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. Chronic fatigue syndrome (CFS) remains an idiopathic and controversial entity.

Method. We screened 31405 individual members of the Swedish Twin Registry (aged 42–64 years) for the symptoms of fatiguing illness via a telephone questionnaire. We refined self-reported symptoms via data from several national registries and from physician review of all available medical records in order to approximate closely the dominant case definition of CFS.

Findings. The 6-month prevalence of CFS-like illness was 2·36% (95% CI 2·19–2·53) and was markedly higher in women than men, odds ratio 3.92 (95% CI 3·24–4·72) with no significant association with age or years of education. There was a highly significant association with occupation that disappeared after accounting for gender.

Interpretation. CFS-like illness may be more common that previously acknowledged. There is a marked increase in risk by gender. Previous reports that CFS is more prevalent in individuals in certain occupational categories were not confirmed and may have been due to confounding by gender.

Background. The quality of subjective experience of dysphoria may predict persistence of depression, independently of severity. This is tested in a clinic sample of adolescents with first episode of major depression using the Depressed States Checklist adapted for adolescents.

Method. Ninety-four adolescents with DSM-IV major depressive disorder (MDD) were followed up at 12 months. Self-devaluative components of dysphoric experience, ruminative style, overgeneral autobiographical memory, and self-reported and observer-rated measures of depression severity were assessed at presentation and evaluated as predictors of persistent MDD.

Results. Persistent MDD was predicted by the independent additive effects of the higher self-devaluative component of dysphoria, lower general intelligence and greater observer-rated severity of depression at presentation. Neither self-reported depression score, overgeneral memory retrieval nor ruminative style contributed.

Conclusions. High levels of self-devaluative dysphoric experience increase the liability for persistence of first-episode MDD. Other affective-cognitive components also contribute. The adolescent version of the Depressed States Checklist is a useful brief measure of cognitive vulnerability for persistence in currently depressed young people.

Background. This and the companion paper present two sequential family studies of obsessive–compulsive disorder (OCD) conducted by the same research group, but with different sampling and best-estimate procedures. In addition to providing further data on familial transmission of OCD, we used comparison of disparate findings (moderate, specific familial aggregation in this first study versus a stronger effect for other anxiety disorders than for OCD alone in the second) to examine possible effects of proband characteristics and informant data on outcome.

Method. In this initial study we interviewed 179 first-degree relatives of 72 OCD probands and 112 relatives of 32 never mentally ill (NMI) controls. Informant data were obtained on an additional 126 relatives (total ‘combined’ samples of 263 and 154 respectively). Analyses used best-estimate diagnoses made by consensus of two ‘blinded’ senior clinicians who reviewed all diagnostic materials including proband informant data about relatives.

Results. Significantly higher risk for OCD but not other anxiety disorders was found in relatives of OCD probands compared to relatives of controls in both the directly interviewed and combined samples. There was no relationship between proband age at onset of OCD and strength of familial aggregation.

Conclusions. These data indicate moderate familial aggregation of OCD, but do not support increased transmission by early onset probands, or a familial relationship between OCD and other anxiety disorders with the possible exception of generalized anxiety disorder.

Background. Prevalence and co-occurrence of mental disorders is high among patients consulting their family general practitioner (GP) for a new health problem, but data on diagnostics and sociodemographics are sketchy.

Method. A cross-sectional two-phase epidemiological study. A total of 1785 consecutive patients with new complaints, aged 18–65 years, consulting 28 family practices during March–April 2000 in Aarhus County, Denmark were screened, in the waiting room, for mental and somatic symptoms with SCL-8 and SCL-Somatization questionnaires, for illness worry with Whitely-7 and for alcohol dependency with CAGE. In a stratified random sample of 701 patients, physician interviewers established ICD-10 diagnoses using the SCAN interview. Prevalence was calculated using weighted logistic regression, thus correcting for sample skewness.

Results. Half of the patients fulfilled criteria for an ICD-10 mental disorders and a third of these for more than one group of disorders. Women had higher prevalence of somatization disorder and overall mental disorders than men. Men had higher prevalence of alcohol abuse and hypochondriasis than women. Psychiatric morbidity tended to increase with age. Prevalence of somatoform disorders was 35·9% (95% CI 30·4–41·9), anxiety disorders 16·4% (95% CI 12·7–20·9), mood disorders 13·5% (95% CI 11·1–16·3), organic mental disorders 3·1% (95% CI 1·6–5·7) and alcohol abuse 2·2% (95% CI 1·5–3·1). Co-morbidities between these groups were highest for anxiety disorders, where 89% also had another mental diagnosis, and lowest for somatoform disorders with 39%.

Conclusions. ICD-10 mental disorders are very prevalent in primary care and there is a high co-occurrence between most disorders. Somatoform disorders, however, more often than not exist without other mental disorders.

Background. Age at onset (AAO) has been useful to explore the clinical, neurobiological and genetic heterogeneity of obsessive–compulsive disorder (OCD). However, none of the various thresholds of AAO used in previous studies have been validated, and it remains an unproven notion that AAO is a marker for different subtypes of OCD. If AAO is a clinical indicator of different biological subtypes, then subgroups based on distinct AAOs should have separate normal distributions as well as different clinical characteristics.

Method. Admixture analysis was used to determine the best-fitting model for the observed AAO of 161 OCD patients.

Results. The observed distribution of AAO in OCD is a mixture of two Gaussian distributions with mean ages of 11·1±4·1 and 23·5±11·1 years. The first distribution, defined by early-onset OCD, had increased frequency of Tourette's syndrome and increased family history of OCD. The second distribution, defined by late-onset OCD, showed elevated prevalence of general anxiety disorder and major depressive disorder.

Conclusions. These results, based on a statistically validated AAO cut-off and those of previous studies on AAO in OCD, suggest that AAO is a crucial phenotypic characteristic in understanding the genetic basis of this disorder.

Introduction. Cognitive therapy (CT) for bipolar disorder emphasizes the monitoring and regulation of mood, thoughts and behaviour. The Sense of Hyper-Positive Self Scale (SHPSS) measures the extent to which bipolar patients value themselves and perceive themselves to possess personal attributes (e.g. dynamism, persuasiveness and productiveness) associated with a state of being ‘mildly high’, which does not reach the severity of clinical hypomania. It is hypothesized that patients who score highly on the SHPSS do not respond well to cognitive therapy.

Method. One hundred and three bipolar-I patients were randomized into CT and control groups. The SHPSS was administered at baseline and at a 6-month follow-up.

Result. The SHPSS had good test–retest reliability after 6 months. At baseline, the Goal-Attainment Dysfunctional Attitudes contributed significantly to the SHPSS scores after the mood measures were controlled for in a regression analysis. There was a significant interaction between baseline SHPSS scores and group allocation in predicting relapse during therapy. Patients who scored highly on the SHPSS had a significantly increased chance of relapse after controlling for mood scores, levels of social functioning at recruitment, and the previous number of bipolar episodes.

Conclusion. Not all patients benefited from CT. For patients with high SHPSS scores, CT was less efficacious. The results also indicate that future studies could evaluate targeting these attributes and dysfunctional beliefs with intensive cognitive behavioural techniques.

Background. Very little research has examined the frequency with which women with major depressive disorder experience premenstrual exacerbation (PME) of depression or the characteristics of those who report such worsening. The NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study provides a unique opportunity to evaluate PME in depressed women seeking treatment in primary care or psychiatric settings.

Method. This report presents data from the first 1500 participants enrolled in the STAR*D study. Premenopausal women with major depressive disorder were asked if they experienced a worsening of their depressive symptoms 5–10 days prior to menses. Those reporting PME were compared with those reporting no PME with regard to sociodemographic characteristics, course of illness features, symptom presentation, general medical co-morbidity, functional impairment, and quality of life.

Results. Of 433 premenopausal women not taking oral contraceptives, 64% reported a premenstrual worsening of their depression. Women who reported PME had a longer duration of their current major depressive episode [30·7 (S.D.=73·7) months versus 13·5 (S.D.=13·2) months; p=0·001], as well as greater general medical co-morbidity. Women reporting PME were also more likely to endorse symptoms of leaden paralysis, somatic complaints, gastrointestinal complaints, and psychomotor slowing, and were less likely to endorse blunted mood reactivity.

Conclusions. PME is endorsed by the majority of premenopausal women with major depressive disorder and appears to be associated with a longer duration of depressive episode. PME is a common and important clinical issue deserving of further attention in both research and practice.

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. Researchers and clinicians use a variety of measures to assess depressive symptoms, including clinician reports [for example the 17-item Hamilton Rating Scale for Depression (HRSD-17) and the 30-item Inventory for Depressive Symptomatology – Clinician Report (IDS-C-30)]; and patient reports [for example, the Beck Depression Inventory (BDI) and the 30-item Inventory for Depressive Symptomatology – Self-Report (IDS-SR-30)]. Although their concurrent convergent validity is well established, the degree to which these measures reflect the same pattern and level of change during treatment is unclear.

Method. We assessed depressive symptoms with two clinician (HRSD-17, IDS-C-30) and two patient (BDI, IDS-SR-30) reports on 14–15 occasions in 127 out-patients with recurrent major depressive disorder treated with 20 sessions of acute-phase cognitive therapy.

Results. Factor analyses revealed that time was the major source of variation in depressive symptom severity and change, with distinct ‘early’ and ‘late’ assessment factors, regardless of measure or rater (patient v. clinician). Average symptom severity decreased rapidly on all measures until mid-treatment, after which gradual decreases continued through the end of treatment. Effect sizes for pre- to post-treatment change were large for all measures (d=1·9–2·2), although there were significant differences among measures at some time-points.

Conclusions. The HRSD-17, BDI, IDS-C-30 and IDS-SR-30 reflect essentially the same symptom severity and change constructs during acute-phase cognitive therapy. Clinicians and researchers using one of these measures may estimate scores on the others with the provided common-factor conversions.

Background. A self-report screening scale of adult attention-deficit/hyperactivity disorder (ADHD), the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS) was developed in conjunction with revision of the WHO Composite International Diagnostic Interview (CIDI). The current report presents data on concordance of the ASRS and of a short-form ASRS screener with blind clinical diagnoses in a community sample.

Method. The ASRS includes 18 questions about frequency of recent DSM-IV Criterion A symptoms of adult ADHD. The ASRS screener consists of six out of these 18 questions that were selected based on stepwise logistic regression to optimize concordance with the clinical classification. ASRS responses were compared to blind clinical ratings of DSM-IV adult ADHD in a sample of 154 respondents who previously participated in the US National Comorbidity Survey Replication (NCS-R), oversampling those who reported childhood ADHD and adult persistence.

Results. Each ASRS symptom measure was significantly related to the comparable clinical symptom rating, but varied substantially in concordance (Cohen's κ in the range 0·16–0·81). Optimal scoring to predict clinical syndrome classifications was to sum unweighted dichotomous responses across all 18 ASRS questions. However, because of the wide variation in symptom-level concordance, the unweighted six-question ASRS screener outperformed the unweighted 18-question ASRS in sensitivity (68·7% v. 56·3%), specificity (99·5% v. 98·3%), total classification accuracy (97·9% v. 96·2%), and κ (0·76 v. 0·58).

Conclusions. Clinical calibration in larger samples might show that a weighted version of the 18-question ASRS outperforms the six-question ASRS screener. Until that time, however, the unweighted screener should be preferred to the full ASRS, both in community surveys and in clinical outreach and case-finding initiatives.

Background. Chronic fatigue has infrequently been studied in twins. Data from twin studies can inform clinical and research approaches to the management and etiology of human complex traits.

Method. The authors obtained telephone interview data on current chronic fatigue from 31406 individuals twins in the Swedish Twin Registry (aged 42–64 years, 75·68% response rate), from both members of 12407 pairs and from one member of 6592 pairs. Of the complete pairs, 3269 pairs were monozygotic, 9010 pairs dizygotic, and 128 pairs of unknown zygosity. Structural equation twin modeling was used to estimate the latent genetic architecture of varying definitions of fatiguing illness.

Results. Estimates of additive genetic effects, shared environmental effects, and individual-specific environmental effects were similar in males and females. No definition of current fatiguing illness (ranging from any fatigue to CFS-like illness) was strikingly distinctive. Individual-specific effects were the predominant source of variation, followed by modest genetic influences. We could not exclude a small but conceptually important contribution of shared environmental effects.

Conclusions. Current fatiguing illness appears to be a complex trait resulting from both environmental and genetic sources of variation without pronounced differences by gender.

Background. Borderline personality disorder (BPD) is a serious mental illness. Due to scepticism about the effectiveness of its treatment, the care of these patients is neglected. In this study we evaluated the effect of treatment 5 years after its ending, of patients with BPD.

Method. Thirty subjects were treated twice weekly for 1 year by psychotherapy based on the ‘Conversational Model’ of Hobson. Outcome measures included time in hospital, number of episodes of violence and self-harm, number of medical appointments, drug use and work history. A ‘morbidity budget’ made up of these items was collated for the year before treatment, the year following treatment, and for the year preceding the 5-year follow-up. Additional measures included DSM-III criteria and a self-report of symptoms. These outcomes were compared to a hypothetical natural history of BPD constructed from the DSM scores of 150 borderline patients aged between 18 and 52 years.

Results. Except for one measure, the improvements evident 1 year following treatment were maintained 4 years later. This improvement was not predicted by the hypothetical natural history.

Conclusion. A particular form of treatment of BPD has relatively long-lasting, beneficial effects.

Background. Overall findings of our first direct interview family study of obsessive–compulsive disorder (OCD) indicated that OCD is familial. In this replication study, we carefully examined the role of informant data in ascertaining OCD in relatives.

Method. We interviewed 112 relatives of 57 OCD patients and 115 relatives of 41 not ill controls predominantly by telephone. Additional analyses included a combined sample of relatives about whom any diagnostic information was available (228 OCD and 239 controls). To examine the contribution of proband information about relatives, we considered two sets of best-estimate diagnoses. First, we ascertained best-estimate diagnoses for relatives using information from direct interviews and from all informants except the proband. Then, we re-diagnosed relatives based on all available information, including reports from the proband about their relatives.

Results. When relative diagnoses were derived without the benefit of proband informant reports, no evidence of familial OCD transmission was found. When diagnoses were made including information from the proband about the relative, evidence of familial OCD was found, but only when the diagnostic threshold was lowered to include cases with probable OCD or OCD symptoms. Other diagnoses (generalized anxiety disorder, social phobia, drug use disorder) were also higher among OCD relatives.

Conclusions. This second study provides less robust support for familial transmission of OCD. Evidence for familial transmission of OCD was found only when diagnoses were made using information from the affected proband about their relatives. Taken in context of past findings, our own inconsistent results suggest that OCD may be heterogeneous with regard to familial transmission. Also, more careful attention should be paid to the contribution of informant reports, especially from relatives affected by the same disorder.

Background. Depression is highly co-morbid with both psychiatric and chronic somatic disease. These types of co-morbidity have been shown to exert opposite effects on underdiagnosis of depression by general practitioners (GPs). However, past research has not addressed their combined effect on underdiagnosis of depression.

Method. Co-morbidity data on 191 depressed primary-care patients selected by a two-stage sampling procedure were analysed. Diagnoses of major depression and/or dysthymia in the last 12 months were assessed using a standardized psychiatric interview (CIDI) and compared with depression diagnoses registered by GPs in patient contacts during the same period. Presence of psychiatric and chronic somatic co-morbidity was determined using the CIDI and contact registration, respectively.

Results. Regression analysis showed a significant interaction effect between psychiatric and chronic somatic co-morbidity on GPs’ diagnosis of depression, while taking into account the effects of sociodemographic variables, depression severity and number of GP contacts. Subsequent stratified analysis revealed that in patients without chronic somatic co-morbidity, a lower educational level, a less severe depression, and fewer GP contacts all significantly increased the likelihood of not being diagnosed as depressed. In contrast, in patients with chronic somatic co-morbidity, only having no psychiatric co-morbidity significantly decreased the likelihood of receiving a depression diagnosis.

Conclusions. Our results indicate that the effects of psychiatric co-morbidity and other factors on underdiagnosis of depression by GPs differ between depressed patients with and without chronic somatic co-morbidity. Efforts to improve depression diagnosis by GPs seem to require different strategies for depressed patients with and without chronic somatic co-morbidity.

Background. Schneider's first-rank symptoms involve an alienated feature of the sense of one's own mental or physical activity. To clarify the brain morphological basis for the production of these symptoms, volumes of the frontal and medial temporal regions and their clinical correlates were examined in patients with schizophrenia.

Method. Twenty-two patients with schizophrenia and 44 age- and gender-matched healthy control subjects were included. All patients were in their psychotic episodes with definite Schneiderian symptoms, rated by using the Scale for Assessment of Positive Symptoms. Volumetric measurements of high-resolution magnetic resonance imaging were performed in the prefrontal area, cingulate gyrus, and precentral gyrus, and the medial temporal structures such as the amygdala, hippocampus, and parahippocampal gyrus.

Results. Patients had significantly decreased volumes in the cingulate gray matter and the amygdala compared to controls. In the patient group, Schneiderian symptom severity showed significant inverse correlations with volumes of the right posterior cingulate gray matter and of the left anterior parahippocampal gyrus.

Conclusions. Schneiderian symptoms may be associated with morphological abnormalities in the limbic-paralimbic regions such as the cingulate gyrus and parahippocampal gyrus, which possibly serve the self-monitoring function and the coherent storage and reactivation of information.

Background. Major depression is a prevalent mental disorder in the general population, with a multi-factorial etiology. However, work stress as a risk factor for major depression has not been well studied.

Method. Using a longitudinal study design, this analysis investigated the association between the levels of work stress and major depressive episode(s) in the Canadian working population, aged 18 to 64 years. Data from the longitudinal cohort of the Canadian National Population Health Survey (NPHS) were used (n=6663). The NPHS participants who did not have major depressive episodes (MDE) at baseline (1994–1995 NPHS) were classified into four groups by the quartile values of the baseline work stress scores. The proportion of MDE of each group was calculated using the 1996–1997 NPHS data.

Results. The first three quartile groups had a similar risk of MDE. Those who had a work stress score above the 75th percentile had an elevated risk of MDE (7·1%). Using the 75th percentile as a cut-off, work stress was significantly associated with the risk of MDE in multivariate analysis (odds ratio=2·35, 95% confidence interval 1·54–3·77). Other factors associated with MDE in multivariate analysis included educational level, number of chronic medical illnesses and child and adulthood traumatic events. There was no evidence of effect modification between work stress and selected sociodemographic, clinical and psychosocial variables.

Conclusions. Work stress is an independent risk factor for the development of MDE in the working population. Strategies to improve working environment are needed to keep workers mentally healthy and productive.

Background. Failure to resist chronic obsessive–compulsive symptoms may denote an altered state of cognitive control. We searched for the cerebral regions engaged in this dysfunction.

Method. Differences in brain regional activity were examined by event-related functional magnetic regional imaging (fMRI) in a group of adolescents or young adults (n=12) with childhood-onset obsessive–compulsive disorder (OCD), relative to healthy subjects. Subjects performed a conflict task involving the presentation of two consecutive and possibly conflicting prime and target numbers. Patients' image dataset was further analysed according to resistance or non-resistance to symptoms during the scans.

Results. Using volume correction based on a priori hypotheses, an exploratory analysis revealed that, within the prime-target repetition condition, the OCD subjects activated more than healthy subjects a subregion of the anterior cingulate gyrus and the left parietal lobe. Furthermore, compared with ‘resistant’ patients, the ‘non-resistant’ OCD subjects activated a bilateral network including the precuneus, pulvinar and paracentral lobules.

Conclusions. Higher regional activations suggest an abnormal amplification process in OCD subjects during the discrimination of repetitive visual stimuli. The regional distribution of functional changes may vary with the patients' ability to resist obsessions.

Background. This paper describes the 12-month prevalence, severity and demographic correlates of 16 DSM-IV psychiatric disorders and service utilization in the Mexican urban population aged 18–65 years of age. This is representative of 75% of the national adult population.

Method. The sample design was a strict probability selection scheme. The response rate was 76·6%. The World Mental Health Survey version of the Composite International Diagnostic Interview was installed on laptops and administered by lay interviewers. An international WHO task force carried out its translation into Spanish.

Results. The 12-month prevalence of any disorder was 12·1%. The most common disorders were specific phobia (4·0%), major depressive disorder (3·7%) and alcohol abuse or dependence (2·2%). The 12-month prevalence of very severe disorders was 3·7% of which only 24% used any services. Age was the only variable associated with any 12-month disorder, with the younger more likely to report any disorder. Income was associated with severity, with low and low–average incomes more likely to report a 12-month disorder. Females were more likely to report a mood and anxiety disorder, but less likely to report a substance disorder. The group of separated/widowed/divorced was more likely to report a mood and an impulse-control disorder.

Conclusions. The results show that while psychiatric disorders are common in the Mexican population, very severe mental disorders are less common and there is extreme under-utilization of mental health services.

Background. Studies of depression in the Chinese have long identified low rates and a greater likelihood of somatization, findings which could reflect cultural influences or real differences. We report a study from a western region examining the impact of acculturation on depression to clarify the role of cultural factors.

Method. In a Sydney-based study, Chinese subjects (n=385) and a matched control group of 143 non-Chinese subjects completed either a Chinese or English questionnaire assessing state and lifetime depression, attributional style, depression recognition and help-seeking. The impact of acculturation was examined by several strategies.

Results. Any tendency by the Chinese to somatize depression appeared to be attenuated by acculturation. State depression levels countered the view that Chinese necessarily deny depression. Lifetime depression rate differences were also attenuated by acculturation, with Chinese subjects being less likely than controls to judge episodes as a distinct disorder and to seek professional help.

Conclusions. Results suggest that Australian Chinese do not differ intrinsically in recognizing and ascribing depressive symptoms, and that the greater the degree of acculturation, the greater the tendency for reporting persistent and impairing depressive episodes.