A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project

OBJECTIVE

The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder. It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning, disability and satisfaction with services. Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates.

METHOD

Clients referred for case management were randomly allocated to one of three groups: standard case management (n = 35), client-focused case management (n = 39), or client-focused case management plus consumer advocacy (n = 45). Measures of functioning, disability, quality of life, burden of care and service satisfaction were measured at baseline and 12 months. Outcome data were collected concerning number and duration of hospital readmission, crisis intervention and compliance with treatment and services.

RESULTS

While there were no differences between the groups on quantitative measures of functioning, disability, quality of life, service satisfaction and burden of care, there were significant between-group differences on qualitative measures of satisfaction with services.

CONCLUSIONS

Several methodological difficulties hampered interpretation of the findings. Although clients did not differ on outcome measures of functioning and disability, the group receiving client-focused case management reported greater satisfaction with service delivery.

Diagnosis and treatment of mental disorders: a survey of Singapore mental health professionals

BACKGROUND

A series of surveys of mental health literacy have been undertaken in Australia, involving members of the general public as well as general practitioners and mental health professionals, whereby respondents consider vignettes of depression and of schizophrenia, offer a diagnosis and rate a series of possible interventions for their judged helpfulness. A similar survey was undertaken in Singapore and is reported in this paper.

METHODS

The survey was undertaken at a large state psychiatric hospital with staff (psychiatrists, allied health professionals, psychiatrically and generally trained nursing staff) rating a vignette of mania, in addition to the vignettes derived in Australia for depression and schizophrenia, and with the Australian intervention options extended somewhat to respect Singapore facilities.

RESULTS

Responses of those in the four professional groups were compared. The psychiatrists were highly accurate in generating diagnoses, other staff somewhat less so for diagnosing depression (with a percentage instead choosing a diagnosis of stress) and mania (with a percentage instead diagnosing a schizophrenic condition). Reported helpfulness ratings identified those interventions judged consensually as likely to be helpful or harmful, as well as establishing some differences across the four professional groups.

CONCLUSIONS

The consensus decisions of helpful treatments for depression and schizophrenia revealed very similar findings to judgements made by Australian professionals. The treated outcome of schizophrenia was judged as somewhat worse than that for mania and depression. While non-medical staff differed from psychiatrists in judging the comparative utility of some drug interventions and lifestyle issues, there was clear evidence of a relatively dominant 'medical model' to recommended treatments, while traditional healing practices and services were rated as distinctly unhelpful.

Subtyping depression: testing algorithms and identification of a tiered model

We seek to distinguish psychotic, melancholic, and nonmelancholic depression by clinical features and to test varying algorithm models to determine optimal criteria sets. We report a study of 269 depressed inpatients and outpatients. A latent class analysis (LCA) of 16 clinical features allowed for specificity or overrepresentation of features to be examined across the three classes. Varying algorithm models for distinguishing melancholic and nonmelancholic depression, involving endogeneity symptoms and observer-rated psychomotor disturbance (PMD) were compared. Psychotic depression was readily distinguished by the specific presence of psychotic features, and PMD was most severe in this class. Melancholic depression was most clearly distinguished from the residual nonmelancholic class by the presence of PMD. Although some endogeneity symptoms were overrepresented in the melancholic class, their specificity was unimpressive. An algorithm involving PMD components alone was highly efficient in discriminating LCA classes and, more importantly, superior to DSM-IV decision rules when examined against a range of clinical validators of melancholia. Subtyping appears assisted by a hierarchical model, based on a small set of features. The move from nonmelancholic to melancholic depression appears defined by a tier of observably rated PMD, whereas the move from melancholic to psychotic depression is determined by a tier of psychotic features and contributed to by significantly higher levels of PMD.

Psychological predictors of single and recurrent major depressive episodes

AIM

To examine for differential psychological risk factors in a nonclinical sample having single or recurrent episodes of major depression.

METHODS

A cohort of 164 subjects was assessed initially in 1978 in their last year of teacher training, and at five-yearly intervals in 1983, 1988 and 1993. Experience of episodes of DSM major depression and anxiety disorders from each wave were summed and three groups (nil, one, and two or more episodes of major depression) were derived. The cohort also completed a series of self-report measures including neuroticism, state and trait depression, self-esteem, dependency, childhood parental environment and social support.

RESULTS

The group with two or more episodes were distinctly more likely to have met lifetime criteria for an anxiety disorder and to have had multiple anxiety disorder diagnoses over their lifetime. Groups with one or more episodes reported higher mean scores for trait depression, neuroticism and maternal overprotection and lower mean scores for paternal care and self esteem at baseline in 1978, but these variables did not predict differences between groups with single and recurrent episodes. At 1993, those with two or more episodes differed from those with none and single episodes in reporting lower trait depression scores and decreased perception of satisfactory social support over time, suggesting a psychological scarring effect for those with repeated episodes.

Smallpox as a biological weapon: medical and public health management. Working Group on Civilian Biodefense

OBJECTIVE

To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of smallpox as a biological weapon against a civilian population.

PARTICIPANTS

The working group included 21 representatives from staff of major medical centers and research, government, military, public health, and emergency management institutions and agencies. Evidence The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox as well as this article. The literature identified was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group.

CONSENSUS PROCESS

The first draft of the consensus statement was a synthesis of information obtained in the evidence-gathering process. Members of the working group provided formal written comments that were incorporated into the second draft of the statement. The working group reviewed the second draft on October 30, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.

CONCLUSIONS

Specific recommendations are made regarding smallpox vaccination, therapy, postexposure isolation and infection control, hospital epidemiology and infection control, home care, decontamination of the environment, and additional research needs. In the event of an actual release of smallpox and subsequent epidemic, early detection, isolation of infected individuals, surveillance of contacts, and a focused selective vaccination program will be the essential items of an effective control program.

Double-blind controlled investigation of transcranial magnetic stimulation for the treatment of resistant major depression

OBJECTIVE

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

METHOD

Eighteen medication-resistant depressed subjects were randomly assigned to 2 weeks of real or sham rTMS, then permitted up to 4 weeks of real rTMS. Effects on mood, neuropsychological function, EEG, and hearing were assessed.

RESULTS

The groups receiving real and sham rTMS improved in mood significantly over the 2-week double-blind period, but there was no significant difference between groups.

CONCLUSIONS

Repetitive transcranial magnetic stimulation did not provide significantly greater improvement than did sham treatment. A 4-week course of rTMS, as administered in this study, was safe.

Risk and the welfare state

The British welfare state developed as a state-centred response to the problem of handling the risks encountered in a typical life-course. The influential work of Giddens and others implies that the traditional welfare state is under attack from two directions: a changing international politico-economic environment limits the freedom of national governments to pursue independent policies involving relatively high taxation to finance social spending. At the same time, changes in the experience of risk and declining confidence in the expertise of welfare state planners and professionals undermine support for state-centred solutions. This approach fails to acknowledge that available non-state services are often inadequate to meet many everyday life risks and that the authority of private sector advisers, insurers and professionals is also increasingly open to question. This article discusses whether people reject welfare state solutions to problems of risk in the context of research on the perceptions and behaviour of people buying or selling their homes, considering provision for long-term care needs and defrauding social security carried out by the ESRC's Economic Beliefs and Behaviour programme. Individual responses endorse the continued provision of state welfare in order to meet unprovided risks alongside disenchantment with the record of both state and private professionals and planners and awareness that state retrenchment requires greater individual responsibility for meeting one's own needs. The theory of risk society requires development to recognize that citizens are not necessarily alienated from state welfare.

Anthrax as a biological weapon: medical and public health management. Working Group on Civilian Biodefense

OBJECTIVE

To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of anthrax as a biological weapon against a civilian population.

PARTICIPANTS

The working group included 21 representatives from staff of major academic medical centers and research, government, military, public health, and emergency management institutions and agencies.

EVIDENCE

MEDLINE databases were searched from January 1966 to April 1998, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of references identified by this search led to identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources.

CONSENSUS PROCESS

The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. Members of the working group provided formal written comments which were incorporated into the second draft of the statement. The working group reviewed the second draft on June 12, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.

CONCLUSIONS

Specific consensus recommendations are made regarding the diagnosis of anthrax, indications for vaccination, therapy for those exposed, postexposure prophylaxis, decontamination of the environment, and additional research needs.

Novel p53 mutants selected in BRCA-associated tumours which dissociate transformation suppression from other wild-type p53 functions

Inheritance of germ-line mutant alleles of BRCA1 and BRCA2 confers a markedly increased risk of breast cancer and we have previously reported a higher incidence of p53 mutations in these tumours than in grade matched sporadic tumours. We have now characterized these p53 mutants. The results of these studies identify a novel class of p53 mutants previously undescribed in human cancer yet with multiple occurrences in BRCA-associated tumours which retain a profile of p53-dependent activities in terms of transactivation, growth suppression and apoptosis induction which is close or equal to wild-type. However, these mutants fail to suppress transformation and exhibit gain of function transforming activity in rat embryo fibroblasts. These mutants therefore fall into a novel category of p53 mutants which dissociate transformation suppression from other wild-type functions. The rarity of these mutants in human cancer and their multiple occurrence in BRCA-associated breast tumours suggests that these novel p53 mutants are selected during malignant progression in the unique genetic background of BRCA1- and BRCA2-associated tumours.

Sub-grouping non-melancholic depression from manifest clinical features

AIM

To determine whether clinical symptoms manifested during an episode of major depression are sufficient to allow meaningful sub-groups of non-melancholic depression to be identified.

METHODS

A sample of 178 non-melancholic patients with a major depressive episode was studied. The initial set of clinical variables was refined to 38 (21 depression, 17 anxiety) items and a cluster analysis undertaken.

RESULTS

A four-cluster solution identified 'anxiety', 'irritability', 'depressed mood' and 'residual' clusters, with these labels clarified by reference to a large data bank of non-symptomatic variables. These analyses suggested that members of the first two clusters could be viewed as having spectrum conditions (whereby Axis I symptom states are able to be linked with precursor or prodromal states and personality).

CONCLUSIONS

We confirm the long-standing suggestion that the non-melancholic depressive class contains sub-groups of those with manifest states of anxious depression and of an irritable or 'hostile' depression, and that such manifest symptoms are likely to be rooted in and fed by temperament and personality characteristics. The delineation of such sub-groups should assist studies designed to identify underlying neurobiological underpinnings and clinical management of the non-melancholic depressive disorders.

Sub-grouping non-melancholic major depression using both clinical and aetiological features

OBJECTIVE

In previous papers we have considered the extent to which two contrasting analytic approaches, examining reported clinical symptom variables alone and aetiological variables alone, assist definition of subgroups of non-melancholic major depression. Here, we address the same objective but combine both sets of variables, and contrast the combined solution with each of the contributing ones.

METHOD

We study a sample of 185 subjects with a putative non-melancholic major depressive disorder, with analyses involving 13 aetiological and 38 symptom variables.

RESULTS

A four-class subgrouping was derived by use of a cluster analytic technique, with 'neurotic depression', non-anxious 'depressed', 'situational' and 'residual' groups. The largest group comprised 'neurotic depression' subjects, with characteristics compatible with a spectrum disorder encompassing both clinical features as well as an underlying temperament and personality style marked by anxiety.

CONCLUSIONS

Comparative advantages and properties of the three differing analytic approaches to defining 'meaningful' non-melancholic major depressive subgroupings are considered. As a 'neurotic depressive' class has been consistently identified across those three approaches, but with quite varying numbers of subjects circumscribed, it is clearly a 'fuzzy' entity which may benefit from a dimensional approach to its measurement. As many of the non-melancholic groupings appear secondary to a substantive predisposing factor such as anxiety or disordered personality functioning, the clinical importance and treatment utility in identifying and circumscribing such classes are clearly supported.

Basilar impression complicating osteogenesis imperfecta type IV: the clinical and neuroradiological findings in four cases

OBJECTIVES

To describe the clinical and neuroradiological features of basilar impression in patients with osteogenesis imperfecta type IV.

METHODS

Four patients with basilar impression were ascertained in a population study of osteogenesis imperfecta. All four had detailed clinical and neuroradiological examination with both CT and MRI of the craniocervical junction and posterior fossa structures.

RESULTS

All four showed significant compression of the posterior fossa structures and surgical decompression was performed with relief of symptoms.

CONCLUSION

Symptoms of cough headache and trigeminal neuralgia occurring in patients with osteogenesis imperfecta are indications for detailed clinical and neuroradiological investigation to document basilar impression.

Characteristics of depressed patients who report childhood sexual abuse

OBJECTIVE

Depressed patients who had and had not been exposed to childhood sexual abuse were studied to determine differences in severity of depressed mood, lifetime histories of anxiety and depression, childhood environment, and disordered personality function.

METHOD

Data were obtained from 269 inpatients and outpatients with major depression (171 women and 98 men) by means of structured clinical interviews and self-report questionnaires.

RESULTS

Forty-six of the 269 patients reported childhood sexual abuse; 40 of these were women. These 40 women were compared with the 131 who did not report childhood sexual abuse. The patients who experienced abuse did not differ from those who had not on psychiatrist-rated mood severity estimates, but they did have higher self-report depression scores. They also evidenced more self-destructive behavior, more personality dysfunction, and more overall adversity in their childhood environment. Childhood sexual abuse status was associated with more borderline personality characteristics independently of other negative aspects of the patients' earlier parenting. Childhood sexual abuse status was linked strongly to adult self-destructiveness, as was early exposure to maternal indifference.

CONCLUSIONS

Multivariate analyses suggest that depression is unlikely to be a direct consequence of childhood sexual abuse. Childhood sexual abuse appears to be associated with a greater chance of having experienced a broadly dysfunctional childhood home environment, a greater chance of having a borderline personality style, and, in turn, a greater chance of experiencing depression in adulthood.

"Acting out" and "acting in" as behavioral responses to stress: a qualitative and quantitative study

In a sample of 270 depressed patients, we describe some behaviors in response to stress. One third acknowledged "acting out" behaviors--angry, destructive acts and "out of control" behaviors. Four fifths acknowledged "acting in" behaviors--most commonly withdrawal. As a percentage of subjects acknowledged both response styles (with alternate expression influenced by situation), we developed a dimensional self-report measure within a subsample of 177 who attended a follow-up reassessment. Assignment to four groups with contrasting expressions of "acting out" and "acting in" scores demonstrated differences in age, diagnostic status, age of onset of depression, and self-injurious behaviors.

Cognitive function in depression: a distinct pattern of frontal impairment in melancholia?

BACKGROUND

Although depressed patients demonstrate impaired performance on a range of neuropsychological tests, there is little research that examines either frontal cognitive deficits or possible differences in test performance between melancholic and non-melancholic subtypes.

METHODS

Depressed subjects were administered a broad neuropsychological battery. In an overall analysis, 77 depressed subjects were compared with 28 controls. In a second set of analyses, the depressed sample was divided into melancholic and non-melancholic subsets according to DSM-III-R, the CORE system and the Newcastle scale. These depressed subsets were contrasted to controls and with each other using ANCOVA controlling for age, IQ, simple reaction time and Hamilton Depression scores where appropriate.

RESULTS

The total depressed sample was impaired on most mnemonic tasks, simple reaction time and Trails B. Similar findings applied to DSM-III-R melancholic and non-melancholic subjects. When defined by the CORE and Newcastle (narrower definitions of melancholia), melancholic patients were additionally impaired on WCST (perseverative response) and (for Newcastle) digit symbol substitution. In contrast, the cognitive performance of the CORE and Newcastle-defined non-melancholic patients was largely unimpaired.

CONCLUSIONS

Using narrower definitions of melancholia, i.e. CORE and (in particular) Newcastle, melancholic patients were impaired on mnemonic tasks and tasks of selective attention, and set-shifting while non-melancholic subjects were largely unimpaired in their cognitive performance. These differences may be due to impairment of specific neuroanatomical regions in narrowly defined melancholic patients, in particular the anterior cingulate.

The influence of anxiety as a risk to early onset major depression

OBJECTIVE

we seek to identify and quantify any risk provided by several expressions of "anxiety" to major depression overall, and to separate melancholic and non-melancholic sub-types.

METHOD

a sample of 269 patients with a current major depressive episode was assessed for rates of separate formalised anxiety disorders, both for lifetime and prior to the initial depressive episode. We also sought for evidence of familial anxiety and, early childhood expression of anxiety forerunners, measured both state and trait anxiety levels as well as anxiety at a "personality" level, and assessed use of anxiolytic medications. Depressive sub-typing was undertaken using DSM-IV criteria, while "early onset" (EO) depression was defined as an initial onset at 25 years or less, and subsequently re-examined with a cut-off age of 20 years or less.

RESULTS

overall. 42% of our sample were assigned as having EO depression, with there being a higher representation of non-melancholic than melancholic EO subjects (i.e., 51% vs. 29%), arguing for sub-type status being respected in the analyses. For both melancholic and non-melancholic subjects two trait anxiety items ("tense"; "keyed up/on edge") were over-represented, suggesting that such a tense anxiety style may provide an antecedent risk to depression (of either sub-type) or be a consequence of depression. Specificity was most evident in the non-melancholic sub-sample, where EO depression was associated with a family history of anxiety, early childhood expressions of anxiety and with two lifetime anxiety disorders (social phobia and obsessive-compulsive disorder). Broadly similar results were returned when "EO" definition was reduced to 20 years or less.

CONCLUSIONS

our study is consistent with previous research in identifying anxiety in the form of social inhibition or social avoidance as being particularly likely to precede and perhaps be a conduit to early onset non-melancholic major depression. This conclusion both sharpens risk factor research and indicates an important fulcrum that could be used to assist primary prevention of the depressive disorders.

Incident monitoring in psychiatry

Critical Incident Monitoring (CIM) as an instrument of quality assurance (QA) has received increasing attention in recent years. The present study was developed to explore a potential role for CIM in QA for clinical psychiatry. A questionnaire was sent to psychiatrists and requested retrospective reporting of clinical incidents, and a pilot study of an inpatient-based incident reporting system was performed. All Fellows of the Royal Australian and New Zealand College of Psychiatry (RANZCP) were sent a questionnaire. Eight psychiatric inpatient services were invited to participate in the pilot study. The returns of the questionnaires were aggregated and analysed to reveal a relatively small number of separate incident types, with little difference between the 'adverse outcome' and 'near-miss' categories. Similar results were found with the pilot study. It was concluded that the development of a unified incident reporting system for use by psychiatric clinicians and psychiatric services may add usefully to existing quality improvement processes.

Development of a consumer advocacy program

OBJECTIVE

The aim of the present paper was to describe the development of a consumer advocacy program within the Eastern Suburbs of Sydney (NSW, Australia).

METHODS

The program was developed within the context of a research project that investigated the effect on outcome of client-focused approaches to community case management for clients with schizophrenia and bipolar disorder.

RESULTS

While the development of the advocacy program was limited by the constraints imposed by the research methodology, the study provided the opportunity to delineate the process involved and identify key components that need to be incorporated into future advocacy programs.

CONCLUSIONS

The main guidelines determined were that consumer participation in service delivery needs to be flexible, consumer driven, have broad-based support, ready access to supervision and debriefing, ongoing training and clear job descriptions. Given adequate support, autonomy and funding, consumer advocates can provide a much needed resource for their fellow consumers.

On modelling personality disorders: are personality style and disordered functioning independent or interdependent constructs?

Current descriptors of personality disorder (PD) are an amalgam of two constructs, personality style and/or disorder. We seek to determine whether their intrinsic personality style descriptors are proxy measures of, or independent of, disordered personality functioning. In a sample of depressed patients, psychiatrists rated 16 differing PD personality style vignettes and assessed eight differing manifestations of disordered functioning. When "personality" vignettes and identified personality clusters were intercorrelated with "disorder" variables, interdependence was generally evident, suggesting that the personality descriptors underpinning current definition of the PDs actually act as proxy criteria for assessing disorder because they are, in and of themselves, descriptors of pathological functioning. The obsessional personality vignette provided an exception, seeming to be independent of disordered function. Such results assist consideration of how best to model, define and measure the personality disorders.

Qualitative and quantitative analyses of a 'lock and key' hypothesis of depression

BACKGROUND

We examine a 'lock and key' ('L-K') hypothesis to depression which posits that early adverse experiences establish locks that are activated by keys mirroring the earlier adverse experience to induce depression.

METHODS

Two-hundred and seventy clinically depressed patients were examined with open-ended and pre-coded interview questions to ascertain both early adverse experiences and precipitating life events. Qualitative and quantitative data analyses examined for any associations between developmental 'locks' and precipitating 'keys'.

RESULTS

Qualitative assessment suggested 'L-K' links in almost one-third of the sample, and examples are provided. While quantitative analyses indicated significant associations between several identical 'lock' and 'key' constructs, evidence of specificity was rare. When individual 'locks' and 'keys' were consolidated into three higher-order constructs, variable models were suggested, including a non-specific link, a specific link and absence of any link. 'L-K' links appeared more likely in those with 'non-melancholic' (versus 'melancholic') depression, with the seemingly greater relevance to 'reactive' (versus 'neurotic') depression in the quantitative analyses inviting speculation that that 'disorder' may be more a reaction to a salient rather than a severe stressor.

CONCLUSIONS

This exploratory study suggests that early adverse experiences may variably establish specific and non-specific patterns of vulnerability to having depression triggered by exposure to salient mirroring life event stressors.

Neural network subtyping of depression

OBJECTIVE

To examine the applicability of a neural network classification strategy to examine the independent contribution of psychomotor disturbance (PMD) and endogeneity symptoms to the DSM-III-R definition of melancholia.

METHOD

We studied 407 depressed patients with the clinical dataset comprising 17 endogeneity symptoms and the 18-item CORE measure of behaviourally rated PMD. A multilayer perception neural network was used to fit non-linear models of varying complexity. A linear discriminant function analysis was also used to generate a model for comparison with the non-linear models.

RESULTS

Models (linear and non-linear) using PMD items only and endogeneity symptoms only had similar rates of successful classification, while non-linear models combining both PMD and symptoms scores achieved the best classifications.

CONCLUSIONS

Our current non-linear model was superior to a linear analysis, a finding which may have wider application to psychiatric classification. Our non-linear analysis of depressive subtypes supports the binary view that melancholic and non-melancholic depression are separate clinical disorders rather than different forms of the same entity. This study illustrates how non-linear modelling with neural networks is a potentially fruitful approach to the study of the diagnostic taxonomy of psychiatric disorders and to clinical decision-making.

p53 mutation with frequent novel condons but not a mutator phenotype in BRCA1- and BRCA2-associated breast tumours

The status of p53 was investigated in breast tumours arising in germ-line carriers of mutant alleles of BRCA1 and BRCA2 and in a control series of sporadic breast tumours. p53 expression was detected in 20/26 (77%) BRCA1-, 10/22 (45%) BRCA2-associated and 25/72 (35%) grade-matched sporadic tumours. Analysis of p53 sequence revealed that the gene was mutant in 33/50 (66%) BRCA-associated tumours, whereas 7/20 (35%) sporadic grade-matched tumours contained p53 mutation (P<0.05). A number of the mutations detected in the BRCA-associated tumours have not been previously described in human cancer databases, whilst others occur extremely rarely. Analysis of additional genes, p16INK4, Ki-ras and beta-globin revealed absence or very low incidence of mutations, suggesting that the higher frequency of p53 mutation in the BRCA-associated tumours does not reflect a generalized increase in susceptibility to the acquisition of somatic mutation. Furthermore, absence of frameshift mutations in the polypurine tracts present in the coding sequence of the TGF beta type II receptor (TGF beta IIR) and Bax implies that loss of function of BRCA1 or BRCA2 does not confer a mutator phenotype such as that found in tumours with microsatellite instability (MSI). p21Waf1 was expressed in BRCA-associated tumours regardless of p53 status and, furthermore, some tumours expressing wild-type p53 did not express detectable p21Waf1. These data do not support, therefore, the simple model based on studies of BRCA-/- embryos, in which mutation of p53 in BRCA-associated tumours results in loss of p21Waf1 expression and deregulated proliferation. Rather, they imply that proliferation of such tumours will be subject to multiple mechanisms of growth regulation.

Non-melancholic depression: the contribution of personality, anxiety and life events to subclassification

BACKGROUND

We sought to develop a clinically useful subtyping system for the non-melancholic depressive disorders, and here we assess one weighted to central aetiological factors.

METHODS

We studied 185 patients meeting DSM-III-R and/or clinical criteria for non-melancholic depression. Data were obtained by self-report, interview of patients and from corroborative witnesses. We developed a set of variables for class definition, assessing: (i) 'P', disordered personality as a vulnerability factor; (ii) 'A', meeting criteria for a lifetime anxiety disorder or positive on probe questions about trait anxiety characteristics, so assessing anxiety as a vulnerability factor; and (iii) 'L', psychiatrist and consensually-rated life event stress prior to depression onset.

RESULTS

A latent class analysis generated a four-class solution for the P-A-L variables. Life event stressors had similar item probabilities across all four classes, and did not influence the four-class 'P-A' solution when deleted from the analysis, suggesting that life event stress may act more as a general provoking agent, rather than constituting any distinct 'reactive' or 'situational' depression class. Three classes generated clinically meaningful groupings, reflecting varying contributions of anxiety and disordered personality functioning, and with evidence of differential outcome over the following 12 months.

CONCLUSIONS

We suggest that a refined aetiologically-weighted model may assist definition of the non-melancholic depressive disorders, and provide the logic for exploring the comparative utility of differing treatments to identified vulnerability-based classes.

Mammalian glycophosphatidylinositol anchor transfer to proteins and posttransfer deacylation

The glycophosphatidylinositol (GPI) anchors of proteins expressed on human erythrocytes and nucleated cells differ with respect to acylation of an inositol hydroxyl group, a structural feature that modulates their cleavability by PI-specific phospholipase C (PI-PLC). To determine how this GPI anchor modification is regulated, the precursor and protein-associated GPIs in two K562 cell transfectants (ATCC and .48) exhibiting alternatively PI-PLC-sensitive and resistant surface proteins were analyzed and the temporal relationship between GPI protein transfer and acquisition of PI-PLC sensitivity was determined. Nondenaturing PAGE analyses demonstrated that, whereas in .48 transfectants the GPI anchors in decay accelerating factor (DAF) and placental alkaline phosphatase (PLAP) were >95% acylated, in ATCC transfectants, they were 60 and 33% unsubstituted, respectively. In contrast, TLC analyses revealed that putative GPI donors in the two lines were identical and were >/=95% acylated. Studies of de novo DAF biosynthesis in HeLa cells bearing proteins with >90% unacylated anchors showed that within 5 min at 37 degreesC (or at 18 degreesC, which does not permit endoplasmic reticilum exit), >50% of the anchor in nascent 44-kDa proDAF protein exhibited PI-PLC sensitivity. In vitro analyses of the microsomal processing of miniPLAP, a truncated PLAP reporter protein, demonstrated that the anchor donor initially transferred to prominiPLAP was acylated and then progressively was deacylated. These findings indicate that (i) the anchor moiety that initially transfers to nascent proteins is acylated, (ii) inositol acylation in mature surface proteins is regulated via posttransfer deacylation, which in general is cell-specific but also can be protein-dependent, and (iii) deacylation occurs in the endoplasmic reticulum immediately after GPI transfer.

Development of a measure profiling problems and needs of psychiatric patients in the community

We argue the advantages of a measure profiling common problems faced by psychiatric patients in the community and indicating a likely need for service recognition, review and possible assistance. We describe the development of such a measure, the 35-item Profile of Community Psychiatry Clients (PCPC), and the identification of four relevant domains. Component scales assess coping limitations, behavioural problems, levels of social support and organic problems. High test-retest reliability was established, and a number of tests of the measure's validity were undertaken. Discriminant validity was established by demonstrating that those case managed by a community mental health service returned significantly higher scale scores than a comparison group who, while having a similar diagnostic profile, were not case managed. Additionally, scale scores were associated with a number of categorical and dimensional validators reflecting aspects of service need, and distinctly with service costs. We demonstrate that PCPC scores correspond with scores generated by the Life Skills Profile (LSP), a measure of disability, and examine the extent to which PCPC scales correspond to those contained in the Health of the Nation Outcome Scales (HoNOS). We argue for the scale's capacity to provide both a profile of central problems faced by patients and their likely need for community-based service assistance.

The SSRI antidepressants: exploring their "other" possible properties

BACKGROUND

Anecdotal reports suggest that the SSRIs may have important properties in addition to their antidepressant effects, possibly modifying mediating variables that dispose to and maintain depression. This preliminary study seeks to identify any such potential variables.

METHODS

Fifty three subjects who had reported substantial general benefit to their clinician after treatment with an SSRI were requested to retrospectively rate change across a range of constructs assessed by questionnaire.

RESULTS

Differential effects were identified. Irritability, trait depression, worry and neuroticism scores showed the most marked improvement, with cognitive style components also showing significant positive change. Equally importantly, there was no evidence of a positive response bias across all constructs.

CONCLUSION

We suggest that the SSRIs may act as "antiworry" agents and reduce irritability, neuroticism and dysfunctional attributions.

LIMITATIONS

Our study was retrospective and relied on self-report by volunteer patients who had been previously depressed. The study design cannot exclude the possibility that improvement reported on a number of measures may have been due to the amelioration of residual depression.

CLINICAL RELEVANCE

The SSRIs, recognised as having antidepressant and anti-obsessional properties, may also have the capacity to lower irritability, worrying and neuroticism. This capacity could be useful per se but may, in addition, reduce the occurrence and duration of depressive episodes, particularly by reducing "anxious worrying".

Withdrawal reactions associated with venlafaxine

OBJECTIVE

The aim of this paper is to describe discontinuation syndromes associated with abrupt and tapered withdrawal fo venlafaxine, and to document that withdrawal symptoms may occur after missing a single dose.

CLINICAL PICTURE

We report on two patients prescribed venlafaxine. One developed a broad range of serious side effects after reaching a dose of 300 mg a day, and a severe withdrawal syndrome (including hallucinations) during a slow taper regime. The second had severe discontinuation symptoms during and aborting a slow taper regime, and described withdrawal responses after missing a single dose of venlafaxine.

CONCLUSIONS

As for the short-acting selective serotonin re-uptake inhibitors, severe discontinuation reactions may occur with venlafaxine, seemingly marked most distinctly by headache, nausea, fatigue, dizziness and dysphoria, and may make cessation of the drug extremely difficult. Two strategies for addressing the concern are considered.

Special feature: the etiology of personality disorders: a review and consideration of research models

In addition to reviewing representative studies of genetic and environmental factors imputed in the etiology of the personality disorders (PDs), a number of models for conceptualizing and conducting etiological research are considered. In particular, it is proposed that research should initially concede a tripartite model (with separate temperament, personality, and disorder components). Such a model would allow identification of etiological factors having specificity to one or more components, and ones that are nonspecific in having relevance to all components.

Neuroleptic management of schizophrenia: a survey and commentary on Australian psychiatric practice

OBJECTIVE

We seek to assess Australian psychiatrists' views and practices concerning provision of neuroleptic medication to patients with schizophrenia, and to determine whether such management strategies are likely to have changed over time and the extent to which they correspond to published treatment guidelines.

METHOD

A sample of 139 psychiatrists based in three Australian capital cities was derived, with respondents completing a brief questionnaire by choosing from a limited-option answer set. Co-authors of this paper comment on the extent to which responses are in line with contemporary recommendations driven by experts or empirical studies.

RESULTS

Overall, survey findings indicate that there has been considerable change in clinical practice over the last decade and provide some estimate of the extent to which Australian management practices are congruent with contemporary recommendations. We identify a number of issues of concern (more in relation to dose levels of neuroleptic medication rather than treatment duration) revealed by survey data and make recommendations for addressing a number of practical clinical issues.

CONCLUSIONS

As this report focuses on central issues involved in managing schizophrenia, and integrates a number of treatment guidelines, we suggest that it should be of assistance for practice review by clinicians.

Characterization and chromosomal localization of human hair-specific keratin genes and comparative expression during the hair growth cycle

During anagen, cell proliferation in the germinative matrix of the hair follicle gives rise to the fiber and inner root sheath. The hair fiber is constructed from structural proteins belonging to four multigene families: keratin intermediate filaments, high-sulfur matrix proteins, ultra high-sulfur matrix proteins, and high glycine-tyrosine proteins. Several hair-specific keratin intermediate filament proteins have been characterized, and all have relatively cysteine-rich N- and C-terminal domains, a specialization that allows extensive disulfide cross-linking to matrix proteins. We have cloned two complete type II hair-specific keratin genes (ghHb1 and ghHb6). Both genes have nine exons and eight introns spanning about 7 kb and lying about 10 kb apart. The structure of both genes is highly conserved in the regions that encode the central rod domain but differs considerably in the C-terminal coding and noncoding sequences, although some conservation of introns does exist. These genes have been localized to the type II keratin cluster on chromosome 12q13 by fluorescence in situ hybridization. They, and their type I partner ghHa1, are expressed in differentiating hair cortical cells during anagen. In cultured follicles, ghHa1 expression declined in cortical cells and was no longer visible after 6 d, whereas the basal epidermal keratin hK14 appeared in the regressing matrix. The transition from anagen to telogen is marked by downregulation of hair cortical specific keratins and the appearance of hK14 in the epithelial sac to which the telogen hair fiber is anchored. Further studies of the regulation of these genes will improve our understanding of the cyclical molecular changes that occur as the hair follicle grows, regresses, and rests.

Examining sex differences in the impact of anticipated and actual life events

To examine for sex differences in anticipated and actual impact of pleasant and unpleasant life events in a non-clinical group, a cohort of 164 subjects was initially assessed in 1978 in their last year of teacher training. They were asked to participate in the life events study in 1979, and 97 subjects complied, providing us with ratings of impact of 'anticipated' life events. In 1983, the original cohort assessed the 'actual' impact of events experienced over the previous year. They also completed measures of neuroticism, state and trait depression, self-esteem, parental bonding and dependency in 1978, and gender roles in 1983. Some analyses for sex differences were undertaken for the entire cohort, with more extensive analyses for the 97 who had completed the 1979 (as well as 1978 and 1983) assessments. There were no sex differences in the scores for 'anticipated' or 'actual' impact of pleasant life events, or for 'anticipated' unpleasant life events. However, there was a statistically significant sex difference between 'actual' unpleasant life event scores, with females rating events as being either more pleasurable or unpleasant than males at both collection points. The actual impact of pleasant events was associated with higher dependency and masculinity scores, whilst unpleasant events was associated with higher dependency for females and higher parental overprotection and dependency scores for males.

An aetiological model of non-melancholic depression: study design and validity of the measures

OBJECTIVE

The aim of this paper is to describe an approach to sub-typing non-melancholic depression and to determine which raters from a variety of backgrounds provided the most valid information on study variables.

METHOD

A sample of non-melancholic depressed patients is described. Multiple raters (i.e. patients, psychiatrists, referrers and corroborative witnesses) completed measures of the patient's trait anxiety levels, severity of recent life event stressors and personality functioning.

RESULTS

The study and representative data are reported. Congruence between several measures employed indicated that psychiatrist rating of disordered personality was superior to corroborative witness report. Assessment of anxiety traits indicated reasonable agreement between referrers and corroborative witnesses but poor agreement between those ratings and interview-elicited ratings. There were also discrepancies in quantifying 'severity' of life event stress, with patients and their corroborative witnesses rating such events as more severe than either the interviewing psychiatrist or psychiatrists involved in consensus rating sessions. Importantly, the psychiatrists' capacity to quantify the relative contribution of disordered personality, anxiety and life-event stress to the particular depressive episode was supported.

CONCLUSIONS

Results indicate some of the difficulties in operationalising determinants that may contribute to and sub-type the non-melancholic depressions, and demonstrate the advantages of using a range of rating strategies and raters. In this study, psychiatrist-generated judgements are clearly favoured, although the advantages of also assessing trait anxiety and life-event stress impact by self-report strategies are conceded. Some techniques for estimating the contribution of disordered personality function, anxiety and life-event stress are offered for both their research and their clinical utility.

Dural arteriovenous fistula in association with heterotopic brain nodule in the transverse sinus

We describe a 56-year-old woman with a dural arteriovenous fistula involving the transverse sinus in association with a nodule of heterotopic brain tissue in the sinus. This finding is discussed in light of a recent radiologic study of nodules in the transverse sinus.

Depressed mood states and their inter-relationship with clinical depression

A study was conducted to contrast depressed mood states in those positive and negative for lifetime depressive syndromes. A non-clinical cohort of 156 subjects was assessed on four occasions over 15 years, with 35% having had a major depression and 22% a minor depression at the most recent assessment. At 5-yearly reviews, estimates were obtained of episode frequency, duration and symptom patterns during depressed mood states. Such characteristics were then contrasted across the three groups of those who had experienced major depression, those who had suffered minor depression and lifetime non-cases. Depressive states were affirmed by at least 96% of subjects at each assessment, with the mean number of episodes per assessment year ranging from 8.6 to 21.2. Those who had experienced a lifetime episode of major depression differed from the two contrast groups (i.e. those with minor depression: non-cases) in having more episodes and more features during episodes. By contrast, there was a gradient across the three groups for two other examined features, with those having major depression being more likely than those with minor depression, who in turn were more likely than the non-cases to have longer episodes and a greater number of symptoms. The greater frequency, severity and duration of depressed mood states in those who met lifetime criteria for a major depressive episode suggest that their threshold to onset and persistence of a variety of depressive experiences is lowered, so supporting a general vulnerability hypothesis.

Disordered personality style: higher rates in non-melancholic compared to melancholic depression

OBJECTIVE

We test whether there is differential representation of disordered personality function across melancholic and non-melancholic depressive sub-types, with levels of differentiation examined against differing sub-typing measures.

METHOD

In a sample of 245 subjects meeting criteria for a non-psychotic major depressive episode lasting less than 2 years, we examine for differential rates of disordered personality style across melancholic and non-melancholic depression, using four differing sub-typing measures (i.e., DSM-III-R and DSM-IV criteria, Newcastle Index, and the CORE measure). Disordered personality was assessed by psychiatrist ratings of 15 differing personality styles underpinning disorder classes, and several parameters and domains that reflect the arenas whereby disordered personality may be manifested.

RESULTS

However defined, those with non-melancholic depression were distinctly more likely to rate as showing disordered personality function, with over-representation to an avoidant personality disorder style being the most consistently and strongly identified personality disorder class. Because of limitations to several of the sub-typing measures, we focus on the DSM-IV system. Discriminant function analyses indicated that those so identified as having non-melancholic depression were significantly more likely to rate as having avoidant and schizoid personality styles. A principal components analysis of our 15 differing personality disorder classes identified three molar classes corresponding to the three-cluster DSM system. Again, non-melancholic (compared to melancholic) subjects were more likely to return higher scores: in order, an 'anxious and fearful' (Cluster C) personality style, then an 'eccentric' Cluster A, and somewhat less clearly, a 'dramatic' Cluster B personality disorder style. Specificity to the non-melancholic depressive class was again suggested in relation to a large number of the parameters and domains measuring disordered personality function.

CONCLUSIONS

Disordered personality function appears distinctly more likely in non-melancholic, compared to melancholic depression.

Sex differences in the experience of depressed mood state over fifteen years

A study was conducted to examine sex differences in frequency, duration and severity of experience of depressed mood state in a non-clinical group and to consider how such findings contribute to the understanding of sex differences in depressive experience. A cohort of 156 subjects, assessed initially in 1978 in their last year of teacher training, was reassessed at 5-yearly intervals over 15 years. On each occasion, the subjects completed self-report ratings of experience of "normal depression" and measures of neuroticism, trait depression, self-esteem and sex role. The study found no sex differences in the number or duration of episodes. Women reported more symptoms per episode and some specific symptoms (including tearfulness, appetite and weight gain) more often. The number of symptoms was correlated with neuroticism, self-esteem and trait depression scores, and with gender but not sex role. The number of episodes was related to trait depression and self-esteem but not neuroticism. The results showed that there are links between female gender, neuroticism and number of symptoms experienced during depressed mood state episodes. These links are related more to female gender than to feminine sex role or premenstrual problems, and are reflected in the severity of affective change (and some specific symptoms) but not in the number of episodes.

Dysfunctional parenting: over-representation in non-melancholic depression and capacity of such specificity to refine sub-typing depression measures

We examine the proposition that dysfunctional parenting is more likely to be experienced by those with non-melancholic (compared to melancholic) depression and that, as a consequence, such specificity allows the validity of varying definitions of melancholia to be examined and their utility sharpened. We study a sample of 245 non-psychotic patients meeting DSM-III-R criteria for a major depressive episode and assign them to melancholic and non-melancholic sub-sets according to five separate sub-typing measures (DSM-III-R; DSM-IV; Newcastle; 'Clinical' and CORE criteria). We assess dysfunctional parenting by use of the Parental Bonding Instrument (PBI), and by structured psychiatrist assessment and self-report ratings of a range of dysfunctional parental experiences, with independent assessment and self-report ratings of a range of dysfunctional parental experiences, with independent assessment of the last by reports from corroborative witnesses and from the patients' referring therapists. The five sub-typing measures assigned varying percentages of the sample (24-42%) to a 'melancholic' sub-type. When Newcastle Index assignments were examined, there was no evidence that dysfunctional parenting had any specificity to non-melancholic depression. Neither the DSM-III-R nor DSM-IV systems demonstrated specificity in relation to PBI scores, but several interview-assessed dysfunctional parenting characteristics were over-represented in their non-melancholic sub-sets. 'Clinical' definition showed the greatest over-representation of dysfunctional parenting to those assigned as having non-melancholic depression. The CORE measure, a behaviourally weighted measure of psychomotor disturbance, was the next most differentiating. Importantly, those assigned as having non-melancholic depression by all five measures were more likely to be rated by corroborative witnesses as being exposed to anomalous parenting, validating the subjects' self-reports, arguing against results being an artefact of clinician-based assessment, and supporting the specificity of dysfunctional parenting to a depressive sub-type.

The development of a refined measure of dysfunctional parenting and assessment of its relevance in patients with affective disorders

BACKGROUND

The Parental Bonding Instrument (PBI) measures fundamental parenting dimensions (care and over-protection), but does not directly assess abusive parenting.

METHODS

We describe the development of the Measure of Parenting Style (the MOPS), comprising refined PBI scales assessing parental indifference and over-control, as well as a scale assessing parental abuse.

RESULTS

We examine psychometric properties of the MOPS, while several analyses build to the concurrent validity of the abuse scale as an experimental measure. We examine the extent to which both the PBI and the MOPS scales showed specificity of dysfunctional parenting to the non-melancholic depressive subtype, and across a range of anxiety disorders. Non-melancholic depressed patients returned anomalous parenting scale scores (compared to melancholic subjects), but only when such subtyping decisions were clinician-generated. Those receiving DSM-III-R lifetime anxiety diagnoses of panic disorder and of social phobia returned higher PBI protection and MOPS over-control scores than non-anxious subjects, while differences were not established for those with generalized anxiety disorder or obsessive compulsive disorder.

CONCLUSIONS

We consider the likely utility of the MOPS scale and note the module capacity of separate MOPS and PBI scales, which allow a set of options for assessing perceived parenting characteristics.

Increased rate of psychosis and psychomotor change in depression with age

BACKGROUND

We examined the phenomenology of depression in younger (< 60 years old) versus older (> or = 60 years) subjects and, more specifically, the interaction between age and psychomotor disturbance associated with depression.

METHOD

Two hundred and eighty-five patients with a DSM-III-R diagnosis of unipolar major depression referred to a mood disorders unit were assessed using the CORE rating scale, a sign-based system for defining melancholia. Subjects were also assessed using the Hamilton Rating Scale for Depression, Zung Depression Scale, Newcastle Endogenous Depression Inventory and the General Health Questionnaire.

RESULTS

The total CORE score (and each of its subscales) was found to interact with age. Rates of psychotic and melancholic depression increased with age. Elderly depressives suffered more severe depression (higher HRSD scores), appetite loss and weight loss. Level of psychomotor disturbance and rates of psychosis did not differ between those elderly subjects with an early onset (before the age of 60 years) and those with a late onset (at or after 60 years) of depression.

CONCLUSIONS

There appear to be robust phenomenological differences in depression between older and younger subjects. The association between age and psychomotor change may assist our understanding of the neurobiology of depression.

Fifteen years on: evolving ideas in researching sex differences in depression

BACKGROUND

A cohort study of a socially homogeneous group of teachers was commenced in 1978 to pursue possible risk factors contributing to the recognized female preponderance of depression.

METHODS

Multiple measures of depressive experience included: (i) lifetime rates, duration and number of depressive episodes using two caseness definitions, DSM-III-R major depression and 'all depression' (which included a category of minor depression); (ii) self-report measures of state and trait depression, neuroticism, and self-esteem. DSM-III-R anxiety disorder rates are also reported and co-morbidity with major depression examined.

RESULTS

At the 15-year review in 1993, the sample had a mean age of 39 years, there was a trend for a female preponderance in lifetime rates of major depression and 'all depression' (and which was more pronounced with the inclusion of data for anxiety disorders), with statistically significant differences in rates of social and simple phobias and combined anxiety disorders. Mean neuroticism scores were consistently higher for women.

CONCLUSIONS

The strong association between anxiety and depressive disorders suggests that greater reporting of anxiety and higher neuroticism scores in women may be a key determinant that contributes to any female preponderance in depression rates.

How distinct is 'distinct quality' of mood?

BACKGROUND

The DSM-IV criteria for melancholia include the clinical feature 'distinct quality', defined as a mood state differing from that experienced in bereavement. Both propositions-its specificity to melancholia and its definition- remain problematical.

METHODS

We examine both propositions by analysing an adjective checklist completed by melancholic and non-melancholic depressed subjects, as well as by a bereaved sample. The checklist was refined by a principal components analysis to four scales-one assessing a general 'mood' severity or dysphoric dimension, and the other three assessing dimensions of 'fatigue', 'numbness' and 'guilt'.

RESULTS

If the concept of "distinct quality' has validity, we would require specificity of the refined qualitative constructs to melancholic depression. The 'numbness' component met that requirement, but only to a degree. While bereaved subjects did differ from those with melancholic depression on a number of our refined qualitative mood domains, such differences appeared more related to lower levels of depression in the bereaved sample.

CONCLUSIONS

We argue for deleting the 'distinct quality' criterion from diagnostic checklists of melancholia until its definition has been improved, its utility demonstrated and its specificity to any depressive subtype established as having clinical significance.

Morbid jealousy as a variant of obsessive-compulsive disorder

OBJECTIVE

To present a representative case vignette and review several previous reports, and to then suggest that a percentage of those with morbid jealousy may have a variant of obsessive-compulsive disorder (OCD).

CLINICAL PICTURE

A patient presented volunteering a diagnosis of depression and anxiety following recent work and marital stresses, before describing recent jealousy and harassment of his wife over an earlier relationship. Obsessional thinking patterns and compulsive behaviours are described, and it is proposed that the picture supports a diagnosis of obsessive-compulsive disorder.

TREATMENT AND OUTCOME

The patient was treated as if he had an obsessive-compulsive disorder, and reported dissipation of his concerns after cognitive-behavioural intervention.

CONCLUSIONS

The proposition is an important one as a diagnosis of morbid jealousy often invites therapeutic pessimism, and as managements effective for OCD (both drug and behavioural) may well be helpful.

Distinguishing psychotic depression from melancholia

We contrast 25 patients with "psychotic depression" (PD) against two age- and sex-matched groups of melancholic depressed patients. In terms of clinical features, specificity of PD was suggested for several features, including delusions, morbid cognitions (involving guilt and a sense of deserving punishment), hallucinations and constipation. In addition, the PDs had significantly higher levels of behaviourally rated psychomotor disturbance. A comprehensive list of risk factors to depression (e.g., socio-demographic, family history, parental influences, medical disorders, anxiety, stressors and personality style) were examined, without clear differentiation between the comparison groups apart from the suggestion that being a "worrier" and having tenuous stability under stress was over-represented in the PDs. Findings favour the view that psychotic depression is a sub-type of melancholic depression (accounting for the similar expression of the majority of clinical and possible aetiological variables across our contrasted "types'). Findings also suggest possible benefits from future phenomenological studies of psychotic depression relying more on observer-based rather than self-report or symptom data sets. Aetiological studies would benefit from focussing on those features identified as distinguishing the condition from melancholic depression.

Early onset depression: the relevance of anxiety

The aim of this study was to determine risk factors that may differentiate early onset from late onset depression. A non-clinical cohort that had been assessed from 1978 to 1993 at 5 yearly intervals and that had a high prevalence rate of lifetime depression took part in the study. We established an appropriate age cut-off to distinguish early onset (i.e. before 26 years) of major and of minor depression, and examined the relevance of a number of possible determinants of early onset depression assessed over the life of the study. Despite several dimensional measures of depression, self-esteem and personality being considered, they generally failed (when assessed early in the study) to discriminate subsequent early onset depression, with the exception of low masculinity scores being a weak predictor of major and/or minor depression. Early onset depression was strongly predicted, however, by a lifetime episode of a major anxiety disorder, with generalised anxiety being a somewhat stronger and more consistent predictor than panic disorder, agoraphobia and minor anxiety disorders (ie social phobia, simple phobia). The possibility that anxiety may act as a key predispositional factor to early onset depression and to a greater number of depressive episodes is important in that clinical assessment and treatment of any existing anxiety disorder may be a more efficient and useful strategy than focussing primarily on the depressive disorder.