This issue features groups of papers dealing with ethnic and transcultural psychiatry, psychopathology in adolescents and their parents, and nicotine withdrawal, together with three papers on other issues, respectively severely mentally ill patients in residential facilities in Italy, interferon-induced cognitive changes, and persistence of impairment in personality disorders. The lead review article by Verdoux et al. (pp. 307–315) reviews studies addressing the question of whether dependence on benzodiazepines, drugs well known to produce cognitive effects when administered currently, is followed by enduring cognitive deficits after withdrawal.

Background. A major public health issue is to determine whether long-term benzodiazepine use may induce cognitive deficits persisting after withdrawal. The aim of the present review was to examine findings from prospective studies carried out in general population samples exploring whether exposure to benzodiazepines is associated with an increased risk of incident cognitive decline.

Method. Using a MEDLINE search and a hand-search of related references in selected papers, we retrieved original studies published in peer-reviewed journals that explored in general population samples the association between benzodiazepine exposure and change in cognitive performance between baseline and follow-up assessment.

Results. Six papers met the inclusion criteria. Two studies reported a lower risk of cognitive decline in former or ever users, two found no association whatever the category of user, and three found an increased risk of cognitive decline in benzodiazepine users.

Conclusions. The discrepant findings obtained by studies examining the link between benzodiazepine exposure and risk of cognitive decline may be due to methodological differences, especially regarding the definitions of exposure and cognitive outcome. As a large proportion of subjects are exposed to benzodiazepines, a small increase in the risk of cognitive decline may have marked deleterious consequences for the health of the general population. This issue needs to be explored further by pharmaco-epidemiological studies.

Background. Recent research in the United States has demonstrated striking health disparities across ethnic groups. Despite a longstanding interest in ethnic disadvantage in psychiatric epidemiology, patterns of psychiatric morbidity across ethnic groups have never been examined in a nationally representative sample.

Method. Ethnic differences in psychiatric morbidity are analyzed using data from the National Comorbidity Survey (NCS). The three largest ethnic groups in the United States – Hispanics, Non-Hispanic Blacks and Non-Hispanic Whites – were compared with respect to lifetime risk and persistence of three categories of psychiatric disorder: mood disorder, anxiety disorder, and substance use disorder.

Results. Where differences across ethnic groups were found in lifetime risk, socially disadvantaged groups had lower risk. Relative to Non-Hispanic Whites, Hispanics had lower lifetime risk of substance use disorder and Non-Hispanic Blacks had lower lifetime risk of mood, anxiety and substance use disorders. Where differences were found in persistence of disorders, disadvantaged groups had higher risk. Hispanics with mood disorders were more likely to be persistently ill as were Non-Hispanic Blacks with respect to both mood disorders and anxiety disorders. Closer examination found these differences to be generally consistent across population subgroups.

Conclusions. Members of disadvantaged ethnic groups in the United States do not have an increased risk for psychiatric disorders. Members of these groups, however, do tend to have more persistent disorders. Future research should focus on explanations for these findings, including the possibility that these comparisons are biased, and on potential means of reducing the disparity in persistence of disorders across ethnic groups.

Background. This study examined the relationship of childhood abuse, both physical and sexual, with subsequent lifetime depressive and anxiety disorders – depression or dysthymia, post-traumatic stress disorder (PTSD), and panic or generalized anxiety disorder (GAD) – among American Indians (AIs).

Method. Three thousand and eighty-four AIs from two tribes – Southwest and Northern Plains – participated in a large-scale, community-based study. Participants were asked about traumatic events and family history, and were administered standard diagnostic measures of depressive/anxiety disorders.

Results. Prevalence of childhood physical abuse was approximately 7% for both tribes. The Southwest tribe had higher prevalence of depressive and anxiety disorders, with rates of PTSD being the highest. Childhood physical abuse was significant in bivariate models of depressive/anxiety disorders, and remained so in the multivariate models.

Conclusions. Childhood physical abuse was a significant predictor of all disorder groups for males in both tribes except for panic/GAD for the Northern Plains tribe in multivariate models; females showed a more varied pattern. Childhood sexual abuse did not significantly differ for males and females, and was an independent predictor of PTSD for both tribes, controlling for childhood physical abuse and other factors, and was significant for the other disorder groups only in the Southwest. Additional covariates that increased the odds of depressive/anxiety disorders were adult physical or sexual victimization, chronic illness, lifetime alcohol or drug disorder, and parental problems with depression, alcohol, or violence. Results provided empirical evidence of childhood and later life risk factors and expanded the population at risk to include males.

Background. In resource-poor countries, there remains an alarming treatment gap for people with schizophrenia, particularly those living in rural areas. Decentralization of mental health services, including community-based outreach programmes, represents one obvious strategy for bringing appropriate care to these communities. This study set out to assess the costs and effects of such a programme in rural Karnataka in India.

Method. Eight rural communities were visited by an outreach team, who identified cases of drug-naive or currently untreated schizophrenia. Recruited cases were provided with appropriate psychotropic medication and psychosocial support, and after obtaining informed consent were assessed every 3 months over one and a half years on symptomatology, disability, family burden, resource use and costs. A repeated-measures analysis was carried out to test for significant change in these outcome measures over this period.

Results. A total of 100 cases of untreated schizophrenia were recruited, of whom 28% had never received antipsychotic medication and the remaining 72% had not been on medication for the past 6 months. Summary scores for psychotic symptoms, disability and family burden were all reduced significantly, with particular improvement observed at the first follow-up assessment. Increases in treatment and community outreach costs over the follow-up period were accompanied by reductions in the costs of informal-care sector visits and family care-giving time.

Conclusions. Efforts to organize community-based care such as outreach services for people with schizophrenia living in more remote areas of resource-constrained countries can bring substantial benefits to patients and families alike.

Background. There is a large literature indicating that the offspring of mothers with Major Depressive Disorder (MDD) are at increased risk for depression. However, much less is known about the effects of paternal MDD on offspring psychopathology.

Method. We addressed this issue using a large community sample of parents and their adolescent and young adult offspring (n=775). Parents and offspring were independently assessed with semi-structured diagnostic interviews. Offspring were interviewed three times from mid-adolescence to age 24 years.

Results. Maternal MDD was significantly associated with offspring MDD. Paternal MDD was also significantly associated with MDD in offspring, but only among offspring with depressive episodes of moderate or greater severity. These effects persisted after controlling for socio-economic status, family intactness, and non-mood disorders in both parents. Rates of MDD were particularly elevated in offspring of mothers and fathers with early-onset MDD, and offspring of fathers with recurrent MDD. The magnitude of the associations between MDD in parents and offspring was generally in the small-to-medium range.

Conclusions. These results confirm previous findings of elevated risk of MDD in the offspring of depressed mothers. In addition, the results suggest that MDD in fathers is associated with increased risk of depression in offspring, but that it is limited to MDD episodes in offspring of moderate or greater severity.

Background. Disasters are believed to have large effects on the mental health of adolescents but the lack of prospective pre- and post-disaster data on affected and control populations have limited our knowledge on the validity of these claims. We examined the medium-term, 12 months' effects of a severe disaster on the mental health of adolescents, and compared them to effects after 5 months.

Method. A café fire in The Netherlands injured 250 adolescents and killed 14. We obtained data 15 months before and 12 months after the disaster about behavioural and emotional problems (using the Youth Self-Report) and substance misuse, in 124 students of an affected school of whom 31 were present at the fire (response 77·5%) and 830 other students (56·4%); mean age at baseline, 13·8 years.

Results. We found differences between students from the affected school and others for excessive use of alcohol (odds ratio 3·42, 95% confidence interval 2·00–5·85, p<0·0001), but not for behavioural and emotional problems and use of other substances. Effects had decreased compared to those after 5 months.

Conclusions. In the long run, the effects of disaster decrease regarding self-reported behavioural and emotional problems, but they remain regarding alcohol misuse among those present at the disaster, and their peers.

Background. Few studies of physical activity in patients with anorexia nervosa (AN) have included a suitable control group. Nor has such research considered the influence of parents' activity on that of their children. Our first prediction was that adolescents with AN would be significantly more active than healthy controls both prior to, and during, the progression of their disorder. We also expected that the activity levels of parents and their daughters would be correlated, and that this relationship would be stronger in patient than control families. Finally, we expected that the AN parents would be more active and report a greater commitment to exercise than the control parents.

Method. In a case-control design, we employed multiple indicators of physical activity from adolescent females and their parents, using longitudinal, retrospective, self-report measurements.

Results. AN patients were significantly more active than controls both during the course of their disorder and prior to its onset. Parents' activity related to their daughter's activity, but this relationship was not stronger in the parents of the patients.

Conclusions. Future research is needed to determine whether the relationship between parents' and children's activity levels reflects environmental or genetic influences, or a combination of both factors. The important observation of a significant increase in patients' activity levels at least a year prior to diagnosis of the disorder suggests that enhanced physical activity may play a role in the development of the disorder. This may also serve as an early warning sign of a subclinical eating disorder in adolescent girls.

Background. The Parental Bonding Instrument (PBI) measures the perception of being parented to the age of 16 years. Low scores on the care dimension and high scores on the overprotection dimension are considered to be risk factors of depression. While the PBI has been shown to be a reliable and valid instrument, the stability of the PBI over extended periods (taking into account individual characteristics and life experience) needs to be demonstrated.

Method. The PBI was measured in a non-clinical cohort on four waves between 1978 and 1998, along with a series of self-report measures including state depression and neuroticism. Differences in PBI change over time were examined by gender, lifetime major depression diagnosis, and life event variables, as well as by scores on neuroticism and state depression.

Results. Acceptable retest coefficients on PBI scores over the 20-year study were found for the cohort. No differences were found in PBI scores over time on the variables examined, including sex and depression measures.

Conclusions. The results indicate long-term stability of the PBI over time. The influences of mood state and life experience appear to have little effect on the stability of the perception of parenting as measured by the PBI. The present study increases confidence in the PBI as a valid measure of perceived parenting over extended time periods.

Background. Depression symptoms and diagnoses are associated with failure to quit smoking in most studies, but not all.

Method. A new measure of internalization (i.e. symptoms of depression or anxiety, or poor mood) was created to investigate whether internalization would predict smoking cessation in 549 smokers from three randomized clinical trials with inconsistent findings.

Results. Predicted item locations based on a map of the construct of internalization agreed with empirical locations based on item response theory. Internalization was highly correlated with neuroticism. Logistic regressions showed that internalization improved upon the predictions of other affect-related measures. High baseline internalization decreased abstinence from smoking at end of treatment and 3 months thereafter. History of major depression (single-episode or recurrent) failed to predict abstinence.

Conclusions. The broad, dimensional construct of internalization as conceptualized herein appears to be an important predictor of smoking cessation.

Background. Nicotine withdrawal is associated with failed smoking cessation and thus contributes to continuance of the habit and increases risk of smoking-related illnesses. Withdrawal is also associated with psychiatric disorders such as depression and alcoholism. However, relatively little is known about how to characterize the severity of withdrawal, including whether withdrawal subtypes exist in male smokers. If so, do these subtypes represent quantitative or qualitative differences?

Method. Smoking and withdrawal data were obtained from 4112 male–male twin pairs of the Vietnam Era Twin Registry during a 1992 administration of the Diagnostic Interview Schedule. Latent Class Analysis (LCA) was used to derive significantly different nicotine withdrawal profiles, and their association with psychiatric disorders was assessed. Genetic and environmental contributions and the correlation between these contributions were evaluated using bivariate biometrical modeling of the withdrawal phenotype and failed smoking cessation.

Results. The LCA model which best fit the data was a four-class severity continuum. Psychiatric disorders were significantly associated with more severe classes and the magnitude of the association increased as withdrawal severity increased. Genetics accounted for 31% and 51% of the variance in risk for withdrawal and failed cessation, respectively. The genetic contributions were significantly correlated (r=0·37).

Conclusions. Nicotine withdrawal classes are characterized by quantitative differences. The strong association between psychiatric disorders and withdrawal severity and the significant genetic correlation between withdrawal and cessation highlight the importance of withdrawal severity. Further refinement of the DSM definition of withdrawal to incorporate severity ratings may be warranted.

Objective. In Italy, Residential Facilities (RFs) have completely replaced Mental Hospitals (MHs) for the residential care of mentally ill patients. We studied all patients resident in 265 randomly sampled Italian RFs (20% of the total).

Method. Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the GAF, and comprehensive information about their sociodemographic and clinical status and care history were gathered.

Results. Of the 2962 patients living in the sampled facilities, most were males (63·2%) who had never married, more than 70% were over 40 years; 85% on a pension, most commonly because of psychiatric disability. A substantial proportion (39·8%) had never worked and very few were currently employed (2·5%); 45% of the sample was totally inactive, not even assisting with domestic activities in the facility. Two-thirds had a diagnosis of schizophrenia; co-morbid or primary substance abuse were uncommon. Twenty-one per cent had a history of severe interpersonal violence, but violent episodes in the RFs were infrequent. The managers judged almost three-quarters appropriately placed in their facilities and considered that very few had short-term prospects of discharge.

Conclusions. Italian RFs cater for a large patient population of severely mentally ill requiring residential care. Discharge to independent accommodation is uncommon. Future studies should attempt to clarify how to match residential programmes with patients' disabilities.

Background. The vegetative symptoms of depression resemble the symptoms of malaise associated with activation of the inflammatory response system (IRS), and can be regarded as an expression of a central motivational state that resets the organism's priorities to promote recovery from infection. Early vegetative symptoms, however, may also contribute to the high rates of depression seen later in the course of immune activation. We hypothesized that the onset of vegetative-depressive symptoms early in the treatment with the pro-inflammatory cytokine IFN-α in chronic hepatitis C patients would increase the risk for subsequent depressive cognitions.

Method. Sixteen patients eligible for IFN-α treatment and free of psychiatric disorders were recruited. The DSM-IV, the Multidimensional Fatigue Inventory, and the Montgomery–Asberg Depression Rating Scale (MADRS) were administered at baseline and 1, 2, 4, 8, 12 and 24 weeks after treatment was initiated. Cognitive-depressive and vegetative-depressive symptom clusters were constructed.

Results. Fatigue and depression scores increased significantly during IFN-α treatment. Depression scores were highest at week 8 of treatment. First week increase in vegetative-depressive symptom score predicted cognitive-depressive symptom score at week 8 and at week 24.

Conclusions. During IFN-α treatment, vegetative symptoms of depression appear earlier than, and are predictive of, their cognitive counterparts. This finding suggests that low mood state may in part be driven by the increase in early vegetative-depressive symptoms in the course of IFN-α-induced immune activation.

Background. A defining feature of personality disorder (PD) is an enduring pattern of inner experience and behavior that is stable over time. Follow-up and follow-along studies have shown considerable diagnostic instability of PDs, however, even over short intervals. What, then, about personality disorder is stable? The purpose of this study was to determine the stability of impairment in psychosocial functioning in patients with four different PDs, in contrast to patients with major depressive disorder (MDD) and no PD, prospectively over a 2-year period.

Method. Six hundred treatment-seeking or treated patients were recruited primarily from clinical services in four metropolitan areas of the Northeastern USA. Patients were assigned to one of five diagnostic groups: schizotypal (STPD) (n=81), borderline (BPD) (n=155), avoidant (AVPD) (n=137), or obsessive–compulsive (OCPD) (n=142) personality disorders or MDD and no PD (n=85), based on the results of semi-structured interview assessments and self-report measures. Impairment in psychosocial functioning was measured using the Longitudinal Interval Follow-up Evaluation (LIFE) at baseline and at three follow-up assessments.

Results. Significant improvement in psychosocial functioning occurred in only three of seven domains of functioning and was largely the result of improvements in the MDD and no PD group. Patients with BPD or OCPD showed no improvement in functioning overall, but patients with BPD who experienced change in personality psychopathology showed some improvement in functioning. Impairment in social relationships appeared most stable in patients with PDs.

Conclusion. Impairment in functioning, especially social functioning, may be an enduring component of personality disorder.