Background. There are no prospective cohort studies of prognostic factors on the outcome of Gulf War veterans. We aimed to test the hypotheses that Gulf War veterans who were older; had more severe symptoms; had more exposures during deployment; had increased psychological distress and believed they had ‘Gulf War syndrome’ would experience greater fatigue and poorer physical functioning at follow-up.

Method. Gulf War veterans who responded to an earlier retrospective cohort study were followed with a postal survey. More symptomatic individuals were oversampled. Outcome was measured on the Chalder fatigue questionnaire, the General Health Questionnaire and the Medical Outcome Study Short-Form 36.

Results. Of those surveyed, 73·8% responded. We found some evidence for four of the five hypotheses. More self-reported exposures at baseline were not associated with poorer outcome, but older people, those with more severe symptoms at baseline, those with psychological distress and who believed they were suffering from ‘Gulf War syndrome’ had more fatigue at follow-up. Officer status was associated with a better outcome. A similar lack of association was found for exposures and physical functioning and GHQ-12 score. ‘Gulf War syndrome’ attribution was associated with a worse outcome for GHQ-12 and physical functioning even after controlling for severity of symptoms at baseline.

Conclusions. This study suggests that while multiple vaccination and military exposures are important risk factors for the onset of symptoms in Gulf War veterans, these are not important risk factors for persistence of such symptoms. Instead the severity of the initial symptoms; psychological distress and attributions may be more important determinants of outcome.

Background. Ruminating when depressed is thought to lower mood and impair problem-solving, while distraction is thought to alleviate mood and assist problem-solving. The present study investigates each of these proposals using both naturally occurring and experimentally induced rumination and distraction in a sample of patients with major depression.

Method. Thirty-six patients with major depression and 36 control participants were randomly allocated to either a rumination or distraction induction condition. Levels of trait rumination and distraction were measured at baseline, mood and problem-solving were measured before and after the inductions.

Results. In terms of trait measures, depressed patients with higher levels of trait rumination reported poorer mood and gave less effective problem solutions than those who were less ruminative. Trait distraction was not associated with mood or problem-solving. In terms of induced responses, depressed patients who were made to ruminate experienced a deterioration in their mood and gave poorer problem solutions. For those receiving the distraction induction, mood improved in all patients and problem-solving improved in patients who were not naturally ruminating at a high level. Neither induction had an impact on mood or problem-solving in control participants.

Conclusions. Treatment for depression associated with adverse life events may need to target rumination as well as problem-solving deficits if interventions are to be effective. The differential effects of self-applied versus experimentally induced distraction require further investigation. Future research will need to consider that high levels of trait rumination may interfere with the impact of experimental inductions.

Background. A considerable body of research has established that transitions out of marriage are generally deleterious for mental health and some have examined transitions out of cohabitation. In this study we depart from these established areas to investigate the effects of poor mental health on the duration and outcome of cohabitations and on the time to, and likelihood of, repartnering after both cohabitation and marriage.

Method. Samples came from the British Household Panel Survey, 1991–2001. These were: (1) 447 cohabiting spells; (2) 5571 paired person-years during cohabitation; (3) 508 spells after cohabitation; (4) 1197 person-year observations within those spells; (5) 869 spells after marriage; and (6) 2736 person-year observations within those spells. Life tables, log-rank tests, multinomial logit and proportional hazard models were used. Mental health was measured by the 12-item General Health Questionnaire.

Results. Poor mental health increased the risk of dissolving a cohabiting union for both men and women. Poor mental health reduced the risk of repartnering after a cohabiting union but had no effect on the risk of repartnering after a marriage. Other factors such as past marital status, age and parental status also had significant effects.

Conclusions. This study provides evidence that poor mental health during a cohabiting union increases the chances of that union dissolving instead of turning into marriage and poorer mental health immediately after a transition out of a cohabiting union is associated with reduced chances of repartnering.

Background. Little is known about the extent to which negative life events predict depressive symptoms in ethnically diverse groups or whether this relationship is proximal or enduring.

Method. The relationship between negative life events in adolescence and depressive symptoms in young adulthood was studied in a sample of over 1300 black and white female adolescents. Five domains of life events were assessed at age 16 years and depressive symptoms were measured at age 18 and again at age 21 years. Questions of interest included whether the association continued over time and whether there were specific domains of life events that predicted symptoms better than others.

Results. The total number of negative life events at time 1 predicted depressive symptoms at both time 2 and time 3. Interpersonal loss events and other adversities, however, predicted depressive symptoms only at time 2, whereas at time 3, only interpersonal trauma was a significant predictor. No ethnic differences were found, indicating that the relationship between life events and depressive symptoms appears to be similar for black and white adolescent girls.

Conclusions. The results suggest that negative life events and some specific type of stressors increase the likelihood of the onset of depression symptoms in future years, for both black and white girls. Early preventive efforts should be directed at adolescents who experience loss due to death of a significant other, traumatic events, and psychosocial adversities to forestall the development of depressive symptoms.

Background. Little is known about how continuation and maintenance cognitive-behavioural therapy (CBT) influences important psychological constructs that may be associated with long-term outcome of major depressive disorder. The goal of this study was to examine whether CBT would help maintain attributional style changes experienced by patients during acute phase fluoxetine treatment.

Method. Three hundred and ninety-one patients with major depressive disorder were enrolled in an open, fixed-dose 8 week fluoxetine trial. Remitters to this acute phase treatment (N=132) were randomized to receive either fixed-dose fluoxetine (meds only) or fixed-dose fluoxetine plus cognitive-behavioural therapy (CBT+meds) during a 6-month continuation treatment phase. The Attributional Style Questionnaire (ASQ) was completed by patients at three time points – acute phase baseline, continuation phase baseline and continuation phase endpoint. Analysis of covariance was used to compare continuation phase ASQ composite score changes between groups.

Results. Patients in both treatment groups experienced significant gains in positive attributional style during the acute phase of treatment. Continuation phase ASQ composite change scores differed significantly between treatment groups, with the CBT+meds group maintaining acute phase positive attributional style changes, and the meds only group exhibiting a worsening of attributional style. The two treatment groups did not significantly differ in rates of relapse and final continuation phase visit HAMD-17 scores.

Conclusions. In this sample, the addition of CBT to continuation psychopharmacological treatment was associated with maintenance of acute treatment phase attributional style gains. Further research is needed to evaluate the role of such gains in the long-term course of depressive illness.

Background. Fibromyalgia (FM), a chronic pain condition of unknown aetiology often develops following a traumatic event. FM has been associated with post-traumatic stress disorder (PTSD) and major depression disorder (MDD).

Method. Patients seen in a referral clinic (N=571) were evaluated for FM and chronic fatigue syndrome (CFS) criteria. Patients completed questionnaires, and underwent a physical examination and a structured psychiatric evaluation. Critical components of the diagnostic criteria of FM (tender points and diffuse pain) and CFS (persistent debilitating fatigue and four of eight associated symptoms) were examined for their relationship with PTSD.

Results. The prevalence of lifetime PTSD was 20% and lifetime MDD was 42%. Patients who had both tender points and diffuse pain had a higher prevalence of PTSD (OR=3·4, 95% CI 2·0–5·8) compared with those who had neither of these FM criteria. Stratification by MDD and adjustment for sociodemographic factors and chronic fatigue revealed that the association of PTSD with FM criteria was confined to those with MDD. Patients with MDD who met both components of the FM criteria had a three-fold increase in the prevalence of PTSD (95% CI 1·5–7·1); conversely, FM patients without MDD showed no increase in PTSD (OR=1·3, 95% CI 0·5–3·2). The components of the CFS criteria were not significantly associated with PTSD.

Conclusion. Optimal clinical care for patients with FM should include an assessment of trauma in general, and PTSD in particular. This study highlights the importance of considering co-morbid MDD as an effect modifier in analyses that explore PTSD in patients with FM.

Background. The present study investigated whether a failure of self-monitoring contributes to core syndromes of schizophrenia.

Method. Three groups of patients with a DSM-IV diagnosis of schizophrenia (n=27), with either prominent paranoid hallucinatory or disorganization syndrome, or without these symptoms, and a matched healthy control group (n=23) drew circles on a writing pad connected to a PC monitor. Subjects were instructed to continuously monitor the relationship between their hand movements and their visual consequences. They were asked to detect gain changes in the mapping. Self-monitoring ability and the ability to automatically correct movements were assessed.

Results. Patients with either paranoid-hallucinatory syndrome or formal thought disorder were selectively impaired in their ability to detect a mismatch between a self-generated movement and its consequences, but not impaired in their ability to automatically compensate for the gain change.

Conclusions. These results support the claim that a failure of self-monitoring may underlie the core symptoms of schizophrenia.

Background. We wished to assess the effect of three types of medication on verbal memory impairments in schizophrenia.

Method. Forty-eight patients with schizophrenia and 40 healthy control subjects underwent a battery of verbal memory tasks, including free recall, recognition and short-term memory span. All the patients were on antipsychotic medication. In addition, 24 were taking anticholinergic drugs (benztropine) and 30 were taking benzodiazepines. A subsample of 39 had clinical ratings for depressive symptoms. Regression analyses were conducted on the memory measures in this subsample, with negative symptoms, depression, type of antipsychotic medication (conventional v. atypical), benzodiazepines and anticholinergic drugs as predictors.

Results. Type of antipsychotic medication made no significant contribution to memory deficits and benzodiazepine use made very little contribution. However, anticholinergic medication was a predictor of memory impairment, especially with regard to semantic organization. Complementary analyses revealed that patients taking any type of drug with anticholinergic activity (benztropine and/or antipsychotic agents) were significantly impaired relative to the other patients on measures reflecting free recall efficiency and semantic organization.

Conclusions. Drugs with anticholinergic activity are the major pharmacological agents that contribute to the verbal memory deficit observed in patients with schizophrenia. These drugs appear to act by impeding semantic organization at encoding.

Background. Auditory hallucinations in psychosis often contain critical evaluations of the voice-hearer (for example, attacks on self-worth). A voice-hearer's experience with their dominant voice is a mirror of their social relationships in general, with experiences of feeling low in rank to both voices and others being associated with depression. However, the direction of the relationship between psychosis, depression and feeling subordinate is unclear.

Method. Covariance structural equation modelling was used with data from 125 participants diagnosed with schizophrenia to compare three ‘causal’ models: (1) that depression leads to the appraisal of low social rank, voice power and distress; (2) that psychotic illness leads to voice activity (frequency, audibility), which in turn leads to depression and the appraisal of voices' power; (3) our hypothesized model, that perceptions of social rank and social power lead to the appraisal of voice power, distress and depression.

Results. Findings supported model 3, suggesting that the appraisal of social power and rank are primary organizing schema underlying the appraisal of voice power, and the distress of voices.

Conclusions. Voices can be seen to operate like external social relationships. Voice content and experience can mirror a person's social sense of being powerless and controlled by others. These findings suggest important new targets for intervention with cognitive and social therapy.

Background. Sociological studies have shown that poor social integration confers suicide risk. It is not known whether poor integration amplifies risk after adjusting statistically for the effects of mental disorders and employment status.

Method. A case-control design was used to compare 86 suicides and 86 living controls 50 years of age and older, matched on age, gender, race, and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls. Social integration was defined in reference to two broad levels of analysis: family (e.g. sibship status, childrearing status) and social/community (e.g. social interaction, religious participation, community involvement).

Results. Bivariate analyses showed that suicides were less likely to be married, have children, or live with family. They were less likely to engage in religious practice or community activities and they had lower levels of social interaction. A trimmed logistic regression model showed that marital status, social interaction and religious involvement were all associated with suicide even after statistical adjusting for the effects of affective disorder and employment status. Adding substance abuse to the model eliminated the effects of religious involvement.

Conclusions. The association between family and social/community indicators of poor social integration and suicide is robust and largely independent of the presence of mental disorders. Findings could be used to enhance screening instruments and identify problem behaviors, such as low levels of social interaction, which could be targeted for intervention.