This issue features groups of papers on recurrent brief depression, psychological treatment of schizophrenia, psychological aspects of depression, attentional processes in ADHD and recovering alcohol abuse, and anxiety disorders. In addition an editorial reviews the role of GABA in mood disorders (pp. 387–393) and a systematic review of psychological autopsy studies of suicide finds mental disorder to be the strongest associated factor, with high population attributable fraction of 47–74% (pp. 395–405).

Classifications of depression based on secondary care samples may have little relevance in primary care settings, where many patients do not fulfil criteria for major depression; for example, through having depressive symptoms that are either too mild or too brief. And yet many such patients receive antidepressant treatments (antidepressants and various psychotherapies). At a time when the appropriate recognition and treatment of people with depressive symptoms is the subject of much discussion, and there is concern about the burgeoning number of new psychiatric diagnoses, the burden and hazards of depressive disorders need to be emphasized. The paper by Pezawas et al. (2003) (in this issue) reports the findings of an epidemiological study in adolescents and young adults, and provides a detailed description of the prevalence and features of one such disruptive disorder, namely recurrent brief depression.

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. 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. 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. The paper describes a randomized controlled trial of targeting cognitive behavioural therapy (CBT) during prodromal or early signs of relapse in schizophrenia. We hypothesized that CBT would result in reduced admission and relapse, reduced positive and negative symptoms, and improved social functioning.

Method. A total of 144 participants with schizophrenia or a related disorder were randomized to receive either treatment as usual (TAU) (N=72) or CBT+TAU (N=72). Participants were prospectively followed up between entry and 12 months.

Results. At 12 months, 11 (15·3%) participants in the CBT group were admitted to hospital compared to 19 (26·4%) of the TAU group (hazard ratio=0·53, P=0·10, 95% CI 0·25, 1·10). A total of 13 (18·1%) participants in CBT relapsed compared to 25 (34·7%) in TAU (hazard ratio=0·47, P<0·05, 95% CI 0·24, 0·92). In addition, the CBT group showed significantly greater improvement in positive symptoms, negative symptoms, global psychopathology, performance of independent functions and prosocial activities.

Conclusions. The study provides evidence for the feasibility and effectiveness for targeting CBT on the appearance of early signs of relapse in schizophrenia. The results are discussed in context of the study's methodological limitations.

Background. Because neurocognitive impairments of schizophrenia appear to be ‘rate limiting’ in the acquisition of skills for community functioning, it is important to develop efficacious rehabilitative interventions that can compensate for these impairments. Procedures based on errorless learning may facilitate work rehabilitation because they effectively automate training of work and other skills, thereby reducing the cognitive burden on persons with schizophrenia.

Method. The present study examined the ability of a training method based on errorless learning to compensate for neurocognitive deficits in teaching two entry-level job tasks (index card filing and toilet-tank assembly) to a sample of 54 unemployed, clinically stable schizophrenic and schizoaffective disorder out-patients. Participants were randomly assigned to one of two training groups, errorless learning v. conventional trial-and-error type instruction. Prior to randomization, all subjects were administered a neurocognitive battery. Job task performance was assessed by percentage accuracy scores immediately after training.

Results. For three of the six inter-relationships among neurocognitive functioning and training condition, the pattern was the same: the errorless learning group scored high in job task performance regardless of neurocognitive impairment, whereas the conventional instruction group showed a close correspondence between job task performance and degree of neurocognitive impairment.

Conclusions. These findings support errorless learning as a technique that can compensate for neurocognitive deficits as they relate to the acquisition of new skills and abilities in the work rehabilitation of persons with schizophrenia.

Background. Despite its clinical relevance, the diagnosis of cycloid psychosis has been relatively neglected in the psychiatric literature and in the current nosological systems. This study examined the clinical validity and nosological status of the cycloid psychosis concept.

Method. Six-hundred and sixty psychotic in-patients were assessed for psychosis-related variables and diagnosed according to DSM-III-R, DSM-IV, ICD-10 and the Perris & Brockington criteria for cycloid psychosis. The cycloid psychosis diagnosis (N=68, 10·3%) was examined in regard to its discriminant validity, concordance with other psychotic disorders, and predictive validity in relation to schizophrenia and psychotic mood disorders. To address putative heterogeneity within cycloid psychosis, affective (N=38) and non-affective (N=30) subgroups were examined.

Results. Cycloid psychosis had good discriminant validity regarding other psychoses (95% of correctly classified cases) and poor concordance with individual diagnoses from the formal diagnostic systems (κ<0·22). Cycloid patients had levels of psychotic, disorganization and first-rank symptoms comparable to schizophrenia, and levels of affective symptoms in-between schizophrenia and mood disorders. Regarding most clinical variables and morbidity risk of mood disorders, cycloid psychosis was closer to mood disorders. Cycloid psychosis had higher psychosocial stressors than schizophrenia and mood disorders. Affective and non-affective groups of cycloid psychosis differed in a number of variables indicating an overall better outcome for the non-affective group.

Conclusions. Cycloid psychosis does not correspond closely to any DSM-III-R, DSM-IV or ICD-10 category of psychosis, and more specifically this nosological concept is not well represented by the different formal definitions of remitting psychotic disorders. Cycloid psychosis seems to be an heterogeneous condition in that affective and non-affective subgroups can be differentiated.

Background. Recent evidence suggests that an abnormal response to performance feedback may contribute to the wide-ranging neuropsychological deficits typically associated with depressive illness. The present research sought to determine whether the inability of depressed patients to utilize performance feedback advantageously is equally true for accurate and misleading feedback.

Method. Patients with major depression and matched controls completed: (1) a visual discrimination and reversal task that featured intermittent and misleading negative feedback; and (2) feedback and no-feedback versions of a computerised test of spatial working memory. In the feedback version, negative feedback was accurate, highly informative, and could be used as a mnemonic aid.

Results. On the Probability Reversal task, depressed patients were impaired in their ability to maintain response set in the face of misleading negative feedback as shown by their increased tendency to switch responding to the ‘incorrect’ stimulus following negative reinforcement, relative to that of controls. Patients' ability to acquire and reverse the necessary visual discrimination was unimpaired. On the Spatial Working Memory task, depressed patients made significantly more between-search errors than controls on the most difficult trials, but their ability to use negative feedback to facilitate performance remained intact.

Conclusions. The present results suggest that feedback can have different effects in different contexts. Misleading, negative feedback appears to disrupt the performance of depressed patients, whereas negative but accurate feedback does not. These findings are considered in the context of recent studies on reinforcement systems and their associated neurobiological substrates.

Background. It is postulated that individuals who score high on neuroticism would ruminate when faced with stress. A ruminative response style to depression is associated with faulty attribution and higher dysfunctional beliefs, which in turn is associated with a higher level of depression and hopelessness. Distraction is associated with less severe depression. Evidence supporting these hypotheses mainly comes from a non-clinical population. Hence it is not clear if these theories apply to clinical depression.

Method. One hundred and nine out-patients suffering from unipolar major depressive disorder were recruited to test these theories, using model-fitting analysis technique.

Results. Certain rumination responses to depression were associated with higher levels of depression and hopelessness, faulty attribution and dysfunctional attitudes when gender and the level of depression were controlled. Principal component analysis of the Rumination Scale yielded four factors: ‘symptom-based rumination’, ‘isolation/introspection’, ‘self-blame’ and ‘analyse to understand’. Unlike the other factors, ‘analyse to understand’ did not correlate with the level of depression. Model fitting analysis, though not reflecting entirely the true model, captures most of the hypothesized relationships between important variables. Neuroticism was associated with stress. Rumination was associated with an increased level of dysfunctional beliefs and faulty attribution, which in turn was associated with increased severity of depression. Distraction, in contrast, was associated with lower levels of negative mood.

Conclusion. The results of our study support the importance of teaching depressed patients to manage their depressive symptoms by avoiding rumination about their symptoms and engaging in distracting and pleasurable activities.

Background. The symptom domain of inattention in attention deficit/hyperactivity disorder (ADHD) suggests that there are neuropsychological fields of attention in which subjects with ADHD express deficits. However, studies using differentiated neuropsychological attentional tests in ADHD are lacking.

Method. A consecutive series of 35 subjects with ADHD aged 9–12 years were assessed on a computer-driven neuropsychological test battery for attentional functions. Their performance was classified according to the data of a normative sample of 187 healthy subjects aged 9–12 years, and compared with the performance of 35 matched healthy control subjects.

Results. According to normative data, most ADHD subjects performed on all attentional measures within the normal range. Comparisons with the control group revealed that ADHD subjects reacted faster on all attentional tests, yielding statistical significance for the Go/No go test and the Divided Attention test. They also performed with significantly fewer errors on the Divided Attention test. On the Go/No go test, Visual Scanning test and Attentional Shift test ADHD subjects committed significantly more errors than control subjects.

Conclusions. Our results suggest a differential pattern rather than a deficit pattern of attentional functions in ADHD. It is suggested that the more rapid response style of ADHD subjects leads to a more erroneous performance in self-paced attentional tasks and to a better performance in externally paced attentional tasks. However, neuropsychological tests of attention do not contribute to the clinical diagnosis of ADHD.

Background. This study examined whether alcohol abuse patients are characterized either by enhanced schematic processing of alcohol related cues or by an attentional bias towards the processing of alcohol cues.

Method. Abstinent alcohol abusers (N=25) and non-clinical control participants (N=24) performed a dual task paradigm in which they had to make an odd/even decision to a centrally presented number while performing a peripherally presented lexical decision task. Stimuli on the lexical decision task comprised alcohol words, neutral words and non-words. In addition, participants completed an incidental recall task for the words presented in the lexical decision task.

Results. It was found that, in the presence of alcohol related words, the performance of patients on the odd/even decision task was poorer than in the presence of other stimului. In addition, patients displayed slower lexical decision times for alcohol related words. Both groups displayed better recall for alcohol words than for other stimuli.

Conclusions. These results are interpreted as supporting neither model of drug cravings. Rather, it is proposed that, in the presence of alcohol stimuli, alcohol abuse patients display a breakdown in the ability to focus attention.

Background. Generalized anxiety disorder is a common condition of excessive worry and tension which tends to run a chronic course associated with significant psychiatric and medical problems. Cognitive behaviour therapy (CBT) has been shown to be of clinical value in about 50% of cases with treatment gains maintained over follow-up periods ranging from 6 to 12 months. The potential value of CBT over the longer term has not been subject to rigorous investigation.

Method. Results are reported of 8–14 year follow-up of two randomized controlled trials of cognitive-behaviour therapy for generalized anxiety disorder employing structured interview with an assessor blind to initial treatment condition. Comparison groups included medication and placebo in one study based in primary care, and analytical psychotherapy in the other based in secondary care. Follow-up samples (30% and 55% of trial entrants) were broadly representative of the original cohorts.

Results. Overall, 50% of participants were markedly improved of whom 30–40% were recovered (i.e. free of symptoms). Outcome was significantly worse for the study based in secondary care in which the clinical presentation of participants was more complex and severe. For a minority (30–40%), mainly from the secondary care study, outcome was poor. Treatment with CBT was associated with significantly lower overall severity of symptomatology and less interim treatment, in comparison with non-CBT conditions, but there was no evidence that CBT influenced diagnostic status, probability of recovery or patient perceptions of overall improvement.

Conclusions. Both CBT and the complexity and severity of presenting problems appear to influence the long-term outcome of GAD.

Background. Discontinuation of benzodiazepine (BZ) treatment results in a well-characterized withdrawal syndrome in 40–50% of anxious patients. While numerous studies have established the role of BZ dose, treatment duration, half-life, potency, rate of withdrawal and severity of underlying anxiety disorder in predicting severity of withdrawal symptoms, fewer studies have examined the role of psychological and personality factors.

Method. In 123 panic disorder patients undergoing gradual tapered discontinuation of alprazolam in conjunction with pre-treatment with carbamazepine or placebo, the relationship between measures of ‘symptom sensitivity’ and ‘harm avoidance’, and severity of withdrawal symptoms measured as peak severity of symptoms, time before taper needed to be slowed due to symptoms, and ability to complete taper, was examined.

Results. After controlling for the less substantial effects of dose, treatment duration, pre-taper anxiety and panic attack frequency, measures of symptom sensitivity and harm avoidance accounted for an additional 3–6% of withdrawal variance.

Conclusions. These results show an effect of symptom sensitivity and harm avoidance on BZ withdrawal symptoms, comparable to prior findings linking dependent personality characteristics to withdrawal severity. Failure to show the expected effect on ability to complete taper may be due to either the more symptomatic nature of the patients in this study.

Background. There are few longitudinal studies of patients with medically unexplained symptoms. The aim of this study was to investigate outcome in frequent attenders in secondary care who present repeatedly with medically unexplained symptoms.

Method. Forty-eight patients presenting with medically unexplained symptoms, from a sample of 61, participated in a 3-year follow-up study. Psychiatric morbidity, functional impairment and use of services were evaluated.

Results. At follow-up there was a high prevalence of psychiatric morbidity with 69% having at least one psychiatric diagnosis. The sample continued to be high users of a range of health services and substantial functional impairment was reported.

Conclusion. In this group of frequent attenders with medically unexplained symptoms outcome as measured by psychiatric morbidity, service use and functional impairment remained poor after 3 years.

Background. This study examined the relative contribution of adolescent self-concept, maternal weight and shape concerns (WSC), and mother–daughter relationships to eating disturbances among girls with type 1 diabetes mellitus (DM).

Method. Eighty-eight adolescent girls (mean=15·0 years, s.d.=2·2) and their mothers completed self-report measures of disordered eating and weight control behaviours, with teens also reporting on disturbed eating and body attitudes. Based on reported symptoms, adolescents were classified as highly (N=18), mildly (N=30) and non-eating disturbed (N=40). Self-concept was assessed by adolescent self-report. Mother–daughter relationships were assessed by adolescent self-report and by observed mother–daughter interactions that were rated using a macroanalytic coding system that assesses intimacy and autonomy in these relationships.

Results. Hierarchical regressions illustrated that adolescent self-concept deficits, maternal WSC, and impaired mother–daughter relationships significantly predicted eating disturbances in girls with DM, accounting for 57% of the variance. Mothers who engaged in dieting and binge-eating were more impaired in their ability to support their daughters' emerging autonomy. The quality of mother–daughter relationships partly mediated the influence of maternal WSC on adolescent eating disturbances. Moreover, the impact of maternal WSC and mother–daughter relationships on eating disturbances was mediated by adolescent self-concept.

Conclusions. Findings illustrate two pathways through which mother–daughter relationships may impact upon risk of eating disturbances in girls with DM and highlight the need to evaluate family-based interventions specifically tailored for this high-risk population.

Background. The role of allelic variation in APOE, the genetic locus for apolipoprotein E, in geriatric depression is poorly understood. There are conflicting reports as to an association between the ε4 allele and depression in late life.

Method. Using a community based study of non-demented elders in Cache County, Utah, that included many very old individuals, we examined the relationship between APOE and late-onset (age >60) depression, with particular attention to possible age effects.

Results. There was no overall association between APOE and depression. However, there was a significant interaction effect of APOE and age such that the relationship of late-onset depression with respect to presence of the ε4 allele was larger among those 80 and older compared with those below age 80. Consistent with previous studies, women were more likely to experience late-onset depression than men.

Conclusions. Because we excluded prevalent cases of dementia, this pattern of relative risk with age may reflect the appearance of depressive symptoms as a prodrome of Alzheimer's disease or vascular dementia. Longitudinal studies should help to confirm or refute this explanation of the data.

Background. The statement that past behaviour is the best predictor of future behaviour has empirical support in respect of whether an individual will, or will not, commit a criminal offence. People who have offended in the past are more likely to offend in the future. The aims of this study were to develop an instrument and to examine whether the same statement applies in respect of the nature and circumstances of successive offences committed by the same person.

Method. A rating instrument to describe seven variables relating to the nature and circumstances of a serious offence, the SODI, was developed by the authors. Inter-rater reliability was measured when the instrument was applied to 80 offences committed by 40 patients leaving high secure hospitals. The data were examined for evidence of similarity in the nature and circumstances of successive offences.

Results. For five of the seven items of the instrument the kappa coefficients for inter-rater reliability were >0·65. No significant associations, in terms of SODI ratings, were found between the offence that led to hospital admission and that which was committed after discharge.

Conclusions. The SODI is a reliable instrument for the description of serious offences committed by this group. Risk assessments in psychiatry should be informed by an awareness that in only a proportion of cases will the nature and circumstances of any serious re-offence resemble the nature and circumstances of the offence which contributed to a patient's admission to hospital.

Background. Transsexualism is thought to be related to cortical processes reflecting a complex mosaic of biological, psychological and social/cultural information. Since the P300 component of event-related potentials is considered as an index of attentional processes, the present study focuses on auditory P300 elicited during a short memory test in male to female (MF) transsexuals, compared with that in healthy controls.

Method. The P300 component was evaluated during the anticipatory period of a short memory test in 13 MF transsexuals who had a gender reassignment operation, at least 3 years previously (mean time 17·6 years, range 3–31 years) and 26 healthy subjects (11 males and 15 females) matched for age and educational level.

Results. MF transsexuals exhibited significant reduction of P300 amplitude in the left frontal and temporoparietal areas in comparison to the control group. Furthermore, the group of transsexuals showed a significant delay of P300 latency in comparison to the controls, at the central frontal region.

Conclusions. These findings point to significant psychophysiological alterations of distributed cortical circuits in MF transsexuals. These alterations may be critically related to the biological substrate of MF transsexualism.