The editorial in this issue reviews the orexins/hypocretins, a recently recognized group of neuropeptides, involved in sleep, arousal, narcolepsy and possibly other disorders.

Two articles concern epidemiology. Kessler and colleagues (pp. 959–976) report large scale development and validation of 10-item and 6-item versions of a scale with impressive performance in screening for DSM-IV psychiatric disorder in US and Australian general populations. Sacker & Wiggins (pp. 977–990) use two longitudinal cohort studies to examine gender and social class differences in psychological distress. Both narrowed over two decades with the higher rates in women and those in manual occupations falling, to become nearer males and non-manual occupations. Disadvantage is apparently lessening.

In another study of gender and disorder Fergusson and colleagues in New Zealand (pp. 991–996) find that the greater exposure of females to sexual violence explains some, but not all of their greater liability to internalizing disorders. In other aetiological studies, Enns et al. (pp. 997–1008) find associations of community disorder with lack of care on the Parental Bonding Instrument, while Reichborn-Kjennerud et al. (pp. 1009–1020) in a Norwegian twin sample find genetic links between back-neck pain and anxiety and depressive symptoms.

Four studies concern depression. In an important neuroendocrine study of chronic depression Watson et al. (pp. 1021–1028) find absence of the usual depressive HPA axis abnormalities, strongly suggesting that these normalize with time. Matsuo et al. (pp. 1029–1038) employ the little-used non-invasive technique of near infrared spectroscopy, to show a reduction in euthymic affective disorder patients compared with controls in the increase of oxyHb in the frontal region during a verbal fluency task and during hyperventilation, indicating persisting or antecedent abnormalities. In a controlled trial Chabrol et al. (pp. 1039–1047) find a brief cognitive-behavioural intervention reduces depression scores in postpartum mothers at risk for post-natal depression. Fava et al. (pp. 1049–1057) find personality disorder diagnoses to decline in frequency after treatment for depression, suggesting that depression contributes to and antidepressant ameliorates the behaviours and attitudes which comprise the personality disorders.

Two studies interface with psychoimmunology. In an important prospective study over up to 9 years, Leserman et al. (pp. 1059–1073) find progression of HIV accelerated by stressful life events, dysphoric mood and raised cortisol. Arnold et al. (pp. 1075–1089) report effects of inducing influenza-like symptoms in patients with chronic fatigue syndrome compared with normal controls. While somatic symptoms of CFS were exacerbated, cognitive and mood symptoms were not.

Three papers report findings in schizophrenia. Hooley & Campbell (pp. 1091–1099) find high expressed emotion relatives attribute more control to ill family members than do low EE relatives, but are actually themselves more controlling. Their high control predicts relapse in schizophrenia but not depression. Gooding & Tallent (pp. 1101–1107) find that schizophrenics show atypical perceptual biases in response to emotional chimeric faces. Malla et al. (pp. 1109–1119) report predictors of outcome at 1 year of first-episode psychosis, including some potential modifiable factors such as medication adherence and residual symptoms.

The orexins/hypocretins are novel neuropeptides synthesized by neurons whose cell bodies are located in the lateral hypothalamus. Although these neurons are few in number, they send projections widely throughout the central nervous system (Kilduff & Peyron, 2000). There has been great excitement about the orexins/hypocretins from both the scientific and medical community. These peptides are remarkable in that they were discovered using state-of-the-art molecular techniques before their physiological actions were studied. Furthermore, there has been an exponential progress in our scientific knowledge of these peptides culminating in the orexins/hypocretins being linked to the sleep disorder, narcolepsy. With the importance of the orexins/hypocretins in sleep and arousal being increasingly recognized, it is likely that these peptides are altered by or contribute to several medical and psychiatric disorders.

Background. A 10-question screening scale of psychological distress and a six-question short-form scale embedded within the 10-question scale were developed for the redesigned US National Health Interview Survey (NHIS).

Methods. Initial pilot questions were administered in a US national mail survey (N = 1401). A reduced set of questions was subsequently administered in a US national telephone survey (N = 1574). The 10-question and six-question scales, which we refer to as the K10 and K6, were constructed from the reduced set of questions based on Item Response Theory models. The scales were subsequently validated in a two-stage clinical reappraisal survey (N = 1000 telephone screening interviews in the first stage followed by N = 153 face-to-face clinical interviews in the second stage that oversampled first-stage respondents who screened positive for emotional problems) in a local convenience sample. The second-stage sample was administered the screening scales along with the Structured Clinical Interview for DSM-IV (SCID). The K6 was subsequently included in the 1997 (N = 36116) and 1998 (N = 32440) US National Health Interview Survey, while the K10 was included in the 1997 (N = 10641) Australian National Survey of Mental Health and Well-Being.

Results. Both the K10 and K6 have good precision in the 90th–99th percentile range of the population distribution (standard errors of standardized scores in the range 0·20–0·25) as well as consistent psychometric properties across major sociodemographic subsamples. The scales strongly discriminate between community cases and non-cases of DSM-IV/SCID disorders, with areas under the Receiver Operating Characteristic (ROC) curve of 0·87–0·88 for disorders having Global Assessment of Functioning (GAF) scores of 0–70 and 0·95–0·96 for disorders having GAF scores of 0–50.

Conclusions. The brevity, strong psychometric properties, and ability to discriminate DSM-IV cases from non-cases make the K10 and K6 attractive for use in general-purpose health surveys. The scales are already being used in annual government health surveys in the US and Canada as well as in the WHO World Mental Health Surveys. Routine inclusion of either the K10 or K6 in clinical studies would create an important, and heretofore missing, crosswalk between community and clinical epidemiology.

Background. In the closing decades of the twentieth century, changes in population sociodemographics took place that might be thought to have an adverse influence on the nation's psychological distress. Here, we examine the stability of social and gender inequalities in psychological distress throughout the 1980s and 1990s.

Methods. The study uses data from the 1958 National Child Development Study and the 1970 British Cohort Study collected when the cohort members were aged between 23 and 42. Multilevel logistic regression models were used to examine the effects of social class, gender, age, period and cohort on psychological distress as measured by the Malaise Inventory.

Results. We identify clear social inequalities in psychological distress during 1981–2000 that reduced in magnitude over this period. Non-linear age effects were observed: psychological distress improves in early adulthood but declines again on approaching mid-life. The 1970 cohort had poorer psychological distress than the 1958 cohort. Although women had higher rates of psychological distress than men, gender differences reduced in magnitude. Declining rates of women's psychological distress over time have not been matched in men. A reduction in social inequalities over time was also observed. Improvements in the psychological health of those in manual occupations were not equalled among those in non-manual occupations.

Conclusions. Both social and gender inequalities have narrowed in the last two decades of the twentieth century.

Background. It is well documented that females have higher rates of internalizing disorders (anxiety, depression) than males. It is also well known that females have higher exposure to childhood sexual abuse and sexual assault. Recently, it has been proposed that the higher levels of internalizing disorders in females may be caused by their greater exposure to sexual violence.

Method. Data were gathered as part of the Christchurch Health and Development Study. In this study a cohort of 1265 children born in Christchurch, New Zealand, in 1977 have been studied from birth to age 21 years. The measures collected included: major depression and anxiety, childhood sexual abuse and adolescent sexual assault.

Results. Findings confirmed the established conclusion that internalizing disorders are over twice as common in females than males (ORs 2·2–2·7). In addition, it was found that females were exposed to higher rates of sexual violence than males (ORs 5·1–8·4). Statistical control for gender related differences in exposure to sexual violence reduced the associations between gender and anxiety and depression. Nonetheless, even after such control, gender was significantly (P<0·0001) related to both anxiety (OR = 1·8; 95% CI, 1·3–2·4) and depression (OR = 1·9; 95% CI, 1·4–2·3).

Conclusions. Greater female exposure to sexual violence may be a factor that contributes to greater female susceptibility to internalizing disorders. However, even after adjustment for gender differences in exposure to sexual violence it is clear that a substantial relationship between gender and internalizing disorder persists.

Background. Research using the parental bonding instrument (PBI) has suggested that lack of parental care and/or overprotection may be important risk factors for adult mental disorders. Much of this research, however, has relied on clinical populations with one or two disorders, or has used highly select community samples.

Method. The association between parenting experiences and the occurrence of 13 common mental disorders in adulthood was evaluated in the US National Comorbidity Survey (N = 5877). The effect of sociodemographic variables (age, education, income) was statistically controlled and the effects of six parenting variables (maternal and paternal care, overprotection and authoritarianism) were examined simultaneously. The effects in men and women were examined separately.

Results. Lack of care was the parenting variable most consistently associated with adult psychopathology. Parenting experiences with one's mother were more consistently associated with adult mental disorders. In general the impact of parenting was diagnostically non-specific. However, there appeared to be some unique effects for externalizing disorders (substance use disorders and antisocial personality disorder) in males; paternal overprotection and authoritarianism conferred a reduced risk of externalizing disorders in adult males. The overall impact of parenting as assessed by the PBI was modest, accounting for about 1 to 5% of the variance in the occurrence of adult mental disorders.

Conclusion. Parenting experiences, particularly lack of care, are potentially causally related in a non-specific manner to a wide variety of forms of adult psychopathology in both men and women. The overall magnitude of the effect is small but statistically significant in a nationally representative US sample.

Background. Clinical and epidemiological studies have shown an association between anxiety and depression and pain in the back and neck. The nature of this relationship is not clear. This study aimed to investigate the extent to which common genetic and environmental aetiological factors contribute to the covariance between symptoms of anxiety and depression and back–neck pain.

Methods. Measures of back–neck pain and symptoms of anxiety and depression were part of a self-report questionnaire sent in 1992 to twins born in Norway between 1967 and 1974 (3996 pairs). Structural equation modelling was applied to determine to what extent back–neck pain and symptoms of anxiety and depression share genetic and environmental liability factors.

Results. The phenotypic correlation between symptoms of anxiety and depression and back–neck pain was 0.31. Individual differences in both anxiety and depression and back–neck pain were best accounted for by additive genetic and individual environmental factors. Heritability estimates were 0.53 and 0.30 respectively. For back–neck pain, however, a model specifying only shared- and individual environmental effects could not be rejected. Bivariate analyses revealed that the correlation between back–neck pain and symptoms of anxiety and depression was best explained by additive genetic and individual environmental factors. Genetic factors affecting both phenotypes accounted for 60% of the covariation. There were no significant sex differences.

Conclusion. The results support previous findings of a moderate association between back–neck pain and symptoms of anxiety and depression, and suggest that this association is primarily due to common genetic effects.

Background. Hypothalamic–pituitary–adrenal (HPA) axis function in patients with chronic depression has previously been shown to be normal when measured using the dexamethasone suppression test (DST). We examined patients with chronic depression using the sensitive dexamethasone/corticotropin releasing hormone (dex/CRH) test and the dexamethasone suppression test (DST) to establish whether HPA axis abnormalities are present in this group. We also compared the sensitivity of the two tests and compared the results with previous studies in depression that have not specifically selected chronic patients.

Method. Twenty-nine patients with the chronic subtype of major depressive disorder and 28 matched controls underwent examination of HPA axis function.

Results. Neither the cortisol response to the DST or the dex/CRH test differed significantly between the patient and control groups. There was a trend in favour of more patients than controls having an abnormal response to the dex/CRH test (P = 0.052). Neither the patients with an abnormally enhanced response, nor the magnitude of response could be predicted by any illness or demographic variable.

Conclusion. The HPA axis is not overtly abnormal in chronic depression. This contrasts with previous findings in acute depression and bipolar disorder and may suggest that the HPA axis abnormalities present in acute depression resolve, but are not accompanied by symptom resolution. Alternatively, a subgroup of depressives with less HPA dysfunction may progress to chronicity. This has implications for treatment and prognosis. The dex/CRH is a more sensitive test of HPA axis function than the DST in patients with chronic depression.

Background. Hypofrontality has been demonstrated in mood disorders by functional brain imaging methods such as positron emission tomography. However, the neurobiological basis of hypofrontality has not been well clarified. Near-infrared spectroscopy (NIRS) is a non-invasive technique for continuous monitoring of alterations in oxygenated (oxyHb) and deoxygenated (deoxyHb) haemoglobin using near-infrared light, which penetrates biological tissues.

Methods. We used NIRS during cognitive and physiological tasks to investigate alterations of haemoglobin oxygenation in the frontal region of euthymic patients with mood disorders (major depressive disorder (MD) and bipolar disorder (BP)) and in controls.

Results. The increase of oxyHb during a verbal fluency task was significantly less in the MD and the BP groups than in the controls. The MD group showed a significantly smaller decrease of oxyHb during hyperventilation than the controls. The BP group also showed a similar trend.

Conclusions. These findings suggest that the hypofrontality in mood disorders may be associated with a poor response in the cerebral blood vessels to neuronal and chemical stimuli.

Background. Research is needed to evaluate the efficacy of prevention and treatment for post-partum depression.

Method. Subjects were screened with the Edinburgh Post-natal Depression Scale (EPDS) at the obstetric clinic. Mothers at risk (N = 258) (EPDS scores [ges ]9) were randomly assigned to a prevention/treatment group or a control group. The prevention group received one cognitive-behavioural prevention session during hospitalization. At 4 to 6 weeks post-partum, subjects were screened again with the EPDS, after drop-out rates (refusals plus no return of the second EPDS) of 25.4% (33/130) in the intervention group and 10.9% (14/128) in the control group. Mothers with probable depression (EPDS scores [ges ]11) were assessed using the Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI). Mothers with major depression continued in the treatment group (N = 18) or in the control group (N = 30). Treated subjects received a cognitive-behavioural programme of between five and eight weekly home-visits.

Results. Compared with the control group, women in the prevention group had significant reductions in the frequency of probable depression (30.2% v. 48.2%). Recovery rates based on HDRS scores of <7 and BDI scores of <4 were also significantly greater in the treated group than in the control group.

Conclusions. The study suggests that this programme for prevention and treatment of post-partum depression is reasonably well-accepted and efficacious.

Background. Personality disorders (PDs) were assessed among depressed out-patients by clinical interview before and after antidepressant treatment with fluoxetine to assess the degree of stability of PD diagnoses and determine whether changes in PD diagnoses across treatment are related to the degree of improvement in depressive symptoms.

Method. Three hundred and eighty-four out-patients (55% women; mean age = 39.9±10.5) with major depressive disorder (MDD) diagnosed with the SCID-P were enrolled into an 8 week trial of open treatment with fluoxetine 20 mg/day. The SCID-II was administered to diagnose PDs at baseline and endpoint.

Results. A significant proportion (64%) of our depressed out-patients met criteria for at least one co-morbid personality disorder. Following 8 weeks of fluoxetine treatment, there was a significant reduction in the proportion of patients meeting criteria for avoidant, dependent, passive-aggressive, paranoid and narcissistic PDs. From baseline to endpoint, there was also a significant reduction in the mean number of criteria met for paranoid, schizotypal, narcissistic, borderline, avoidant, dependent, obsessive–compulsive, passive aggressive and self-defeating personality disorders. While changes in cluster diagnoses were not significantly related to improvement in depressive symptoms, there were significant relationships between degree of reduction in depressive symptoms (percentage change in HAM-D-17 scores) and degree of change in the number of criteria met for paranoid, narcissistic, borderline and dependent personality disorders.

Conclusions. Personality disorder diagnoses were found to be common among untreated out-patients with major depressive disorder. A significant proportion of these patients no longer met criteria for personality disorders following antidepressant treatment, and changes in personality disorder traits were significantly related to degree of improvement in depressive symptoms in some but not all personality disorders. These findings suggest that the lack of stability of PD diagnoses among patients with current MDD may be attributable in part to a direct effect of antidepressant treatment on behaviours and attitudes that comprise PDs.

Background. The primary aim of this study is to examine prospectively the association of stressful life events, social support, depressive symptoms, anger, serum cortisol and lymphocyte subsets with changes in multiple measures of human immunodeficiency virus (HIV) disease progression.

Methods. Ninety-six HIV-infected gay men without symptoms or anti-retroviral medication use at baseline were studied every 6 months for up to 9 years. Disease progression was defined in three ways using the Centers for Disease Control (CDC) classifications (e.g. AIDS, clinical AIDS condition and mortality). Cox regression models with time-dependent covariates were used, adjusting for control variables (e.g. race, age, baseline, CD4 T cells and viral load, number of anti-retroviral medications).

Results. Higher cumulative average stressful life events and lower cumulative average social support predicted faster progression to both the CDC AIDS classification and a clinical AIDS condition. Higher anger scores and CD8 T cells were associated with faster progression to AIDS, and depressive symptoms were associated with faster development of an AIDS clinical condition. Higher levels of serum cortisol predicted all three measures of disease progression.

Conclusions. These results suggest that stressful life events, dysphoric mood and limited social support are associated with more rapid clinical progression in HIV infection, with serum cortisol also exerting an independent effect on disease progression.

Background. Individuals with acute infections experience a range of symptoms including fatigue, malaise, muscle aches, and difficulties with concentration and memory that are usually self-limited. This cluster of symptoms is otherwise, similar to those that characterize chronic fatigue syndrome (CFS). The goal of the present study was to evaluate the cognitive and psychological functioning of CFS patients and normal controls (NCs) when they both were experiencing acute influenza-like symptoms. To induce influenza-like symptoms, we administered interleukin-6 (IL-6), a cytokine that temporarily activates the acute phase immunological and endocrine responses.

Methods. Nineteen patients who met the 1994 International CFS Study Group Criteria and ten normal controls (NCs) completed routine clinical evaluations, neuropsychological tests of short-term memory, selective attention, and executive control, and self-ratings of somatic symptoms and psychological mood before, shortly following, and 1 day after IL-6 administration.

Results. CFS patients consistently reported more somatic symptoms, even when both groups perceived that they were ill. Both groups somatic symptoms increased during the IL-6 challenge, but the CFS patients symptoms increased more rapidly than controls. In general, the CFS patients performed similarly to NCs on the cognitive measures before, during, and after the IL-6. In contrast to predictions, IL-6 provocation did not impair the cognitive performance of either CFS patients or NCs.

Conclusions. The IL-6 provocation exacerbated the patients self-reported symptoms but did not reveal notable cognitive impairments between patients and controls during cytokine-induced acute influenza-like symptoms.

Background. Expressed emotion (EE) is a measure of the family environment that is a well replicated psychosocial predictor of psychiatric relapse. Theoretical models of EE place heavy emphasis on the notion of control. We explored the extent to which high and low EE relatives made both attributions of control about patients and engaged in controlling behaviours.

Methods. Trained raters who were blind to information about EE coded interviews with 35 relatives of patients with schizophrenia and 42 relatives of patients with unipolar depression. Relatives were rated on two reliable scales that assessed relatives' tendencies to make illness controllability attributions and relatives' efforts to exert direct behavioural control over patients.

Results. In both the schizophrenia and depressed groups, high-EE relatives attributed more control to their ill family members than did low EE relatives. They also behaved in a more controlling manner. Examination of patients' clinical outcomes during a 9-month follow-up period revealed that high levels of behavioural control on the part of relatives significantly predicted relapse in patients with schizophrenia but not in patients with depression.

Conclusions. These findings support the attribution-based model of EE. They further suggest that controlling behaviours on the part of relatives may mediate the EE-relapse link in schizophrenia. Such behaviours may be important targets for modification in family-based interventions for schizophrenia.

Background. In a prior study, we observed that schizophrenia patients display atypical perceptual biases in response to emotional (happy/neutral) facial chimeras.

Methods. The present study was an attempt to replicate and extend those findings, using emotional stimuli with negative affective valence (angry/neutral chimeras) as well as positive valence, and including more than one type of non-affective facial comparison task. We compared schizophrenia patients (N = 37) and controls (N = 48) on free-vision tasks that typically yield left spatial field biases indicative of right hemisphere activation. There were six chimera tasks, including two emotion (happy, angry) chimeras, two non-emotion (gender, age) chimeras and two non-face (dots, gradients) chimeras.

Results. We observed a Group×Task interaction, with schizophrenia patients displaying significantly less of the expected left spatial perceptual bias in response to the happy/neutral chimeras and the angry/neutral chimeras relative to the controls. In contrast, the patients and controls did not differ in terms of their response to the Gender, Age, Dots, or Gradients tasks.

Conclusions. These findings are consistent with the assertion that, compared with healthy controls individuals with schizophrenia perceive emotion differently.

Background. The differential strength of correlation between symptoms, cognition and other patient characteristics with community functioning in first-episode psychosis has not been fully investigated.

Method. In a sample of 66 first-episode psychosis patients demographic variables, ratings of pre-morbid adjustment, positive and negative symptoms, duration of untreated psychosis (DUP) and assessment of cognitive functions at baseline, and symptoms, cognitive functions and adherence to medication at 1 year, were correlated with scores on social relations and activities of daily living (ADL) (outcome) at 1 year. Hierarchical regression analysis was used to confirm the independent contribution of baseline and concurrent variables to functional outcome at 1 year.

Results. Scores on functioning related to social relations and ADL were both significantly correlated with pre-morbid adjustment, all dimensions of residual positive and negative symptoms and adherence to medication at 1 year. Scores on social relations were also modestly correlated with DUP and several cognitive measures at baseline and 1 year (verbal IQ, attention, visual memory, word fluency and working memory). Hierarchical regression confirmed independent contribution of pre-morbid adjustment, total residual symptoms and adherence to medication at 1 year for both dimensions of outcome, and psychomotor poverty and working memory for social relations.

Conclusions. In addition to pre-morbid adjustment potentially malleable variables such as level of residual (but not acute) symptoms, adherence to medication and cognitive deficits are likely to influence outcome on aspects of community functioning in individuals treated for first episode of psychosis.

Objective. To determine the association between anxiety disorders, panic attack and the risk of major depression among adults in the community.

Method. Data were drawn from the Epidemiologic Catchment Area Program survey waves 1 (N = 20291) and 2 (N = 15849). Multivariate logistic regression analyses were used to determine the risk of incident major depression at 12-month follow-up (wave 2) associated with each anxiety disorder and panic attacks assessed at wave 1, adjusting for differences in sociodemographic characteristics, and then controlling simultaneously for all anxiety disorders, and other psychiatric co-morbidity.

Results. Specific phobia (OR = 1.7 (1.6, 1.8)), agoraphobia (OR = 2.3 (2.2, 2.5)), obsessive–compulsive disorder (OR = 5.4 (5.0, 5.8)) and panic attack (OR = 1.9 (1.8, 2.1)) each made an independent contribution to the risk of major depression, which persisted after adjusting simultaneously for sociodemographic differences and other psychiatric co-morbidity.

Conclusions. Each anxiety disorder and panic attacks appear to confer an independent risk for the onset of major depression within 12-months among adults in the community. Understanding the key role played by anxiety in depression onset is needed for prevention strategies.

Background. The authors' goal was to investigate the presence or absence of theory of mind impairments among people with schizophrenia during remission. Recent research results interpret theory of mind deficits as state rather than trait characteristics, connecting these impairments mainly to the acute episode of psychosis.

Methods. Twenty patients with schizophrenia in remission and 20 matched control subjects were evaluated. Participants were presented with one first-order theory of mind task, one second-order theory of mind task, two metaphor and two irony tasks adapted from previous studies.

Results. The schizophrenic patients performed a statistically significant impairment in the irony task, as there were no significant differences in the cases of the other evaluated tasks.

Conclusions. These preliminary results suggest that theory of mind impairments can be detected not only in the acute phase as found in previous research studies, but also in remission.

Background. Suicide rates, anxiety/depression scores and stress scores are routinely used as mental health indicators in populations, but their inter-relationships have not been explored. Our aim was to explore the association of suicide rates with anxiety/depression and stress scores, while also referring to deprivation scores, which are known to be linked to suicide rates.

Methods. We undertook an ecological analysis of English Health Authorities, regressing suicide rates (1993–1994), on General Health Questionnaire and stress scores (1994), and also on Jarman deprivation scores (1991).

Results. Overall, Jarman deprivation score was a better predictor of suicide rate than the psychological distress measures. There were no statistically significant associations between suicide rates and GHQ scores, although there was a weak association between suicide rate and mean stress level in women.

Conclusions. Suicide rates, though important in themselves, are not reliable indicators of the levels of neurotic symptoms or stress in populations. Suicide rates are more strongly associated with area-based measures of social disadvantage, though a possible stress–suicide relationship in women could be investigated further.