The aim of this Editorial is to discuss depression as an important disorder for public health. The literature regarding epidemiology, consequences, adequacy of service delivery and prevention of depression is reviewed. Depression is a common disorder with high lifetime rates, particularly in women, and those experiencing social adversity. It is a major cause of disability, and causes death both by suicide and due to raised rates of physical disorders. Many cases are undiagnosed and treatment is often inadequate. Primary prevention is not yet easily feasible but secondary prevention by earlier recognition, public and professional education, can produce benefits. There is a need for public health programmes aimed at improving recognition, treatment, and reducing consequences.

The National Institute of Clinical Excellence (NICE) in the UK is responsible for producing evidence based guidelines for the treatment of most common illnesses, both physical and psychological. NICE uses a hierarchy of evidence, ranging from data from meta-analyses of randomised controlled trials (RCT's) at the apex, to the opinions of acknowledged experts at the bottom. The task of preparing guideline for depression involved us in performing clean meta-analyses of around 8,000 published RCTs of the treatment of this disorder. Where drug treatments were concerned we used three indicators of efficacy, as well as considering toxicity, tolerability and cost. We also distinguished between studies carried out in primary care, and studies in patients treated by the mental health services. We found it helpful to arrange our report in terms of a “stepped care” model, addressing the indications for patients being referred on for more specialised, and expensive, treatments. In the full guideline we included our doubts that depression was a homogenous clinical entity, and our awareness of the limitations of relying on randomised controlled trials (RCT's) as the only source of evidence. This Editorial summarises the content of the guideline on the treatment of depression and discusses how it was received and also what it did not say.

This Editorial presents recent research on the transmission of depression across three generations and discusses the implications for improving detection, treatment and prevention and for identifying important subgroups for biological studies. It reports a case-control study of three generations at high or low risk for major depression. The first two generations were followed longitudinally for 20 years and were assessed blind to the clinical status of the other generations. Depression is highly familial across three generations. Over 60% of grandchildren (average age 12 yrs.) with two generations affected with depression already have some psychopathology. Anxiety disorders are usually the first presentation before puberty with an increase in depression in adolescents, especially among girls. New opportunities for early detection and treatment exist. Families with three generations affected with depression present a potentially important group for biological, genetic and neuroimaging studies.

Aim – This study examines the relationship between prenatal cocaine exposure and parent-reported child behavior problems at age 7 years. Methods – Data are from 407 African-American children (210 cocaine-exposed, 197 non-cocaine-exposed) enrolled prospectively at birth in a longitudinal study on the neurodevelopmental consequences of in utero exposure to cocaine. Prenatal cocaine exposure was assessed at delivery through maternal self-report and bioassays (maternal and infant urine and infant meconium). The Achenbach Child Behavior Checklist (CBCL), a measure of childhood externalizing and internalizing behavior problems, was completed by the child's current primary caregiver during an assessment visit scheduled when the child was seven years old. Results – Structural equation and GLM/GEE models disclosed no association linking prenatal cocaine exposure status or level of cocaine exposure to child behavior (CBCL Externalizing and Internalizing scores or the eight CBCL sub-scale scores). Conclusions – This evidence, based on standardized ratings by the current primary caregiver, fails to support hypothesized cocaine-associated behavioral problems in school-aged children with in utero cocaine exposure. A next step in this line of research is to secure standardized ratings from other informants (e.g., teachers, youth self-report).

Declaration of Interest: This research was conducted in the context of an ongoing longitudinal study funded by the National Institutes of Health National Institute on Drug Abuse (R01 DA 06556). Support was also provided by a NIDA career development award (K01 DA 16720), a NIDA research training award (T32 DA 07292), the General Clinical Research Center (MOI RR 16587), and the Health Foundation of South Florida.

Aims – The present study is part of a longitudinal project aimed at identifying the personal characteristics and the developmental pathways conducive to successful adaptation from childhood to adulthood. The study examined the concurrent and longitudinal impact of self-efficacy beliefs on subjective well-being in adolescence, namely positive thinking and happiness. Positive thinking has been operationalized as the latent dimension underlying life satisfaction, self-esteem and optimism. Happiness has been operationalized as the difference between positive and negative affects, as they are experienced in a variety of daily situations. Methods – In a group of 664 Italian adolescents, a structural model positing adolescents' emotional and interpersonal self-efficacy beliefs as proximal and distal determinants of positive thinking and happiness has been tested. Results – Findings attest to the impact of affective and interpersonal-social self-efficacy beliefs on positive thinking and happiness both concurrently and longitudinally. Conclusions – Adolescents' self-efficacy beliefs to manage positive and negative emotions and interpersonal relationships contribute to promote positive expectations about the future, to mantain a high self-concept, to perceive a sense of satisfaction for the life and to experience more positive emotions.

Declaration of Interest: none.

Aim – To test the efficacy of a Behavioural Family Therapy (BFT) in a routine setting, both short and long term, of a community mental health service (CMHS). Methods – In a randomised clinical trial 24 patients with a diagnosis of schizophrenia, as confirmed by PSE-IX, were assigned to the BFT according to Falloon (n = 12) or to individual usual treatment (n = 12). They were assessed before and at the end of the active treatment (after one year), and after an 11-years follow-up with compared on basic indicators (hospitalisations, length of stay, drop-out rate) and standardised instruments of psychopathological symptoms, social functioning, family burden. Results – At one-year follow-up clinical important and statistically significant differences were observed for psychotic positive symptoms (p<0.01), self-care (p<0.01), autonomy in daily life (p<0.001), subjective/objective family burden (p<0.001). Other psychosocial variables showed positive outcomes non reaching statistical significance. At the 11-year follow-up, marked differences were observed only in hospitalisations and drop-outs. Conclusions – The BFT was rather easy to implement in a CMHS and very cost effective. However, as it has been shown in other studies, to keep all the benefits a consistent program of monitoring with booster sessions is essential.

Declaration of Interest: in the last 2 years, none of the authors has had any interest or he/she has received any form of support, including that from drug companies and “honoraria” for lectures and consultancies, potentially in conflict with this scientific work.

Aims – The aims of the study are to evaluate the prevalence rates for headache among an Italian sample of early-adolescents and the role of possible related factors (school stress and social support). Methods – The survey reported here is part of the larger Health Behaviour in School Aged Children (HBSC) trans-national study, which is co-ordinated by the European Office of the World Health Organization. The data were gathered through self-administered questionnaires filled out by a representative sample of 4, 386 (48.4% males) Italian students (11-, 13- and 15-year old). The main areas covered in the questionnaire were health and health behaviour. Results – The overall prevalence of frequent headache (at least once a week) was 40.5%. Boys are less at risk than girls and the prevalence increases with age. Moreover, school demands (positively) and teacher's support (negatively) showed a significant association with the outcome. Conclusions – Compared to other countries, results revealed how this symptom is very common among Italian's early adolescents. Further, results shows the relevance of the school setting, in terms of teacher's demands and support, for the prevention of this symptom among early adolescents.

Declaration of Interest: The HBSC study is partly funded by the University of Padova through a scholarship attributed to Dr. Alessio Vieno (Year 2001 - prot. CPDR013233).

Background – The patterns of antidepressant and antipsychotìc drag prescribing have rarely been studied in large and geographically defined catchment areas. In the present study we examined the prevalence and distribution of antidepressant and antipsychotic prescribing in Lombardy, a northern Italy region of nine million inhabitants. Methods – This study used the Regional Administrative Database of Lombardy. This database includes all prescriptions reimbursed by the National Health System in the population living in this region. All antidepressant and antipsychotic prescriptions dispensed from the 1st January to the 31st December 2001 were extracted and prevalence data calculated by dividing antidepressant and antipsychotic users by the total number of male and female residents in each age group. In addition, from the Regional database of hospital admissions we extracted all patients aged 65 or above with cerebrovascular-related outcomes for the year 2002. The two databases were linked anonymously with the aim of investigating the relationship between exposure to psychotropics and occurrence of cerebrovascular accidents in the elderly. Results – During the study period 404, 238 individuals were dispensed antidepressants, yielding a prevalence of use of 2.85 (95% CI 2.84, 2.87) per 100 males and 5.92 (95% CI 5.90, 5.94) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old individuals. The majority of individuals received a pharmacological treatment with selective-serotonin reuptake inhibitors only, slightly more than 12% received a treatment with tricyclic antidepressants. A total of 86, 187 subjects were dispensed antipsychotic agents, yielding a prevalence of use of 0.87 (95% CI 0.86, 0.88) per 100 males and 1.01 (95% CI 1.00, 1.02) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old subjects. Concerning the relationship between exposure to second-generation antipsychotics (SGAs) and occurrence of cerebrovascular (CBV) accidents, the analysis showed a significantly increased risk of CBV events in elderly subjects exposed to SGAs in comparison with those exposed to first-generation antipsychotics (FGAs) (3, 31%, 95% CI 2, 95–3, 69 vs. 2, 37%, 95% CI 2, 19–2, 57). Finally the analysis indicated no differences in the proportion of cerebrovascular events in elderly subjects exposed to TCAs and SSRIs. Conclusions – The very high rates of antidepressant and antipsychotic drug prescribing detected in late life suggest the need of characterising these individuals in terms of medical and psychiatric characteristics, needs and quality of life. It also suggests the need for pragmatic clinical trials, carried out in the general practice, with the aim of assessing whether antidepressants are effective in these conditions. The data provide preliminary epidemiological evidence that exposure to SGAs, in comparison with exposure to FGAs, significantly increased the risk of cerebrovascular accidents in the elderly.

Declaration of Interest: none.