This issue features papers on consequences of trauma, psychiatric epidemiology, somatization and genetics.

In their editorial Breslau and colleagues (pp. 573–576) discuss two related issues: the linkage in PTSD between trauma and specific symptoms, and the place of the disorders that often occur co- morbidly with PTSD. They argue for the centrality of the first in the delineation of PTSD. The symptoms that follow trauma are the subject of several empirical papers later in the issue. Mayou & Bryant (pp. 671–675) report a range of symptoms 3 years after a road traffic accident, Altier et al. (pp. 677–685) report a variety of psychological disturbances 5 years after severe burns, and Simpson & Tate (pp. 687–697) report high rates of suicidal ideation and suicide attempts after traumatic brain injury. In a related paper Davidson and colleagues (pp. 661–670) examine in detail the effects of sertraline on PTSD.

The official definition of post-traumatic stress disorder (PTSD) in DSM-III and is subsequent DSM editions is based on a conceptual model that brackets traumatic or catastrophic events from less severe stressors and links them with a specific syndrome. The diagnosis of PTSD requires an identifiable stressor and the content of the defining symptoms refers to the stressor, for example, re-experiencing the stressor and avoidance of stimuli that symbolize the stressor. Temporal ordering is also required: when sleep problems and other symptoms of hyperarousal are part of the clinical picture, they must not have been present before the stressor occurred. The ICD-10 definition of PTSD follows the same model. The defining symptoms alone, without a connection to the stressor, are not regarded as PTSD (Green et al. 1995). Since the introduction of PTSD in DSM-III, the official definition has been adopted in most studies, although discussions about the validity of the definition has continued (Breslau & Davis, 1987; Davidson & Foa, 1993; Green et al. 1995). Although it is widely believed that other disorders (e.g. major depression) can be precipitated by external events, these disorders can occur independent of stressors and do not require a link with a traumatic event in their diagnostic criteria. Previous classifications that separated major depression into stress-related (reactive) or endogenous have been abandoned in newer versions of the DSM, because of lack of evidence of the validity of this distinction.

Background. We describe for the first time the epidemiology of homicide–suicide incidents for England and Wales. Previous descriptions have been of incidents in London (1946–62) and Yorkshire and Humberside (1975–1992).

Methods. Death certificates were obtained for all who died in homicide–suicide incidents in England and Wales (1988–1992) that were reported by the police to the Home Office. Incidents were included in the analysis if the interval between death or fatal injury of victim and suspect was 3 or fewer days.

Results. Three hundred and twenty-seven people died in 144 incidents (180 victims and 147 suspects). Eighty per cent of incidents had one victim and one suspect. Three incidents were also suicide pacts between two suspects killing their children. Eighty-eight per cent of incidents exclusively involved members of the same family, 9% acquaintances or strangers, and 3% both family and acquaintances or strangers. Seventy-five per cent of victims were female, 85% of suspects male. The victims of male suspects were predominantly their womenfolk, past and present, and their children, and of female suspects their young children. Car exhaust and firearms accounted for 40% of victim and 50% of suspect deaths. Of all homicides during 1988–1992, 3% of male, 11% of female and 19% of child deaths occurred in homicide–suicide incidents. Similarly, of all suicides, 0·8% of male and 0·4% of female deaths occurred in homicide–suicide incidents.

Conclusions. Homicide–suicide in England and Wales is mostly ‘a family matter’, men of predominantly lower social class killing their kin, and pre-menopausal mothers their young children, before they kill themselves. A few men kill strangers during a crime and then themselves.

Background. Previous epidemiological studies indicate large cross-national differences in prevalence of depression.

Methods. At 15 centres in 14 countries, 25916 primary care patients were screened for common mental disorders. A stratified random sample of 5447 primary care patients completed a baseline diagnostic assessment and 3197 completed a 12-month follow-up assessment. Psychiatric symptoms and diagnoses were assessed using the Composite International Diagnostic Interview (CIDI). Interviewer-rated disability was assessed using the Social Disability Schedule (SDS).

Results. Prevalence of current major depression varied 15-fold across centres. When centres were divided into three groups according to prevalence rates, the symptom pattern or latent structure of depressive illness was generally similar at low-, medium-, and high-prevalence centres. Depression was universally associated with disability, but this association varied significantly (t = 3·51, P = 0·0005) across centres. At higher-prevalence centres, depression was associated with lower levels of impairment. At 1 year follow-up, higher prevalence centres had both significantly higher rates of depression onset (t = 3·11, P = 0·002) and higher rates of persistence among those depressed at baseline (t = 2·49, P = 0·013).

Conclusions. Large cross-national variations in depression prevalence cannot be attributed to ‘category fallacy’ (cross-national differences in the nature or validity of depressive disorder). Use of identical measures and diagnostic criteria may actually identify different levels of depression severity in different countries or cultures. Cross-national differences in the onset and outcome of depression may reflect either true prevalence differences or differences in diagnostic threshold.

Background. Studies that examined community samples have reported several risk factors for the development of depressive episodes. The few studies that have been performed on primary care samples were mostly cross-sectional. Most samples had originated from highly developed industrial countries. This is the first study that prospectively investigates the risk factors of depressive episodes in an international primary care sample.

Methods. A stratified primary care sample of initially non-depressed subjects (N = 2445) from 15 centres from all over the world was examined for the presence or absence of a depressive episode (ICD-10) at the 12 month follow-up assessment. The initial measures addressed sociodemographic variables, psychological/psychiatric problems and social disability. Logistic regression analysis was carried out to determine their relationship with the development of new depressive episodes.

Results. At the 12-month follow-up, 4·4% of primary care patients met ICD-10 criteria for a depressive episode. Logistic regression analysis revealed that the recognition by the general practitioner as a psychiatric case, repeated suicidal thoughts, previous depressive episodes, the number of chronic organic diseases, poor general health, and a full or subthreshold ICD-10 disorder were related to the development of new depressive episodes.

Conclusions. Psychological/psychiatric problems were found to play the most important role in the prediction of depressive episodes while sociodemographic variables were of lower importance. Differences compared with other studies might be due to our prospective design and possibly also to our culturally different sample. Applied stratification procedures, which resulted in a sample at high risk of developing depression, might be a limitation of our study.

Background. The association between depression and mortality has become a topic of interest. Little is known about the association between the course of depression and mortality.

Methods. In an initially non-depressed cohort (N = 325) and a depressed cohort (N = 327), depression was measured using the Center for Epidemiologic Studies Depression scale (CES-D) at eight successive waves over a period of 3 years. Both cohorts were then followed with respect to mortality status for up to 3·5 additional years. Clinical course types as well as theoretical course type parameters (basic symptom levels, increases in symptoms and instability over time) were distinguished to study the effect of the course of depression on mortality.

Results. Contrary to transient states of depression, both chronic depression and chronic intermittent depression predicted mortality at follow-up. Additionally, evidence was found that the effect on mortality is related to severity of depression; high basic symptom levels and increases in symptoms over time were predictive of mortality. A high degree of instability over time was not associated with mortality.

Conclusions. Since the mortality effect of depression is a function of both exposure time and symptom severity, more attention should be paid to the treatment of depression in order to prevent severe longstanding depression.

Objective. We aimed to assess the diagnostic outcome of self-reported hallucinations in adolescents from the general population.

Method. The sample consisted of 914 adolescents between ages 11–18 participating in an ongoing longitudinal study. The participation rate from the original sample was 70%. Responses on the Youth Self-Report questionnaire were used to ascertain hallucinations in adolescents. Eight years later, Axis 1 DSM-IV diagnoses were assessed using the 12-month version Composite International Diagnostic Interview in 783 (86%) of 914 study subjects. No subjects were diagnosed with schizophreniform disorders or schizophrenia.

Results. Hallucinations were reported by 6% of adolescents and 3% of young adults. Self-reported hallucinations were associated with concurrent non-psychotic psychiatric problems in both age groups. Adolescents who reported auditory, but not visual, hallucinations, had higher rates of depressive disorders and substance use disorders, but not psychotic disorders, at follow-up, compared to controls.

Conclusions. Self-reported auditory hallucinations in adolescents are markers of concurrent and future psychiatric impairment due to non-psychotic Axis 1 disorders and possibly Axis 2 disorders. It cannot be excluded that there was selective attrition of children and adolescents who developed Schizophrenic or other psychotic disorders later in life.

Background. This paper reports the prevalence, disability, sociodemographic and clinical association of psychiatric morbidity among attenders in general health care in Taiwan where, as in the rest of non-Western countries, few studies have been carried out.

Methods. A cross-sectional survey with a two-phase design was carried out at out-patient clinics of three health stations and a general hospital.

Results. A total of 990 patients completed the brief screen in the first phase, 486 of whom completed the independent assessment in the second phase. The proportion of screening positives was 46·0% and the weighted prevalence of definite psychiatric disorder was 38·2%. Common mental disorders were associated with female gender and unemployment. Housewives, students and patients with higher educational attainment were at lower risk of having alcohol use disorders. Patients with common mental disorders were more likely to present with psychological complaints, to attribute their illness to psychosocial causes and to perceive their mental and physical health as poor. Psychiatric morbidity was associated with excess life events. Common mental disorders, particularly depressive disorders, were significantly associated with self-reported disability.

Conclusions. Psychiatric morbidity is a major health problem in general health care in Taiwan. Physicians should be aware of these health problems.

Background. Knowledge of the level of psychosocial impairment associated with psychosis is important in evaluating the impact of the illness on those affected. When such knowledge is derived from community-based epidemiological surveys, it can help in providing a public health perspective for service planning with information derived from representative samples of patients.

Methods. A two-phase epidemiological survey of persons with psychosis in four predominantly urban areas of Australia. First phase screening for psychosis (N = 5710) was followed by a semi-structured interview of a stratified random sample (N = 980) to assess psychopathology (lifetime and current) and psychosocial disability.

Results. Most of the interviewees were unemployed and had never married. There was widespread impairment in sexual and social relationships and in the performance of activities of daily living. Over half expressed dissatisfaction with life in general. Persons with affective psychoses were often as disabled as those with schizophrenia and diagnostic categorizations were not important in the conferment of risk for disability. Rather, poor pre-morbid work or social adjustment and poor course of illness were potent risk factors for diverse forms of disability in persons with psychosis.

Conclusion. A large proportion of persons with experience of psychosis living in the community suffers from significant levels of psychosocial disability. Disablement seems to reflect, in part, a diathesis of poor pre-morbid functioning and less than optimal response to treatment of the disorder.

Background. This paper reports population data on DSM-IV generalized anxiety disorder from the Australian National Survey of Mental Health and Well-Being.

Methods. The data were obtained from a nationwide household survey of adults using a stratified multi-stage sampling process. A response rate of 78·1% resulted in 10641 persons being interviewed. Diagnoses were made using the Composite International Diagnostic Interview. The interview was computerized and conducted by trained lay interviewers.

Results. Prevalence in the total sample was 2·8% for 1-month GAD and 3·6% for 12-month GAD. Persons over 55 years of age were less likely to have GAD than those in the younger age groups. Logistic regression analysis also showed that a diagnosis of GAD was significantly associated with being of younger to middle age, being separated divorced or widowed, not having tertiary qualifications or being unemployed. Co-morbidity with another affective, anxiety, substance use or personality disorders was common, affecting 68% of the sample with 1-month DSM-IV GAD. GAD was associated with significant disablement, and 57% of the sample with DSM-IV GAD had consulted a health professional for a mental health problem in the prior 12 months.

Conclusions. The survey provides population data on DSM-IV GAD and its correlates. GAD is a common disorder that is accompanied by significant morbidity and high rates of co-morbidity with affective and anxiety disorders, and is associated with marital status, education, employment status, but not sex. Changes to DSM-IV diagnostic criteria did not appear to affect the prevalence rate compared to previous population surveys.

Background. Sertraline has a proved efficacy in post-traumatic stress disorder (PTSD), but it is unknown which symptoms respond or in what sequence this occurs. Such information might be useful clinically and heuristically.

Method. The study examined the effects of sertraline on the individual symptoms of PTSD. It also examined whether early changes in anger explained drug-induced change in other symptoms over time. Mixed models analysis was applied to datasets from two 12-week placebo-controlled trials of sertraline. A validated self-rating scale (DTS) was used to assess treatment efficacy.

Results. Sertraline was superior to placebo on 15 of 17 symptoms, especially in the numbing and hyperarousal clusters. A strong effect was found on anger from week 1, which partly explained the subsequent effects of sertraline on other symptoms, some of which began to show significantly greater response to drug than to placebo at week 6 (emotional upset at reminders, anhedonia, detachment, numbness, hypervigilance) and week 10 (avoidance of activities, foreshortened future).

Conclusions. Sertraline exercises a broad spectrum effect in PTSD. Effects are more apparent on the psychological rather than somatic symptoms of PTSD, with an early modulation of anger and, perhaps, other affects, preceding improvement in other symptoms.

Background. Road traffic accidents are known to have significant consequences for mental state and quality of life in the ensuing year that are largely unrelated to the nature of the injuries. Little is known of longer-term outcome in a representative population.

Methods. Questionnaires covering mental state and social adjustment were sent to 770 subjects who had previously participated in a prospective study of consecutive attenders at an emergency department following a road traffic accident and who had completed questionnaires at baseline, 3 months and 1 year. Outcomes were not predicted by measures related to injury type or severity but were predicted by baseline and later non-injury variables.

Results. Replies were received from 507 (66%) subjects. Although 76% of injuries were medically minor bruises and lacerations, 132 (26%) reported symptoms of psychiatric disorder and 104 (21%) moderate or severe pain at 3 years. There was little evidence of improvement in prevalence between 1 and 3 years, with continuing physical symptoms, psychiatric disorder and reported consequences for everyday life. There was a significant reduction in the number of cases of post-traumatic stress disorder (PTSD) despite there being 21 late onset cases. Psychiatric outcomes and pain were unrelated to the severity of injury and were largely predicted by post-accident variables.

Conclusions. Road traffic accidents have much greater consequences than would be expected from the largely minor nature of the physical injuries. There is a need for changes in medical care and in socio-legal procedures.

Background. To date, there is little information about how severely burned patients compare to unburned healthy individuals in terms of psychological profile and quality of life. As part of a larger study on the sensory consequences of burns, we assessed psychological functioning and quality of life in burned patients and unburned healthy control subjects. We also examined whether burn patients experiencing pain and/or paresthetic sensations (i.e. symptomatic patients) present a profile that is different from those who are asymptomatic.

Methods. Forty-nine burned patients (% total body surface area = 34·59%±13·40; 82% males/18% females) were evaluated 63·59±28·1 months post-burn. They were matched with 49 unburned healthy volunteers on age, sex, and education level. All subjects were administered the Symptom Checklist 90-Revised (SCL-90-R) to assess psychological functioning and the 36-item Short-Form Health Survey (SF-36) to assess quality of life.

Results. Approximately 25% of the burn patients presented clinically-significant psychological disturbances compared to 12% in the control group. Burn patients enjoyed a quality of life comparable to that of the control subjects, although they perceived some deterioration in their general health. More symptomatic than asymptomatic patients suffered from clinically-relevant somatization and obsessive–compulsive disturbances.

Conclusions. Severely burned patients adjust relatively well, although some develop clinically-significant psychological disturbances such as somatization and phobic anxiety. Burn patients experiencing abnormal sensations in their healed wounds (i.e. symptomatic patients) do not suffer from maladjustment to a greater extent than their asymptomatic counterparts, although more symptomatic patients experience somatization and obsessive–compulsive behaviours.

Background. In spite of the high frequency of emotional distress after traumatic brain injury (TBI), few investigations have examined the extreme of such distress, namely, suicidality, and no large scale surveys have been conducted. The current study examined both the prevalence and demographic, injury, and clinical correlates of hopelessness, suicidal ideation and suicide attempts after TBI.

Methods. Out-patients (N = 172) with TBI were screened for suicidal ideation and hopelessness using the Beck Scale for Suicide Ideation and the Beck Hopelessness Scale. Data were also collected on demographic, injury, pre-morbid and post-injury psychosocial variables and included known risk factors for suicide.

Results. A substantial proportion of participants had clinically significant levels of hopelessness (35%) and suicide ideation (23%), and 18% had made a suicide attempt post-injury. There was a high degree of co-morbidity between suicide attempts and emotional/psychiatric disturbance. Results from regression analyses indicated that a high level of hopelessness was the most significant association of suicide ideation and a high level of suicide ideation, along with occurrence of post-injury emotional/psychiatric disturbance, were the most significant associations of post-injury suicide attempts. Neither injury severity nor the presence of pre-morbid suicide risk factors contributed to elevated levels of suicidality post-injury.

Conclusions. Suicidality is a common psychological reaction to TBI among out-patient populations. Management should involve careful history taking of previous post-injury suicidal behaviour, assessment of post-injury adjustment to TBI with particular focus on the degree of emotional/psychiatric disturbance, and close monitoring of those individuals with high levels of hopelessness and suicide ideation.

Background. We sought to determine whether a brief psycho-educational intervention reduced disability in patients with benign palpitation.

Method. In a pragmatic randomized controlled trial within a cardiology clinic at a district general hospital, 80 consecutive patients diagnosed as having benign palpitation – either palpitation due to awareness of extrasystoles or sinus rhythm – with associated distress or disability were randomized to an intervention group (usual care plus nurse-delivered intervention based on cognitive-behavioural principles) or to a control group (usual care). Principal outcome was difference in proportion of participants with good or excellent researcher-rated activity levels at 3 months. Subsidiary outcomes were self-rated symptoms, distress and disability, researcher-rated unmet treatment needs.

Results. The principal outcome showed a statistically and clinically significant benefit for the intervention group, with a number needed to treat of 3 (95% CIs 2 to 7). All but one subsidiary outcomes also showed a difference in favour of the intervention group, and several differences reached statistical significance. Significantly more of the control group had unmet treatment needs at 3 months.

Conclusions. A brief, nurse-delivered, psycho-educational intervention, was an effective treatment for benign palpitation. Further evaluation, including assessment of cost-effectiveness, is needed. The findings have application to the care of patients presenting with other types of ‘unexplained’ medical symptoms.

Background. The DSM-IV definition of hypochondriasis is contrasted with hypochondriacal dimensions as provided by the Whiteley Index (WI) and Illness Attitude Scales (IAS).

Methods. Exploratory factor analysis was conducted on self-report data from 570 patients with mental and psychophysiological disorders. Of these, 319 were additionally diagnosed according to DSM-IV by structured interviews.

Results. The three ‘classic’ factors of the WI labelled disease phobia, somatic symptoms and disease conviction were confirmed. The IAS consisted of two dimensions indicating health anxiety and illness behaviour. The overall scores of both instruments were highly correlated (0·80). Optimal cut-off points for case identification yielded sensitivity/specificity rates of 71/80% (WI) and 72/79% (IAS). The IAS was superior to the WI when patients with hypochondriacal disorder were to be discriminated from non-hypochondriacal somatizers. Largest group differences were found for scales related to affective components (health anxieties), smallest for illness behaviours. Affective components of hypochondriasis explained more variance of diagnostic group membership than somatization symptoms. The subscales of disease phobia (WI) and health anxiety (IAS) were most sensitive to treatment-related changes.

Conclusions. The self-rating scales are valid for screening, case definition and dimensional assessment of hypochondriacal disorder, including the differentiation between hypochondriasis and somatization. The existence of distinguishable affective and cognitive components was confirmed.

Background. A portion of the genetic risk factors for the personality trait neuroticism (N) may also increase risk for major depression (MD). Females have both higher levels of N and higher rates of MD than males, suggesting that these traits may be more genetically correlated in females.

Methods. Structured interviews, including a lifetime assessment for MD by DSM-III-R criteria, were administered to 863 male–male MZ (monozygotic), 649 male–male DZ (dizygotic), 506 female–female MZ, 345 female–female DZ, and 1408 opposite-sex twin pairs. N was assessed using the short-form of the Eysenck Personality Questionnaire. A sex-limited Cholesky model was fitted which allowed us to decompose into additive genetic, common environmental, and individual-specific environmental components two main classes of correlations: within-sex between-variable and between-sex within-variable.

Results. Our best-fitting model contained only additive genetic and individual-specific environmental factors for both N and MD. The within-sex genetic correlations between N and MD were estimated at +0·68 in men and +0·49 in women. This model fitted only slightly better than one in which the N–MD within-sex genetic correlation was constrained to be equal across the sexes, and estimated at +0·55. There may be sex-specific genes influencing both N and MD.

Conclusion. Our best-fitting model failed to establish a significant sex difference in the genetic correlation between N and MD. These results, as well as evidence for sex-specific genetic factors for both traits, have implications for the diagnosis, classification, and treatment of the affective disorders, and molecular genetic approaches to the study of these traits.

Background. Although there is evidence that genetic factors influence individual differences in environmental risk exposure, there are few findings on genetic effects on differential parenting. The present study sought to examine this issue.

Methods. The sample comprised 1117 pairs of like-sex male and female twins, aged 8–16 years, and their parents, recruited from the school population of Virginia. Differential ratings of the within-family experiences were provided by the Twin Inventory of Relationships and Experiences (TIRE).

Results. Dimensions describing the within-family environment based on differential ratings contrasting the twins with one another, were influenced, to an approximately equal extent, by both genetic and environmental factors.

Conclusions. The findings suggest that genetic differences between like-sex siblings lead them to experience their family environment differently, but also that environmental influences significantly affect interactions within the family.

Background. In evidence-based medicine, stratum-specific likelihood ratios (SSLRs) are now being increasingly recognized as a more convenient and generalizable method to interpret diagnostic information than an optimal cut-off and its associated sensitivity and specificity. We previously examined the SSLRs of the General Health Questionnaire (GHQ) in primary care settings. The present paper aims to examine if these SSLRs are generalizable to the community settings.

Methods. The Composite International Diagnostic Interview (CIDI) and the GHQ were administered on a representative sample of the Australian population in the Australian National Survey of Mental Health and Well-Being. We first compared the SSLRs of GHQ in urban Australia with the estimates that we had previously obtained from the developed urban centres in the WHO Psychological Problems in General Health Care study. If the SSLRs in the community were found to differ significantly from those in the primary care, we sought for explanatory variables.

Results. The SSLRs in urban Australia and in the urban centres in the WHO study were significantly different for three out of the six strata. When we limited the sample to those with physical problems who visited a health professional, however, the SSLRs in the Australian study were strikingly close to those observed for primary care settings.

Conclusions. Different sets of SSLRs apply to primary care and general population samples. For general population surveys in developed countries, the results of the Australian National Survey represent the currently available best estimates. For developing countries or rural areas, the results are less definitive and an investigator may wish to conduct a pilot study.