Background. Mental disorders amplify suicide risk across the lifecourse, but most people with mental disorder do not take their own lives. Few controlled studies have examined the contribution of stressors to suicide risk.

Method. A case–control design was used to compare 86 suicides and 86 controls aged 50 years and older, matched on age, gender, race and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls.

Results. Perceived physical illness, family discord and employment change amplified suicide risk after controlling for sociodemographic covariates and mental disorders that developed [ges ]1 year prior to death/interview. Only the effect of physical illness (OR 6·24, 95% CI 1·28–51·284) persisted after controlling for all active mental disorders.

Conclusions. Interventions to decrease the likelihood of financial stress and to help families manage discord and severe physical illness may effectively reduce suicides among middle-aged and older adults.

Background. The evidence regarding the independent influence of duration of untreated psychosis (DUP) on rate and time to remission is far from unequivocal. The goal of the current study was to examine the role of predictors for rate and time to remission in first-episode psychosis (FEP).

Method. The differential effect of age, gender, age of onset, duration of untreated psychosis (DUP), duration of untreated illness (DUI), pre-morbid adjustment, co-morbid diagnosis of substance abuse and adherence to medication on the rate of and time to remission were estimated using a logistic and Poisson regression, and survival analysis respectively, in FEP patients.

Results. In a sample of 107 FEP patients 82·2% achieved remission over a period of 2 years after a mean of 10·3 weeks (range 1–72). Regression analysis, based on complete data on all variables of interest (n=80), showed status of remission to be positively influenced by better pre-morbid adjustment (RR 0·57, 95% CI 0·34–0·95, p<0·05), later age of onset (RR 1·09, 95% CI 1·05–1·13, p<0·0001), higher level of adherence to medication (RR 1·96, 95% CI 1·38–2·76, p<0·001) and shorter DUI (RR 0·99, 95% CI 0·997–0·999, p<0·005). Time to remission was influenced by age of onset (HR 1·04, 95% CI 1·00–1·08, p<0·04) and adherence to medication (HR 1·58, 95% CI 1·11–2·23, p<0·01).

Conclusions. Improving adherence to medication early in the course of treatment may be an important intervention to improve short-term outcome.

The Mini-Mental State Examination was administered to 1865 general-practice patients aged 75 years and over. Even when demented cases were removed from analysis, respondents with relatively little education, together with those in social classes Ill-manual and below, were significantly more likely to score below the cut-off point used in North American community surveys to denote ‘cognitive impairment’. Education and social class influenced scores on all sections within the MMSE with the exception of registration. Sex influenced scores on tests of calculation and spelling backwards but had no effect on total scores. These findings emphasize the importance of investigating low scorers in more detail before making a diagnosis of dementia.

Depression is well recognized to be rooted in the down-regulation of positive affect systems. This paper reviews some of the social and non-social theories that seek to explain the potential adaptive advantages of being able to tone down positive affect, and how dysfunctions in such affect control can occur in some contexts. Common to most evolutionary theories of depression is the view that loss of control over aversive events and/or major resources/rewards exert downward pressure on positive affect. Social theories, however, suggest that it is loss of control over the social environment that is particularly depressogenic. Two evolutionary theories (the attachment-loss, and the defeat-loss theories) are briefly reviewed and their interaction considered. It is suggested that phenotypes for toning down positive affect, in the face of loss of control, may become more severe in the context of socially hostile, unsupportive and/or excessively competitive environments. The paper briefly considers how human competencies for self-evaluation in relation to others, rumination, self-criticism, and modern social contexts can accentuate dysfunctional expressions of affect regulation.

Background. Hopelessness is considered a pre-eminent risk factor for suicide and non-fatal self-harm. We aimed to quantify the ability of the Beck Hopelessness Scale (BHS) to predict these two outcomes.

Method. Medline, Embase, PsycINFO and Cinahl were searched to January 2006. We included cohort studies in which the BHS was applied and patients were followed-up to establish subsequent suicide or non-fatal self-harm. Four studies provided usable data on suicide, and six studies provided data on non-fatal self-harm. Summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios (DORs) were calculated for each study. Random effects meta-analytic pooling across studies at the standard cut-off point ([ges ]9) was undertaken and summary receiver operating characteristic (ROC) curves constructed.

Results. For suicide, pooled sensitivity was 0·80 [95% confidence interval (CI) 0·68–0·90], pooled specificity was 0·42 (95% CI 0·41–0·44), and the pooled DOR was 3·39 (95% CI 1·29–8·88). For non-fatal self-harm, pooled sensitivity was 0·78 (95% CI 0·74–0·82), pooled specificity was 0·42 (95% CI 0·38–0·45), and the pooled DOR was 2·27 (95% CI 1·53–3·37).

Conclusion. The standard cut-off point on the BHS identifies a high-risk group for potential suicide, but the magnitude of the risk is lower than previously reported estimates. The standard cut-off point is also capable of identifying those who are at risk of future self-harm, but the low specificity rate means it is unlikely to be of use in targeting treatment designed to lower the rate of repetition.

The gradual shift towards non-institutional treatment for severe and chronic psychiatric illnesses has been accompanied by a recognition of potentially harmful effects (‘burden’) upon the patient's caregivers. This paper aims to provide a framework for the development of further research into the burden of ‘community care’ by offering a clear definition of the burden concept, an exposition of the criteria for evaluating rating scales to measure the concept, a review of major rating scales of burden, and some suggestions for improvements in methodology which are urgently required.

Background. Although psychiatric patients with eating disorders are known to be at risk for a variety of health problems, relatively little is known about eating disorders and associated health problems in other populations. An epidemiological study was conducted to investigate health problems and impairment associated with bulimia nervosa (BN) and binge eating disorder (BED) among female primary care and obstetric gynaecology patients.

Methods. Psychiatric disorders, physical illnesses, disabilities, functional status and stress were assessed among 4651 female patients (age range:18 to 99 years) at 8 primary care and 7 obstetric gynaecology clinics throughout the United States.

Results. Two hundred eighty-nine women (6·2%) were diagnosed with BN or BED. The prevalence of BN was approximately 1% among young and middle-aged women. The prevalence of BED increased steadily from early (3·3%) through middle (8·5%) adulthood. Anxiety disorders, mood disorders and diabetes were much more common among women with BN or BED than among women without these eating disorders. Women with BN or BED reported markedly poorer functioning and much higher levels of disability, health problems, insomnia, psychosocial stress and suicidal thoughts than did women without BN or BED, after co-occurring psychiatric disorders were controlled statistically. Yet, fewer than one of ten cases of BN or BED was recognized by the patients’ physicians.

Conclusions. Patients with BN or BED often experience considerable disability, impairment, distress and co-occurring illnesses. Increased recognition of eating disorders may be a crucial step towards encouraging more patients to seek treatment for these disabling conditions.

Background. Neuroticism has been shown to increase the risk of depression whereas extraversion is associated with a reduction of risk. These personality traits play a central role in aetiological theories of affective disorder but their role in schizophrenia is unclear. In this study, the risk for schizophrenia associated with neuroticism and extraversion was examined and quantified.

Methods. Neuroticism and extraversion rated at the age of 16 years were examined in relation to adult schizophrenia in a national birth cohort of 5362 individuals.

Results. Neuroticism increased the risk of later schizophrenia independent of the level of affective symptoms in adult life (odds ratio over three levels: 1·93, 95% CI 1·09–3·43), whereas extraversion reduced the risk (OR: 0·44, 95% CI 0·23–0·84).

Conclusions. Depression and schizophrenia may share personality risk-increasing and risk-reducing factors. Coping styles associated with particular personality traits may determine whether isolated symptoms progress to full-blown illness.

Forty-four young adults, admitted to a rehabilitation centre after very severe head injury, were followed-up 2 years after their accident. Comparison with a control group showed that the head injured had experienced marked changes in work, leisure activities, contact with friends and family life. Though these changes still created problems, the majority of patients and relatives appeared to have made a number of successful adaptations to their altered situation. Neurophysical status, personality change and memory loss all affected work capacity, while presence of personality changes was especially important in the loss of pre-accident friendships.

An earlier survey of a random sample of women in Camberwell in South London has shown that the majority of new occurrences of depressive disorders were brought about by certain kinds of life event and ongoing difficulty (provoking agent) and that the risk was increased under these circumstances by the presence of certain other social factors (vulnerability factors). Working-class women were much more likely to develop depression because they experienced more of these factors. A new survey in a rural population in the Outer Hebrides has confirmed the importance of these factors in the genesis of depression, although provoking agents occurred much less frequently in this rural setting. However, integration into the traditional way of life, rather than a middle-class status, was related to a lower chance of developing depression, and this appears to be explained by the relationship of provoking agents and vulnerability factors to such integration in the Outer Hebrides, and to social class status in Camberwell.

Neuroendocrine tests are now available for studying monoamine function in the brains of patients with mental illness. Great care is required in the selection of drugs which act upon specific monoamine receptors to produce specific hormonal responses. Equal care is required in the control of biological variables which may influence hormonal release.

Recently reported neuroendocrine studies of depressive illness are assessed in these terms. The results of these studies support the hypothesis that there is defective noradrenergic function in the brains of some patients with depressive illness.

Background. Most of the available evidence on the effects of depression is based on in- and out-patient samples focusing on individuals suffering from major depression. The aims of this study were to examine cognitive functioning in population-based samples and to determine whether cognitive performance varies as a function of depression subgroup.

Method. Population-based samples (aged 20–64 years) with major depression (N=68), dysthymia (N=28), mixed anxiety-depressive disorder (N=25) and minor depression (N=66) were examined on a variety of cognitive tasks (i.e. episodic memory, verbal fluency, perceptual-motor speed and mental flexibility). One hundred and seventy-five non-depressed individuals served as controls.

Results. The total group of depressed individuals showed impairments in tasks tapping episodic memory and mental flexibility. Of more interest, however, was the observation that the pattern of impairments varied as a function of depression subgroup: the major depression and mixed anxiety-depressive disorder groups exhibited significant memory dysfunction, whereas individuals with dysthymia showed pronounced difficulties in mental flexibility. Minor depression did not affect cognitive performance. Verbal fluency and perceptual-motor speed were not affected by depression.

Conclusions. These results indicate that persons with depressive disorders in the population exhibit cognitive impairments in tasks tapping episodic memory and mental flexibility and that cognitive impairment varies as a function of depressive disorder.

Background. Patients with obsessive–compulsive disorder (OCD) have symptoms that pre-dominantly concern washing (washers) or checking (checkers), or both. Functional neuroimaging has been used to identify the neural correlates of the urge to ritualize but has not distinguished between washing and checking symptoms in OCD. We used functional magnetic resonance imaging to compare the neural response to emotive pictures in washers and checkers.

Methods. In one of two 5-minute experiments, washers (N = 7), checkers (N = 7) and age-matched normal controls (N = 14) were scanned while viewing alternating blocks of normally disgusting (rated as disgusting by all subjects) and neutral pictures. In the other experiment, all patients and a normal subgroup (N = 8) viewed alternating blocks of washer-relevant (rated as more disgusting by washers than normal controls or checkers) and neutral pictures.

Results. In all subjects, normally disgusting pictures activated visual regions implicated in perception of aversive stimuli and the insula, important in disgust perception. Only in washers were similar regions activated by washer-relevant pictures. In checkers, these pictures activated fronto-striatal regions associated with the urge to ritualize in OCD. Normal controls were more similar in neural response to checkers than washers to these pictures. Both normal controls and checkers had frontal regions activated significantly more by washer-relevant than normally disgusting pictures, and had these regions activated significantly more than washers by washer-relevant pictures.

Conclusions. We demonstrate a differential neural response to washer-relevant disgust in washers and checkers: only washers demonstrate a neural response to washer-relevant disgust associated with emotion perception rather than attention to non-emotive visual detail.

A prospective follow-up study was undertaken of two groups of women first studied in the mid 1960s when they were children: 94 girls reared in institutions to which they had been admitted because of a breakdown in parenting, and 51 girls in a general population comparison group. Both groups were interviewed in detail when aged 21–27 years and home observations were undertaken for those with young children. The institution-reared women showed a markedly increased rate of poor psychosocial functioning and of severe parenting difficulties in adult life. However, the support of a non-deviant spouse and of good living conditions in adult life provided a powerful protective effect.