Background. Research shows that psychopathology, child sexual abuse and other childhood adversities are risk factors for suicide. However, few have investigated their joint and independent roles in the pursuit of a reliable, predictive model of suicidal behaviour.

Methods. Data are from the National Comorbidity Survey (N = 5877), a nationally representative study of prevalence, risk factors, and social consequences of psychiatric disorders in the US. Discrete time survival analysis and population attributable risk methodologies were utilized.

Results. Among those sexually abused as children, odds of suicide attempts were 2–4 times higher among women and 4–11 times higher among men, compared with those not abused, controlling for other adversities. Odds ratios were reduced but most remained statistically significant after adjusting for lifetime psychiatric illnesses preceding suicide attempts. In the same predictive equation, 79% of serious suicide attempts among women could be attributed to psychiatric disorders while 12% was attributable to rape and 7% to molestation. The highest probability of a first attempt was during early adolescence for those who were sexually abused and had a lifetime disorder, but it was 8–12 years older for those sexually abused without any disorders.

Conclusions. In the US, a strong association exists between child sexual abuse and suicidal behaviour, mediated by psychopathology. There is a substantial proportion of suicide risk attributable to child sexual abuse beyond the presence of psychopathology and other adversities. From a clinical standpoint, abuse survivors represent a high-risk population for suicidal behaviour. Further research into this preventable antecedent of suicide attempts is necessary.

Background. The objectives were to assess thoughts about suicide, plans to commit suicide and suicide attempts in the community, to investigate the use of health services following a suicide attempt, and to describe basic socio-cultural indices of the community.

Method. The community survey was one component of the larger WHO multisite intervention study on suicidal behaviours (SUPRE-MISS). In each site, it aimed at randomly selecting and interviewing at least 500 subjects of the general population living in the catchment area of the emergency department where the intervention component of the study was conducted. Communities of eight SUPRE-MISS sites (in Brazil, China, Estonia, India, Iran, South Africa, Sri Lanka, and Viet Nam) participated plus two additional sites from Australia and Sweden conducting similar surveys.

Results. Suicide attempts (0·4–4·2%), plans (1·1–15·6%), and ideation (2·6–25·4%) varied by a factor of 10–14 across sites, but remained mostly within the ranges of previously published data. Depending on the site, the ratios between attempts, plans, and thoughts of suicide differed substantially. Medical attention following a suicide attempt varied between 22% and 88% of the attempts.

Conclusions. The idea of the suicidal process as a continuous and smooth evolution from thoughts to plans and attempts of suicide needs to be further investigated as it seems to be dependent on the cultural setting. There are indications, that the burden of undetected attempted suicide is high in different cultures; an improved response from the health sector on how to identify and support these individuals is needed.

Background. The goal of this investigation was to determine the association between self-reported childhood trauma and physical disorders among adults in the United States.

Method. Data were drawn from the National Comorbidity Survey (N=S877). Multiple logistic regression analyses were used to determine the associations between childhood physical abuse, sexual abuse, and childhood neglect and the likelihood of specific physical disorders among adults.

Results. Childhood physical abuse, sexual abuse and neglect were associated with a statistically significantly increased risk of a wide range of physical illnesses during adulthood. After adjusting for demographic characteristics, lifetime anxiety and depressive disorders, alcohol and substance dependence, and all types of trauma: results showed that childhood physical abuse was associated with increased risk of lung disease (OR=1·5 (1·1, 2·2)), peptic ulcer (OR=1·5 (1·03, 2·2)) and arthritic disorders (OR=1·5 (1·1, 2·2)); childhood sexual abuse was associated with increased risk of cardiac disease (OR=3·7 (1·5, 9·4)); and childhood neglect was associated with increased risk of diabetes (OR=2·2 (1·1, 4·4)) and autoimmune disorders (OR=4·4 (1·7, 11·6)).

Conclusions. Consistent with previous work, these results suggest that self-reported childhood trauma is associated with increased risk of a range of physical illnesses during adulthood. Future research that includes replication of these findings using prospectively assessed physical and mental disorders with objectively measured biological data using a longitudinal design, including other known risk factors for these diseases and more detailed information on specific forms of abuse, is needed to understand the potential mechanisms of these links.

The distinction between normality and psychopathology has long been subject to debate. DSM-III and DSM-IV provided a definition of mental disorder to help clinicians address this distinction. As part of the process of developing DSM-V, researchers have reviewed the concept of mental disorder and emphasized the need for additional work in this area. Here we review the DSM-IV definition of mental disorder and propose some changes. The approach taken here arguably takes a middle course through some of the relevant conceptual debates. We agree with the view that no definition perfectly specifies precise boundaries for the concept of mental/psychiatric disorder, but in line with a view that the nomenclature can improve over time, we aim here for a more scientifically valid and more clinically useful definition.

Validity coefficients of the 30-item, 28-item and 12-item versions of the General Health Questionnaire (GHQ) were determined by comparison with the Present State Examination (PSE) in a sample of 200 17-year-olds. The PSE classified 7 people (3·5%) as cases, although only 47% were identified as free of symptoms. Misclassification rates, sensitivity and specificity values are presented for different cutting scores for the three versions of the GHQ. The GHQ-28 had superior values, especially with a cutting score of 5/6; the GHQ-12 with a 2/3 cutting score also had acceptable values. All versions of the GHQ correlated highly with the PSE Index of Definition and total scores, providing support for the treatment of GHQ scores as a continuous variable in this kind of population. Correlations between sub-scales of the GHQ-28 give further evidence for a general factor and the relative independence of the social dysfunction sub-scale.

Background. We examine potential sources of the sex differences in post-traumatic stress disorder (PTSD) in the community.

Methods. Data were obtained from a representative sample of 2181 persons aged 18–45 years in the Detroit primary metropolitan statistical area, which is a six-county area containing more than four million residents. A random digit dialling method was used to select the sample and a computer-assisted telephone interview was used to obtain the data. DSM-IV PTSD was assessed with respect to a randomly selected trauma from the list of qualifying traumas reported by each respondent.

Results. The lifetime prevalence of exposure and the mean number of traumas were lower in females than males. The overall conditional risk of PTSD (i.e. the probability of PTSD among those exposed to a trauma) was approximately twofold higher in females than males, adjusting for the sex difference in the distribution of trauma types. The sex difference was due primarily to females' greater risk following assaultive violence. The sex difference in the avoidance and numbing symptom group following assaultive violence exceeded the sex differences in other symptom groups.

Conclusions. Future research should focus on sex differences in the response to assaultive violence, including potential explanations for females' greater probability to experience avoidance and numbing.

Background. There is little evidence to support possible structural changes in the amygdala and hippocampus of patients with severe depression.

Methods. Quantitative MRI of the amygdala and hippocampus, as well as proton spectroscopy (MRS) of mesial temporal structures were studied in 34 drug-resistant in-patients with major depression and compared with 17 age-matched controls. Volumetric MRI data were normalized for brain size.

Results. The volume of the left hippocampus was significantly smaller in the patients compared with the controls. Both groups exhibited similar significant hippocampal asymmetry (left smaller than right). The patients, but not the controls, had significant asymmetry of the amygdalar volumes (right smaller than left). No differences were observed between the patients and controls in the T2 relaxation times for the hippocampus and amygdala. Mesial temporal lobe MRS revealed a significantly elevated choline/creatine ratio in the patients compared with the controls.

Conclusions. This quantitative MRI study provides support for a possible association between structural and biochemical substrates and severe drug-resistant major depression.

We present an integrative review of the development of child anxiety, drawing on a number of strands of research. Family aggregation and genetic studies indicate raised vulnerability to anxiety in offspring of adults with the disorder (e.g. the temperamental style of behavioural inhibition, or information processing biases). Environmental factors are also important; these include adverse life events and exposure to negative information or modelling. Parents are likely to be key, although not unique, sources of such influences, particularly if they are anxious themselves. Some parenting behaviours associated with child anxiety, such as overprotection, may be elicited by child characteristics, especially in the context of parental anxiety, and these may serve to maintain child disorder. Emerging evidence emphasizes the importance of taking the nature of child and parental anxiety into account, of constructing assessments and interventions that are both disorder specific, and of considering bidirectional influences.

Background. Given our poor understanding of the very long-term course of anorexia nervosa, many questions remain regarding the potential for recovery and relapse. The purpose of the present study was to investigate long-term outcome and prognosis in an anorexic sample 21 years after the initial treatment.

Method. A multidimensional and prospective design was used to assess outcome in 84 patients 9 years after a previous follow-up and 21 years after admission. Among the 70 living patients, the follow-up rate was 90%. Causes of death for the deceased patients were obtained through the attending physician. Predictors of a poor outcome at the 21-year follow-up were selected based on the results of a previous 12-year follow-up of these patients.

Results. Fifty-one per cent of the patients were found to be fully recovered at follow-up, 21% were partially recovered and 10% still met full diagnostic criteria for anorexia nervosa. Sixteen per cent were deceased, due to causes related to anorexia nervosa. The standardized mortality rate was 9·8. The three groups also showed significant differences in psychosocial outcome. A low body mass index and a greater severity of social and psychological problems were identified as predictors of a poor outcome.

Conclusions. Recovery is still possible for anorexic patients after a period of 21 years. On the other hand, patients can relapse, becoming symptomatic again despite previously achieving recovery status. Only a few patients classified as having a poor outcome were found to seek any form of treatment, therefore, it is recommended that these patients should be monitored regularly and offered treatment whenever possible.

Recognition of prodromal symptoms of schizophrenia offers the potential of early intervention to avert relapse and re-hospitalization (Carpenter & Heinrichs, 1983). The present study investigated how a strategy to detect prodromal signs might be effectively applied in the clinical setting. A standard monitoring system was developed involving completion of a new early signs scale (ESS) measuring changes in key symptoms phenomenologically (self-report) and behaviourally (observer report). The ESS was subject to rigorous psychometric evaluation and tested in a prospective pilot investigation. The ESS reliably identified early signs and predicted relapse with an overall accuracy of 79%. Several different patterns of relapse were identified. Observer reports compensated for loss of insight in some patients. In two cases where early signs indices were detected, prompt increases in medication appeared to arrest relapse and avert readmission. The ESS offers itself as a reliable, valid and administratively feasible measure and demonstrates considerable potential as a cost-effective procedure for secondary prevention.

We have previously described focal abnormalities of regional cerebral blood flow (rCBF) in the left dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex and angular gyrus in 40 patients with major depression. We now report on the patterns of change in rCBF in a subgroup of 25 of the same patients who were rescanned following clinical remission of depression. Fifteen patients were scanned when optimally matched for drug treatment (4) or drug free on both occasions (11). The other 10 patients were fully recovered but could not be matched for drug status for clinical and ethical reasons. In a paired comparison of the same patients when ill and following recovery it was evident that remission was associated with a significant increase in rCBF in the left DLPFC and medial prefrontal cortex including anterior cingulate. Increases in rCBF in the angular gyrus were not seen when the comparison of depressed and recovered scans was matched for medication. The previously described relationship between clinical symptoms and brain perfusion in the depressed state was no longer present in the recovered state; this supports the hypothesis of state relatedness. Thus, recovery from depression is associated with increases in rCBF in the same areas in which focal decreases in rCBF are described in the depressed state in comparison with normal controls.

The long-term relationships between various forms of childhood adversity and adult episodes of major depression are explored in a representative household survey of the United States adult (age 25 +) population. Seven of the eight childhood adversities considered are significantly associated with recent (12-month) episodes of depression. These effects are largely indirect consequences of some childhood adversities leading to a life history of depression and prior depression leading to new episodes. Only three of the eight childhood adversities directly affect recent onset or recurrence. The paper closes with a discussion of implications for future research on the long-term effects of childhood adversities.

The paper focuses on recent criticisms of the study of the role of life-events in the onset of psychiatric conditions and suggests that measurement error and bias can be reasonably well controlled by various methodological procedures. Failure to comply with these may be expected, however, to increase rather than decrease the chances of establishing a ‘positive’ resuit. Three further factors to do with the design of studies and the analysis of data are discussed which are likely to mask real differences between patient and comparison group, and which therefore might explain the ‘negative’ results reported in the literature. They concern: (1) the choice of an appropriate comparison group; (2) specification of the length of the period between event and onset; and (3) specification of the event in terms of some measure of severity. Results from two London studies of schizophrenic and depressive patients are presented to illustrate the argument. The studies suggest that life-events do play an important causal role in bringing about both disorders.

Background. High rates of depression associated with childbirth have been reported in many parts of the developing world. However, the prevalence and associations of antenatal and post-natal depression in the rural population remain unknown. Disability associated with depression and its impact on infant health and development could have important public health implications for many developing countries where large proportions of the population are rural.

Method. All women living in southern Kahuta, Pakistan, in their third trimester of pregnancy were interviewed at 6 weeks before delivery (N=632) and again at 10–12 weeks after delivery (N=541), using WHO Schedule for Clinical Assessment in Neuropsychiatry (SCAN), Personal Information Questionnaire (PIQ) and Brief Disability Questionnaire (BDQ).

Results. The point prevalence of ICD-10 depressive disorder was 25% in the antenatal period and 28% in the post-natal period. Depressed mothers were significantly more disabled, had more threatening life events, and poorer social and family support than non-depressed mothers. Vulnerable mothers were more likely to be depressed during pregnancy, rather than have an onset in the post-natal period.

Conclusion. Over one-quarter of mothers in a rural sub-district of Pakistan suffer from depression shortly before and after childbirth. Rapidly changing traditional family structures and practices may be increasing the risk of depression in many women. Recognizing and treating depression should be initiated during the antenatal, rather than post-natal period.

This paper explores the hypothesis that depression in chronic schizophrenia is in part a psychological response to an apparently uncontrollable life-event, namely the illness and its long-term disabilities. It is suggested that depression is linked to patients' perception of controllability of their illness and absorption of cultural stereotypes of mental illness. Clinically and operationally diagnosed schizophrenic and manic-depressive patients receiving long-term maintenance treatment were studied. The cross-sectional prevalence of depression in schizophrenics was 29% and 11% for patients with bipolar affective illness. The hypothesis was supported. Multivariate analyses revealed that patients' perception of controllability of their illness powerfully discriminated depressed from non-depressed psychotic patients. Although those patients who accepted their diagnosis reported a lower perceived control over illness and an external locus of control, label acceptance was not associated with lowered depression, self-esteem or unemployment. The cross-sectional nature of the study makes the direction of causality and the role of intrinsic illness variables difficult to ascertain; however, the results set the scene for prospective and intervention studies and the various possibilities are discussed.

This paper discusses the magnitude of the effect of life events in the causation of psychiatric illness. It is argued that an established epidemiological concept, relative risk, provides a useful measure of association which can be approximately adapted for retrospective controlled studies. Examination of studies employing general population controls consistently indicates effects of some importance, with risks of illness increased by factors of between 2 and 7 in the 6 months after an event. Risks are greater for the more stressful types of events, greater for depression and neuroses than schizophrenia, and even greater for suicide attempts. However, similar events occur commonly and a large proportion of event occurrences are not followed by illness. Events must interact with a wide variety of background factors, and the appropriate model is one of multifactorial causation.