrenic patients were significantly impaired in their ability to generate effective mnemonic strategies on both tasks. In addition, on the visuospatial task there was no difference between the groups on the memory scores, but the schizophrenic patients made significantly more perseverative errors than controls. They were disproportionately worse on the verbal strategy task, showing impairment on memory as well as on strategy scores and were also impaired at semantically classifying the words. Performance was similar to the deficit seen in patients with frontal lobe excisions and Parkinson's disease, in terms of the inability to generate an effective strategy. The deficit on the verbal task was similar to patients with temporal lobe excisions who show impaired verbal memory. However, the pattern differed in the sense that the temporal lobe patients were able to generate effective strategies, unlike the patients with schizophrenia.

Conclusions. High functioning schizophrenic patients are impaired in utilizing visuospatial and verbal mnemonic strategies. By comparing the results with those of neurosurgical excision patients, further evidence is provided for both frontal and temporal lobe involvement in schizophrenia.

Background. A prospective study, covering just over a 1-year period, sought to confirm an earlier finding that around 40% of women who experience a severe life event in the presence of two ongoing psychosocial vulnerability factors, (negative close relationships and low self-esteem) will develop a major depressive episode. Distal risk factors were examined to see if they improved prediction.

Methods. A population sample of 105 mainly working-class mothers with vulnerability and without depression were interviewed three times over a 14-month period to date the occurrence of severe life events and onset of major depression. Degree of vulnerability was assessed at first contact together with distal risk in terms of childhood neglect/abuse and any earlier episodes of depression.

Results. Thirty-seven per cent of these vulnerable women became depressed in the study period. The majority experienced a severe life event, and of these, 48% had onsets. Contrary to expectation, risk was only a little less among those with just one of the two vulnerability factors. Two-thirds of women with an onset had been depressed in previous years. Although this was associated with increased risk, the effect was greatest for those who had experienced an episode before age 20. A relationship between childhood neglect/abuse and onset was entirely accounted for by such early depression.

Conclusion. An aetiological model of depression outlined in earlier research was confined with a new factor of teenage depression shown to increase risk of onset.

Background. Few studies have explored the variance in individual symptoms by race in older adults.

Methods. Data were analysed from the Duke site of the Established Populations for Epidemiologic Studies of the Elderly (EPESE), a community sample of persons 65 years-of-age and older, 54% of whom were African-Americans. Of the 3401 subjects with adequate data on depressive symptomatology, confirmatory factor analysis and LISREL were first used to confirm the presence of the factor structure previously reported for the CES-D. Next, bivariate analysis was performed to determine the prevalence of individual symptoms by race. Finally, LISREL analysis was performed to control for potential confounding variables.

Results. When bivariate comparisons of specific symptoms by race were explored, African-Americans were more likely to report less hope about the future, poor appetite, difficulty concentrating, requiring more effort for usual activities, less talking, feeling people were unfriendly, feeling disliked by others and being more ‘bothered’ than usual. When LISREL analyses were applied to these data (controlling for education, income, cognitive impairment, chronic health problems and disability and other factors) racial differences in somatic complaints and life satisfaction disappeared, yet differences in interpersonal relations persisted.

Conclusions. This study confirms earlier findings of minimal overall differences in symptom frequency between African-American and non-African-American community-dwelling older adults in controlled studies.

Background. Previous work has indicated that the 2[ratio ]1 female[ratio ]male sex ratio in unipolar depressive disorders does not emerge until some time between ages 10 and 15.

Methods. Data from four annual waves of data collection from the Great Smoky Mountains Study (GSMS) involving children aged nine to 16 were employed.

Results. Pubertal status better predicted the emergence of the expected sex ratio than did age. Only after the transition to mid-puberty (Tanner Stage III and above) were girls more likely than boys to be depressed. The timing of this transition had no effect on depression rates. Before Tanner Stage III, boys had higher rates of depression than girls, and the prevalence of depression appeared to fall in boys at an earlier pubertal stage than that at which it began to rise in girls. In addition, recent transition to Tanner Stage III or higher had a transient effect in reducing the prevalence of depression in boys.

Conclusions. The period of emergence of increased risk for depression in adolescent girls appears to be a relatively sharply demarcated developmental transition occurring in mid-puberty. Previously reported effects of the timing of puberty (which have tended to be transient) appeared less important in increase of risk for depression than pubertal status.

Background. Sumatriptan, a specific agonist at 5-HT1D receptors, stimulates release of growth hormone (GH) and inhibits release of prolactin (PRL).

Methods. We gave sumatriptan (6 mg subcutaneously) to 11 patients with unipolar major depression and 11 control subjects matched for age, sex, weight and menstrual cycle phase. Serum GH and PRL were measured at 0, 15, 30, 45, 60 and 90 min after injection.

Results. The maximal rise in GH was significantly reduced in the depressed patients, with 60% showing no increase over baseline compared with 18% of controls. There were no significant differences in PRL responses.

Conclusions. These results suggest reduced sensitivity of 5-HT1D receptors in major depression. Our results and those of studies investigating 5-HT1A receptors imply that both 5-HT1A and 5-HT1D autoreceptors may show reduced function in major depression.

Background. Affected sibling pairs provide a valuable means of investigating the familial basis of clinical heterogeneity in schizophrenia.

Methods. Associations of schizophrenia subtypes, psychotic symptoms (defined by SAPS/SANS and OPCRIT), affective episodes and demographic variables were studied in 109 sibling pairs with DSM-IV schizophrenia or schizoaffective disorder.

Results. None of the subtypes or affective episodes were significantly associated within pairs. A broad definition of positive formal thought disorder, grandiose delusions and delusions of influence (all from OPCRIT) were modestly associated. There was no excess of same-sex pairs. There were modest associations for age of illness onset, pre-morbid adjustment and illness severity. Caution is required in interpreting the results because many statistical tests were carried out.

Conclusions. None of the variables appears to be closely associated with specific genetic or shared environmental factors that contribute liability to schizophrenia. They are at best only weakly associated with such factors, and/or are associated with factors unrelated to the aetiology of schizophrenia.

Background. The paper reports on the development of the WHOQOL-BREF, an abbreviated version of the WHOQOL-100 quality of life assessment.

Method. The WHOQOL-BREF was derived from data collected using the WHOQOL-100. It produces scores for four domains related to quality of life: physical health, psychological, social relationships and environment. It also includes one facet on overall quality of life and general health.

Results. Domain scores produced by the WHOQOL-BREF correlate highly (0·89 or above) with WHOQOL-100 domain scores (calculated on a four domain structure). WHOQOL-BREF domain scores demonstrated good discriminant validity, content validity, internal consistency and test–retest reliability.

Conclusion. These data suggest that the WHOQOL-BREF provides a valid and reliable alternative to the assessment of domain profiles using the WHOQOL-100. It is envisaged that the WHOQOL-BREF will be most useful in studies that require a brief assessment of quality of life, for example, in large epidemiological studies and clinical trials where quality of life is of interest. In addition, the WHOQOL-BREF may be of use to health professionals in the assessment and evaluation of treatment efficacy.

Background. The current study investigated the fundamental nature of the cognitive processing deficit that has been demonstrated to be associated with dieting to lose weight. Previous work has characterized this deficit as being primarily one of a reduction in working-memory capacity. The present study investigated the particular components of the working-memory system affected during dieting.

Method. A sample of female subjects was classified as either low/medium restrained eaters (N=34), highly restrained eaters (N=18) or current dieters (N=19), based on their responses to a modified version of the Dutch Eating Behaviour Questionnaire (DEBQ). Each subject completed tasks that assessed the Visuo-Spatial Sketchpad (mental rotation), Phonological Loop (effect of phonological similarity on recall) and the Central Executive (Tower of London Task) components of working memory.

Results. Those subjects who reported themselves to be currently dieting displayed poorer recall on the Phonological Loop task and slower planning times on the Tower of London Task. Performance on both these tasks correlated significantly with a self-report measure of body shape concern.

Conclusions. These results support the hypothesis that the mediating variable in this deficit is that of preoccupying cognitions concerning food and body shape.

Background. It has been suggested that patients with unipolar depression show abnormal responses to negative feedback in the performance of cognitive tasks. Positron emission tomography (PET) has previously identified blood flow abnormalities in depressed patients during cognitive performance. We have also used PET to identify regions where there is differential neural response to performance feedback in normal volunteers. In this study we aimed to test the hypothesis that blood flow in these regions, the medial caudate and ventromedial prefrontal cortex, would be abnormal in depressed patients.

Methods. Six patients with unipolar depression and six matched controls were scanned using PET while performing cognitive tasks in the presence and absence of feedback.

Results. Compared with controls, depressed patients failed to show significant activation in the medial caudate and ventromedial orbitofrontal cortex. Blood flow was lower and a differential response, observed in normals, under different task and feedback conditions was not seen in the patients.

Discussion. The findings suggest that the behavioural response to feedback in depressed patients is associated with an abnormal neural response within the medial caudate and ventromedial orbitofrontal cortex, regions implicated in reward mechanisms. We argue that the observed abnormalities may depend on a combination of psychological factors, with both cognitive and emotive components.

Background. A prospective epidemiology study evaluated the role of specific social and psychological variables in the prediction of depressive symptomatology and disorders following childbirth in a community sample. Measures of social support used previously in clinically depressed populations facilitated further comparison.

Methods. Nulliparous pregnant women (N=507) were interviewed during pregnancy with the Interview Measure of Social Relationships (IMSR) and a contextual assessment of pregnancy-related support and adversity and 427 were followed up at 3 months postpartum with the 30-item GHQ, including six depression items. To establish the clinical representativeness of the GHQ, high GHQ scorers and a random subsample of low scorers were interviewed using the SCAN. Regression models were developed using the GHQ Depression scale (GHQ-D), the IMSR and other risk factor data.

Results. GHQ-D after childbirth was predicted by lack of perceived support from members of the woman's primary group and lack of support in relation to the event becoming pregnant; this held even after controlling for antenatal depression, neuroticism, family and personal psychiatric history and adversity. Informant-rated deficits in provision of social support also predicted later depression. The size of the primary social network group previously found to be related to depression in women, did not predict depressive symptom development.

Conclusion. Predictors of depressive symptom development differ from predictors of recovery from clinical depression in women. Interventions should be designed to reduce specific deficits in social support observed in particular study populations.

Background. Systematic comparisons of the psychological and physical responses of caregivers of Alzheimer's disease (AD) patients in the US and China have not been previously reported.

Methods. Informal caregivers of community dwelling AD patients in Shanghai, China and demographically-matched non-caregiving Chinese controls were compared with a sample of American caregivers residing in San Diego, California and demographically-matched American controls.

Results. Despite some demographic discrepancies, caregivers from both China and the US were similar. Caregivers from both cultures reported more depressive symptoms and more physical symptoms when compared with non-caregivers. Both groups of caregivers reported that patients required similar amounts of care and help with activities of daily living (ADLs). However, Shanghai caregivers reported less access to emotional support when compared with the San Diego sample. A conceptual model, guided by the stress process model of Pearlin et al. (1990), was used to explore multivariate relationships between caregiver characteristics and the physical and psychological health of our sample of AD caregivers in Shanghai, China. Results from a path analytical procedure revealed that the relationships among these variables and health outcome did not differ significantly from those observed in the US sample.

Conclusions. Although elderly family members are venerated in the stereotypical Chinese family unit, and informal caregiving of disabled family members is socially mandated, the negative health consequences of caregiving appear to be similar to those observed among caregivers in the US.

Background. Significant alterations in total serum protein (TSP) patterns obtained in serum protein electrophoresis and serum proteins have been reported in patients with major depression and in subjects submitted to a combination of psychological and physical stress. The aim of the present study was to examine the effects of academic examination stress, on TSP and patterns obtained in serum protein electrophoresis.

Methods. TSP and the concentrations and percentages of the major electrophoretically separated serum proteins were measured in 41 healthy biomedical students the day before a difficult academic examination (i.e. the stressful condition), as well as a few weeks before and after the stressful condition (i.e. two baseline conditions).

Results. Academic examination stress increased TSP and the α1, α2, β and γ concentrations in stress-reactors, but not in stress non-reactors (as defined by changes in the Perceived Stress Scale). Academic examination stress reduced the percentage of albumin in the stress-reactors, but not in stress non-reactors. There were significant positive relationships between the stress-induced changes in TSP and serum α2, β and γ concentrations and the stress-induced changes in the Perceived Stress Scale.

Conclusions. The results show that even mild psychological stress of short duration can lead to measurable changes in TSP and in patterns obtained in serum protein electrophoresis.