I have been asked to comment on the three articles on social phobia in this issue of Psychological Medicine. The three papers in one way or another concern themselves with important issues in the assessment and diagnosis of social phobia (also known as social anxiety disorder; Liebowitz et al. 2000). I do so with the caveat that I am an author on one of the papers and do not claim the same degree of objectivity in examining my own work as I do in examining the work of others. The three papers concern the psychometric evaluation of a modified version of the Clinical Global Impression (CGI) (Guy, 1976) in a sample of persons with social phobia (Zaider et al. 2003), the development of a self-report screening questionnaire for social phobia (Newman et al. 2003) and the characteristics of social phobia in the Australian National Survey of Mental Health and Wellbeing (NSMHWB) (Lampe et al. 2003).

Well conducted investigations into the long-term outcome of depressive disorders are rare. This issue of Psychological Medicine publishes two important papers reporting on different cohorts of depressed patients, one series from Japan (Kanai et al. 2003) and the other from Cambridge UK (Kennedy et al. 2003). Both were ascertained in the early 1990s and have been followed for 5–6 and 8–10 years respectively. Each study demonstrates methodological advances. Both invite comparison with previous reports of the long-term outcome of depression whose follow-up periods span the last 40 years. Is the outcome of depressive disorders at last improving in the era of modern treatments? Is this merely an artefact of better research methods, or does it also reflect therapeutic advances? If there has been very little improvement in some aspects of outcome, what lessons can we learn for future research and practice development?

Background. The aims of this research were to use data gathered over the course of a 21 year longitudinal study to examine the linkages between cannabis dependence at ages 18 and 21 and rates of psychotic symptoms taking into account previous symptom levels and other confounding factors.

Method. Data were gathered during the course of the Christchurch Health and Development Study (CHDS). The CHDS is a longitudinal study of a birth cohort of 1265 children who have been studied from birth to age 21. As part of this study, data were gathered on cannabis dependence and psychotic symptoms at ages 18 and 21.

Results. Young people meeting DSM-IV criteria for cannabis dependence had elevated rates of psychotic symptoms at ages 18 (rate ratio = 3.7; 95% CI 2.8–5.0; P<0.0001) and 21 (rate ratio = 2.3; 95% CI 1.7–3.2; P<0.0001). These associations were adjusted for previous psychotic symptoms and a range of other confounding factors using a generalized estimating equation model. This analysis showed that after adjustment for confounding factors, those meeting criteria for cannabis dependence still had an increased rate of psychotic symptoms (rate ratio = 1.8; 95% CI 1.2–2.6; P<0.005).

Conclusions. The results show that the development of cannabis dependence is associated with increased rates of psychotic symptoms in young people even when pre-existing symptoms and other background factors are taken into account.

A γ-aminobutyric acid (GABA)-ergic theory of mood disorders was proposed by Emrich and colleagues (1980) following observations of the efficacy of the GABAergic anticonvulsant, valproate, in the treatment of mania. Since then, increasing biochemical and pharmacological evidence from animal and human studies has supported the hypothesis that mood disorders are associated with abnormalities in brain GABA function.

Background. Counselling is frequently used in the management of common mental disorders (such as anxiety and depression) in primary care. However, there are concerns over the clinical effectiveness of counselling, both in comparison with usual general practitioner care, and with other treatments such as alternative psychological therapies and antidepressant treatment. This study used systematic review methodology to assess the current evidence-base.

Method. A systematic literature review located seven trials of relevance, comparing counselling with usual general practitioner care, cognitive-behaviour therapy and antidepressant medication. Data on internal and external validity were examined using a standardized quality rating scheme. Data concerning the impact of counselling on symptoms of anxiety and depression were pooled using meta-analytical procedures.

Results. The main analyses showed significantly greater clinical effectiveness of counselling compared with usual general practitioner care in the short-term (standardized mean difference −0·28, 95% CI −0·43 to −0·13, N=741, six trials) but not the long-term (standardized mean difference −0·07, 95% CI −0·26 to 0·12, N=447, four trials). Sensitivity analyses were undertaken to test the robustness of the results.

Conclusion. Counselling is associated with modest improvement in short-term outcome compared with usual general practitioner care, and thus may be a useful addition to mental health services in primary care.

Background. We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm.

Method. Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months.

Results. Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0·78, 95% CI 0·53 to 1·14, P=0·20).

Conclusion. Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

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.

Background. Epidemiological findings suggest that cannabis use is a risk factor for the emergence of psychosis, and that the induction of psychotic symptoms in the context of cannabis use may be associated with a pre-existing vulnerability for psychosis. This study investigated in a non-clinical population the interaction between cannabis use and psychosis vulnerability in their effects on psychotic experiences in daily life.

Method. Subjects (N = 79) with high or low levels of cannabis use were selected among a sample of 685 undergraduate university students. Experience sampling method (ESM) was used to collect information on substance use and psychotic experiences in daily life. Vulnerability to develop psychosis was measured using a clinical interview assessing the level of psychotic symptoms. Statistical analyses were performed using multilevel linear random regression models.

Results. The acute effects of cannabis are modified by the subject's level of vulnerability for psychosis. Subjects with high vulnerability for psychosis are more likely to report unusual perceptions as well as feelings of thought influence than subjects with low vulnerability for psychosis, and they are less likely to experience enhanced feelings of pleasure associated with cannabis. There is no evidence that use of cannabis is increased following occurrence of psychotic experiences as would be expected by the self-medication model.

Conclusion. Cannabis use interacts with psychosis vulnerability in their effects on experience of psychosis in daily life. The public health impact of the widespread use of cannabis may be considerable.

Background. The psychological autopsy method offers the most direct technique currently available for examining the relationship between particular antecedents and suicide. This systematic review aimed to examine the results of studies of suicide that used a psychological autopsy method.

Method. A computer aided search of MEDLINE, BIDS ISI and PSYCHLIT, supplemented by reports known to the reviewers and reports identified from the reference lists of other retrieved reports. Two investigators systematically and independently examined all reports. Median proportions were determined and population attributable fractions were calculated, where possible, in cases of suicide and controls.

Results. One hundred and fifty-four reports were identified, of which 76 met the criteria for inclusion; 54 were case series and 22 were case–control studies. The median proportion of cases with mental disorder was 91% (95% CI 81–98%) in the case series. In the case–control studies the figure was 90% (88–95%) in the cases and 27% (14–48%) in the controls. Co-morbid mental disorder and substance abuse also preceded suicide in more cases (38%, 19–57%) than controls (6%, 0–13%). The population attributable fraction for mental disorder ranged from 47–74% in the seven studies in which it could be calculated. The effects of particular disorders and sociological variables have been insufficiently studied to draw clear conclusions.

Conclusions. The results indicated that mental disorder was the most strongly associated variable of those that have been studied. Further studies should focus on specific disorders and psychosocial factors. Suicide prevention strategies may be most effective if focused on the treatment of mental disorders.

Background. The aim of this paper was to examine the association between major depression and cigarette smoking among young adults in a birth cohort before and after adjusting for confounding factors.

Method. Data were gathered over the course of the Christchurch Health and Development Study (CHDS). The CHDS is a longitudinal study of a birth cohort of 1265 New Zealand children studied to age 21. Data were gathered by interview on: (a) major depression over the period 16–21 years; (b) daily smoking and nicotine dependence over the period from 16–21 years. In addition, the study included extensive information on social, family, and behavioural factors in childhood and adolescence.

Results. Young people meeting DSM-IV criteria for major depression had elevated rates of daily smoking and nicotine dependence. These associations were reduced substantially by control for potential confounding child and adolescent factors. Nonetheless, even after such control, major depression was associated with increased rates of daily smoking (IRR=1·19; 95% CI=1·03, 1·39) and elevated rates of nicotine dependence (OR=1·75; 95% CI=1·13, 2·70).

Conclusions. The results suggest that much of the association between smoking and depression reflects common confounding factors that are associated with both outcomes. Nonetheless, even after control for these factors there is evidence of a possible causal linkage between smoking and depression. The direction of causality between smoking and depression remains unknown.

Background. There is a heritable component to suicidal behaviour, encouraging the search for the associated risk alleles. Given the putative role of the 5-HT (5-hydroxytryptamine; serotonin) system in suicidal behaviour, serotonergic genes are leading candidates. In particular, several studies have reported an association with variants in the tryptophan hydroxylase (TPH) gene.

Method. We studied six serotonergic gene polymorphisms in a well-characterized sample of 129 deliberate self-harm subjects and 329 comparison subjects. The polymorphisms were TPH (A779C), 5-HT transporter (5-HTT, LPR S/L), monoamine oxidase A (MAOA G941T), 5-HT1B receptor (HTR1B G861C), 5-HT2A receptor (HTR2A T102C), and 5-HT2C receptor (HTR2C Cys23Ser). Genotyping was done using polymerase chain reaction (PCR)-based assays. The primary analyses compared allele and genotype frequencies between cases and controls. There were a limited number of planned secondary analyses within the deliberate self-harm group.

Results. The TPH A779 allele was more common in deliberate self-harm subjects than in controls (OR 1·38, 95% CI 1·02–1·88; P=0·03). None of the other polymorphisms was associated with deliberate self-harm. Within the deliberate self-harm group there were no associations with impulsivity, suicide risk, lifetime history of depression, or family history of deliberate self-harm.

Conclusions. Our data extend the evidence that allelic variation in the TPH gene is a risk factor for deliberate self-harm. No evidence was found to implicate the other polymorphisms.

Background. Depression is common in people with schizophrenia and is associated with substantial morbidity and an increased risk of suicide. Our aim was to review systematically all the randomized controlled trials that have investigated the clinical effectiveness of antidepressant medication in the treatment of depression in people who also suffer with schizophrenia.

Method. Electronic searches of ClinPsych, the Cochrane Library, the Cochrane Schizophrenia Group's Register of Trials, EMBASE and Medline were completed. Reference lists from identified articles were hand searched.

Results. Eleven small studies were identified and all randomized fewer than 30 subjects to each group. We could only perform analyses on a subset of the trials. For five trials (aggregate N=209) the proportion improved in the antidepressant group was 26% (95% CI 10% to 42%) higher than in the placebo group. In six studies (aggregate N=267) the standardized mean difference on the Hamilton Rating Scale for Depression at the end of the trial was −0·27 (95% CI −0·7 to 0·2). There was no evidence that antidepressant treatment given during the stable phase of illness led to a deterioration of psychotic symptoms in the included trials.

Conclusions. The literature reviewed was, overall, of poor quality and only a small number of trials could contribute towards the meta-analysis. The results provide weak evidence for the effectiveness of antidepressants in those with schizophrenia and depression and could be explained by publication bias. We need further research to determine the best approach towards treating depression in people with schizophrenia.

Background. The efficacy and safety of bilateral prefrontal repetitive transcranial magnetic stimulation (rTMS) for treating resistant major depression were examined in a double-blind, placebo-controlled study.

Method. Nineteen medication-resistant depressed subjects were randomly assigned to 3 weeks of active or sham rTMS. Effects on mood and neuropsychological function were assessed.

Results. Both groups improved significantly in mood over the 3 weeks, but there was no significant difference between active and sham treatments. There were no significant neuropsychological effects.

Conclusions. Bilateral rTMS was not superior to sham in treating resistant depression in this pilot study, but caused no neuropsychological impairment.

Background. Conflicting results have been reported in previous association studies of the serotonin transporter promoter repeat length polymorphism (5-HTTLPR), seasonal affective disorder (SAD) and seasonality (seasonal variations in mood and behaviour). The aim of this study was to test for association in new case–control and population-based materials, and to perform a combined analysis of all published studies of 5-HTTLPR and SAD.

Method. One hundred and forty-seven new SAD cases and 115 controls were genotyped for 5-HTTLPR and in total 464 patients and 414 controls were included in the pooled analysis. In addition, 226 individuals selected for unusually high or low seasonality scores from a population based material and 46 patients with non-seasonal depression were analysed. Different genetic models were tested and seasonality was analysed both as a qualitative (high v. low) and as a quantitative trait in the different sample sets.

Results. No association between 5-HTTLPR and SAD was found in the new case–control material, in the combined analysis of all samples, or when only including 316 patients with controls (N=298) selected for low seasonality. A difference was detected between the population based high and low seasonality groups, when assuming a recessive effect of the short allele (20% and 10% short allele homozygotes, respectively, OR (95% CI): 2·24 (1·03–4·91)). Quantitative analysis of seasonality revealed no association with 5-HTTLPR in any sample set.

Conclusions. These results do not suggest a major role of the short variant of 5-HTTLPR in susceptibility to SAD, but provide modest evidence for an effect on seasonality.

Background. Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death.

Method. Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves.

Results. Differences in total cost per patient were statistically significant at 6 months in favour of MACT (−£897, 95% CI −1747 to −48, P=0·04), but these differences did not remain significant at 12 months (−£838, 95% CI −2142 to 466, P=0·21). Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is >90% probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual. The results for quality of life were not conclusive.

Conclusion. Cost-effectiveness acceptability curves demonstrate that, based on the evidence currently available, to reject MACT on traditional grounds of statistical significance and to continue funding current practice has <10% chance of being the correct decision in terms of cost-effectiveness.

Background. This article presents prospective lower bound estimations of findings on prevalence, incidence, clinical correlates, severity markers, co-morbidity and course stability of threshold and subthreshold recurrent brief depressive disorder (RBD) and other mood disorders in a community sample of 3021 adolescents.

Method. Data were collected at baseline (age 14–17) and at two follow-up interviews within an observation period of 42 months. Diagnostic assessment was based on the Munich Composite International Diagnostic Interview (M-CIDI).

Results. Our data suggest that RBD is a prevalent (2·6%) clinical condition among depressive disorders (21·3%) being at least as prevalent as dysthymia (2·3%) in young adults over lifetime. Furthermore, RBD is associated with significant clinical impairment sharing many features with major depressive disorder (MDD). Suicide attempts were reported in 7·8% of RBD patients, which was similar to MDD (11·9%). However, other features, like gender distribution or co-morbidity patterns, differ essentially from MDD. Furthermore, the lifetime co-occurrence of MDD and RBD or combined depression represents a severe psychiatric condition.

Conclusions. This study provides further independent support for RBD as a clinically significant syndrome that could not be significantly explained as a prodrome or residual of major affective disorders.

Background. Cognitive-behavioural therapy (CBT) brings about significant clinical improvement in anxiety and depression, but therapists are in short supply. We report the first phase of a randomized controlled trial of an interactive multimedia program of cognitive-behavioural techniques, Beating the Blues™ (BtB), in the treatment of patients in general practice with anxiety, depression or mixed anxiety/depression.

Method. One hundred and sixty-seven adults suffering from anxiety and/or depression and not receiving any form of psychological treatment or counselling were randomly allocated to receive, with or without medication, BtB or treatment as usual (TAU). Measures were taken on five occasions: prior to treatment, 2 months later, and at 1, 3 and 6 months follow-up using the Beck Depression Inventory, Beck Anxiety Inventory and Work and Social Adjustment Scale.

Results. Patients who received BtB showed significantly greater improvement in depression and anxiety compared to TAU by the end of treatment (2 months) and to 6 months follow-up. Symptom reduction was paralleled by improvement in work and social adjustment. There were no interactions of BtB with concomitant pharmacotherapy or duration of illness, but evidence, on the Beck Anxiety Inventory only, of interaction with primary care practice. Importantly, there was no interaction between the effects of BtB and baseline severity of depression, from which we conclude that the effects of the computer program are independent of starting level of depression.

Conclusions. These results demonstrate that computerized interactive multimedia cognitive-behavioural techniques under minimal clinical supervision can bring about improvements in depression and anxiety, as well as in work and social adjustment, with and without pharmacotherapy and in patients with pre-treatment illness of durations greater or less than 6 months. Thus, our results indicate that wider dissemination of cognitive-behavioural techniques is possible for patients suffering from anxiety and/or depression.

Background. This paper examines the associations between puberty and three important health behaviours (smoking, food intake and exercise) and explores whether these associations are mediated by puberty's relationship to stress and psychological difficulties.

Method. Data were taken from the first year of the ongoing, 5-year, Health and Behaviours in Teenagers Study (HABITS). This is a school-based study set in 36 schools in London. In the first year of the study, 4320 students (2578 boys, 1742 girls) in their first year of secondary education took part.

Results. Among girls, being more pubertally advanced was associated with a greater likelihood of having tried smoking. Among boys, being more pubertally advanced was associated with a greater likelihood of having tried smoking, a higher intake of high-fat food and higher levels of exercise. More pubertally advanced girls experienced more stress but not more psychological difficulties. There were no associations between puberty and either stress or psychological difficulties in boys. Stress and psychological difficulties were associated with health behaviours in girls and boys, but neither of these factors mediated the relationship between pubertal stage and health behaviours found in girls.

Conclusions. These results suggest that the onset of puberty has a marked effect on the development of health behaviours. Puberty was related to an acceleration of the development of unhealthy behaviours, except for exercise behaviour in boys, where advanced puberty was associated with more exercise. These changes were unrelated to adolescent issues of stress and a causal explanation for these associations must be sought elsewhere.

Background. This longitudinal study investigated whether patterns of cortisol and DHEA that precede the onset of an episode of major depression influence time to recovery in a community ascertained sample of adolescents meeting DSM-IV criteria for major depression.

Method. Sixty adolescents aged 12 to 16 at high risk for psychiatric disorders were followed for 24 months. At 12 months, 30 had experienced an episode of major depression and 30 had not. The second follow-up repeated the psychiatric evaluations with all participants completing the Kiddie-SADS Schedule for Schizophrenia and Affective Disorders. Hormone characteristics and self-reports completed at entry (the Mood and Feelings questionnaire and the Ruminations scale) together with intervening undesirable life events in the 12 months prior to onset, were used to determine the best pattern of psychosocial and endocrine features to predict persistent major depression.

Results. Compared to the never depressed (N=30) and remitted adolescents (N=19), persistently depressed cases (N=11) had a raised morning cortisol/DHEA ratio at entry. Only persistent cases had higher levels of self-reported depressive symptoms and ruminations at entry compared to never depressed. There was no difference in exposure to undesirable life events before onset of disorder between remitted and persistent groups. Logistic regression techniques showed that only the cortisol/DHEA ratio predicted persistence.

Conclusions. In community adolescents at high risk for psychiatric disorder persistent major depression may be distinguished from sporadic forms by the 08.00 h salivary cortisol/DHEA ratio prior to onset.

Background. It has been proposed that adverse life events involving loss or humiliation are particularly potent in provoking depressive episodes. We have also previously suggested that experiencing high rates of non-severe events may play a role in the development of resilience to the impact of severe threatening events when these occur.

Method. The Life Events and Difficulties Schedule (LEDS) (Brown & Harris, 1978) was used to record the life events experienced by 108 depressed probands and their nearest aged siblings as well as 105 healthy control subjects and their nearest aged siblings. All subjects were interviewed using the Schedule for the Clinical Assessment of Neuropsychiatry (SCAN) (Wing et al. 1990).

Results. Depressed probands were significantly more likely to have experienced a severe threatening event, loss event, or a humiliation event compared to the other subjects. These events also made up a greater proportion of the total number of events, in the depressed probands. Humiliation events were more frequent in depressed men than depressed women. There were no differences between the four groups for experiencing a non-severe event, although depressed probands also experienced more difficulties than the other three groups. Fifty-six healthy subjects who had not become depressed despite having experienced at least one severe and threatening event, had significantly more non-severe events, than the 116 subjects who were depressed at the time of interview.

Conclusions. The findings support the hypothesis that loss and humiliation events are particularly depressogenic. Experiencing a high rate of non-severe events may be associated with resilience to becoming depressed in the face of a threatening event.