| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
British Medical Bulletin 57:17-32 (2001)
© 2001 Oxford University Press
Recent developments in understanding the psychosocial aspects of depression
Socio-Medical Research Centre, Academic Department of Psychiatry, St Thomas' Hospital, London, UK
 |
Abstract |
|---|
Top
Abstract
IntroductionRecent advances in the psychosocial understanding of depression have elaborated an already complex aetiological model. Yet each new strand seems to echo, and forge links with, themes uncovered earlier, making it easier to see what is common about the 'final common pathway' to onset. For example, although recent stressors have for some time been recognised predictors of onset, new insights about the origins of these stressors have overlapped with other new work on depression and childhood adversity to identify a group who 'produce' their own severe life events in response to early negative experience. And recent studies have traced the well-known gender difference in depressive prevalence to differences both in gender role involvement with the provoking life events and in styles of support-seeking/support-giving. What emerges is the powerlessness, loss and humiliation characterising the final pathway. Both naturalistic studies and controlled trials suggest that psychosocial situations reflecting the opposite emotional meaning, that is new hope, characterise a similar pathway to remission. Conclusions speculate whether awareness of this pathway might enhance purely pharmacological treatment.
|
Introduction |
|---|
For some years now, lip service has been paid to a tripartite ‘biopsychosocial’ model of human development and disease, but the full-scale integration of perspectives implied by such homage is still slow to come about in practice: research, and thus understanding, is still by and large boundaried by the academic departments through which funding is administered. The topic of depression is no exception: even within the ‘social’ part of the triad, epidemiological and sociological research workers do not always attempt a shared vision and, while respectful of each others' contributions, authors of pharmacological and psychological papers rarely bother to include each other's predictors as control variables in models of depressive onset or remission. The last decade has, however, seen more of a rapprochement between those investigating the disorder via the impact of the social outer world and those mapping its relation to the psychic inner world, with the epithet ‘psychosocial’ increasingly correctly describing such work. This convergence has perhaps occurred more frequently in the context of intervention projects attempting to promote recovery where theory is inevitably forced to reshape itself in relation to the buffets incurred in trying to change the world. But it is more appropriate to begin with an account of recent advances in the aetiological theories on which these interventions were based, even though space limitations mean it is impossible to do justice to the wealth of recent evidence.
|
Differential prevalence and current environmental precipitation or adversity |
|---|
An integral part of the multidisciplinary perspective on the aetiology of depression was a view that there existed a final common pathway1
. For some years there has been an acknowledgement that this pathway was likely to involve the triad of cognitions described by Beck2 – the self as worthless, the world as pointless and the future as hopeless – cognitions which overlap to some degree with what some psychiatric schedules label depressive symptoms. That self-depreciation and social withdrawal were seen as integral to the disorder created a climate where the prodromal roles of low self-esteem and lack of social support became accepted during the 1980s. It is against this background that the following recent developments in the social strands of the multidisciplinary model should be viewed.
Social class differences: the role of severe life events
Other chapters have focused on cultural differences in rates of depression so these will not be discussed here. Suffice it to say that demographic differences in rates of depression noted in the 1970s, such as higher rates in the lower social status groups, continue to be reported3,4.
However, often there is no further examination of variables which could explain such demographic differences (see comments in Van Os5), only a brief reference to (unmeasured) poverty or lack of education. However, work in the 1970s had already pinpointed severe life events and ongoing difficulties as the key determinants of class6 and urban–rural7,8 differences, so it is fitting to turn to these next.
Life events and meaning
Humiliation/entrapment (H/E) and depressive onset
Reworking qualitative data on individuals' experiences of stress has brought new insights. First the severe events6 or events with negative impact9 identified as preceding depressive onset have been examined in more detail and categorised according to their emotional meaning in order to note any ‘match’ with prior vulnerabilities: whereas attention used to be specially given to events involving loss, either of person, object or of cherished idea, later refinement identified experiences of humiliation or entrapment as particularly prominent before depressive onset among the losses of cherished idea10. Those losses which did not involve humiliation – for example redundancy and temporary unemployment as a result of a large firm going bankrupt, a loss for which the interviewee would, therefore, not be held to blame – were followed by a much lower rate of depressive onset (13% as compared with 31%). The ‘match’ between the shamefulness of such events and the shame felt by people with low self esteem, whose vulnerability to depression was already acknowledged, encouraged a perspective akin to that of Gilbert's insights about shame and depression11 and to evolutionary theory12 with its challenging notions that depression has proved a condition of great functional benefit for the survival of the human species.
Fresh start experiences and remission from depression
Even more thought-provoking was the investigation of the ‘meaning’ of those fresh start experiences which, more often than not, preceded depressive remission13–16. Although all these data were collected retrospectively, the time order between these and remission, and the high proportion of such events which were independent of the subject's agency, lent plausibility to this being the effect of the environment on pathology. It seemed fresh starts were the mirror image of those producing the generalised hopelessness of Beck's depressive cognitive triad2. They either involved events like starting a new job after months unemployed, starting a course after years as a housewife, establishing a regular relationship with a new boy friend/girl friend after many months single, or the reduction of a severe difficulty, usually with interpersonal relationships, housing or finance. They seemed to embody the promise of new hope against a background of deprivation. It was notable that even for women who continued to experience difficulties of a depressogenic severity in one life domain such as marriage, a fresh start in another life domain – starting an access course – often seemed to tip the balance and set them on course for remission.
Event production
One recent important elaboration of the psychosocial model of depression has been the quest for the origins of the severe life events that had emerged as so crucial before onset17. For this it became important to distinguish events brought about by the persons themselves (variously ‘contingent’, ‘controllable’ or ‘dependent’ events) from those coming, as it were, from outside (‘independent’ or ‘uncontrollable’ events)18. Unsurprisingly, one set of sources was identified as environmental with not only social class position and inner-city residence as critical influences, but also certain past experiences (see below): people in some environments seemed to have mounted a conveyor belt to continued adversity from which they could only exit with extraordinary effort. Of other more internal sources considered, depression itself was a prime candidate, either previous19,20 or current21. High neuroticism scores were also found to be highly predictive22–24 along with extraversion25. One longitudinal study was able to predict adult severe events by teenage behaviour problems measured on the Rutter B scale26. A similar predictor was current dramatic (cluster B) personality disorder which nearly doubled the rate of humiliation/entrapment (H/E) events, and quadrupled the rate of contingent H/E events27. Studies with twin pairs also found that the ‘controllable’ events were the ones particularly due to genetic influence28, or, in the terminology of another genetic study, ‘personal’ as opposed to ‘network’ events24. Personality traits such as impulsiveness, frustration tolerance and risk taking were suggested as the possible genetically influenced origins of these events. It was rare for studies to pursue the possible origins of such traits in yet earlier experiences of events (see below on childhood adversity)27.
Social capital
One new way of looking at demographic differences which seems to span this divide between an individual's events/difficulties and the more epidemiological features of a locality is to incorporate the notion of social capital, a concept rapidly gaining credence in the public health field as New Labour has invited Putnam29 to give seminars in Downing Street. Defined30 as ‘consisting of features of social organisation – such as trust between citizens, norms of reciprocity and group membership – that facilitate collective action’, it is conceivable as a factor (low levels of which could act to provoke depression independently of actual personal experiences): living in an area with many burglaries/assaults might prove depressogenic even in the absence of actual experience of these by the subject or his immediate neighbours (only the latter would count as on-going difficulties/events)31. Initial investigations in relation to mental health are still being analysed – although one study reports that the ‘social milieu’ can be protective against depression32. This promises to be an area of interesting data in the next few years.
Endogenous depression
Before leaving the topic of environmental provocation of depression, it is perhaps important to mention the classic debate concerning depressive subtype. According to mid-20th century orthodoxy, syndromes involving the more vegetative symptoms such as early waking, morning worsening and lack of reactivity were ‘endogenous’ in the sense of lacking environmental provocation. Standardisation of life event measures had produced data that caused a radical reconsideration of this perspective6,33 with one team even changing sides when their second data set challenged the orthodox view supported by their first34,35. Yet, despite the new consensus, there was still a sense that depressions without this type of provocation did often show the specified symptom pattern. New light was thrown on the puzzling inconsistency of previous results by the reports in two data sets of different rates of provocation between first and subsequent melancholic episodes, with experience of at least one severe event for first melancholic episodes as high as for all with neurotic depression36,37. It was suggested that the lower percentages for later melancholic episodes resembled Post's work on the role of sensitisation, or scarring, after a first episode, particularly for bipolar disorder38.
|
Differential prevalence and past adversity |
|---|
The 1990s placed childhood sexual abuse in the forefront of attention as a source of adult mental health problems. But it was important to heed, but not outdo, earlier scepticism concerning the frequency of such abuse which some attributed to retrospectively distorted accounts of childhood39
. Moreover the psychiatric literature on the long-term effects of adverse childhood experiences was already riven with contradictions, even for experiences such as parental death or divorce that could be independently corroborated by civil certificates. Towards the end of the 1980s, some consensus emerged over the conflicting findings concerning the impact of childhood parental loss on adult depression: parental death seemed less depressogenic than parental divorce40, but the key predictor of later depression was less the loss than the on-going deprivation of adequate care which often accompanied such loss and was found to play a similar role even in families without such loss41–43. Later refinement of an interview measure of such neglect also focused on the depressogenic impact of physical and sexual abuse, identifying a raised rate of depression among those with such ‘childhood adversity’ using the Childhood Experience of Care and Abuse or CECA44–47, particularly in samples of the homeless48,49. Other research teams focusing on such abuse, even without also investigating neglect, also came up with increased rates50–53. CECA-defined childhood adversity was also found to predict chronicity of depression both in a patient54 and a community sample55. Despite the retrospective nature of the CECA, a series of sister pairs provided evidence of high corroboration of their sister's account of any abuse or neglect experienced as a child56,57. A study of mothers and their teenage daughters revealed a strong association between repeated abuse/neglect among the daughters and early inadequate parenting during the mothers' childhoods58, highlighting the process of intergenerational transmission of vulnerability to depression heralded by Rutter and Madge59.
Parallel work on the effects of maternal depression on children's emotional and cognitive development seemed to be echoing this theme: it seemed that a rearing style involving neglect or abuse was often a corollary of a mother's depression60 (see Murray & Cooper61 for key references). A number of alternative models have been elaborated to explain these aetiological pathways: most involve long-term damage to self-esteem or to attachment style (and thus to the ability to access emotional support) as a result of the early toxic relationships with key care-givers, the two factors mentioned above in connection with the final common pathway to depressive onset62,63. It is in the context of interventions with postnatally depressed mothers that these models can best be evaluated.
|
Differential prevalence and gender |
|---|
The flood of evidence linking depression with childhood adversity suggested the possibility that this might be able to account for one of the best established associations between the disorder and sociodemographic factors – the 2-fold greater prevalence among women. Could this be due to a greater tendency for girls to suffer childhood abuse? Pathare and Craig investigated this possibility in a series of 83 brother–sister pairs47
: the expected gender differences in depression, both current and life-time, were found but childhood experience could not be held accountable, as although rates of sexual abuse were higher among the sisters, overall rates including neglect and physical abuse were not so different. Sisters were asked to corroborate their brothers' experiences and there was little evidence of systematic under-reporting by men. What was striking, however, was the tendency among the brothers for childhood adversity to be associated only with externalising disorders such as substance abuse, whereas among the sisters it was with depression, conventionally seen as an internalising disorder. A similar picture emerged in a sample of 96 young men64, brothers of the young women mentioned earlier as examined alongside their mothers58.
A more promising avenue for the exploration of gender differential rates came from a study of couples selected for experience of a shared severe life event in order to compare the ways in which women would respond differently from men65. Similarity of experience was maximised by excluding couples where the event was severe for one but not for the other (for example the death of one spouse's sibling would only be severe for the other in unusual circumstances). Among those with severe events involving work or marriage, rates of depression were much the same, but among the 47 couples with events concerning children, reproduction or housing, the expected higher female rate was found, and it was possible to relate this to women's higher rate of ‘commitment'’ and ‘involvement’ in such domains. For 13 of these 47 crises, ‘role salience’ was rated considerably less given the relatively greater involvement of the male partner in the home, and here there was no difference in rate of depressive onset. In this series, gender differences in social support were also interesting66: while a supportive marriage was protective for both, women expressed greater need for support within marriage, and were also more likely to seek support from close relationships outside marriage. Receiving support from outside marriage, which was protective for women, was associated with higher depression among men. The authors speculate that this may be due to men feeling more demeaned by confiding their emotions and so postponing support seeking until they are under more emotional pressure to do so, that is, perhaps, until depressive disorder has already begun.
One final comment: these findings concerning the types of provoking events that account for gender differences in depression must have a bearing on recent reports of single mothers as even more prone to depression than other mothers, through their higher rates of H/E events and their lower levels of self-esteem and social support67. An empirical investigation of maternal depression and factors associated with it in child and family care social work highlighted the high proportion both of depression and of lone mothers (either divorced or always single) among this client group, along with a higher number of problems with parenting and behavioural difficulties with children68. Despite this high frequency, social workers were very poor at identifying depression and their interventions did not differ in any marked respect compared to families without depressed mothers.
|
Differential prevalence and social support with adversity |
|---|
Confirmation of the key protective role of social support has continued69
, whether examined in terms of the positive provision of a confidant62 or the absence of negative input such as marital difficulties54,55 or ‘critical comments’ (references cited in Leff et al71)70, although there has been one failure to replicate this latter72. As with the growth of interest in origins, not merely impact, of events, there has been a corresponding development of interest in the origins of poor support. Here too, personality, if not actually PD, has begun to be explored as the source of support deficits, and again Attachment Theory has been co-opted, with its subclassification of different personal styles of failed intimacy, the fearful or the dismissive who avoid seeking support compared with the enmeshed and ambivalent who may alienate potential confidants73. |
Psychosocial interventions for depression |
|---|
The rise of evidence-based medicine has brought a wave of specialist treatment trials in the last decade, many of which are reviewed in other papers in this issue. Although from the inter-disciplinary point of view, there is an impressive number of comparisons of antidepressants with psychological treatments such as cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT), any more social aspects of these psychological interventions are ignored in the write-ups (see critique in Parry74
). Comparisons of CBT with couple therapy (cited in Leff et al71) have been exceptions here, probably because, with the marital/partner relationship being the focus of couple therapy, changes in its quality would inevitably also need to be monitored in the CBT comparison group. However, other psychosocial factors (for example conflict with in-laws) were not so monitored. Another exception is the series of trials of problem-solving75 in primary care76,77. But the potential impact of the problem solving upon the relevant social predictors is unclear from the analyses: just how many problems did the patients face at intake and how many were actually reduced or eliminated before recovery, and could such a disappearance be justifiably attributed to the treatment or was it independent? It could be argued that such an estimate of the psychosocial context is long overdue for all treatments, not just for those like problem solving which target such factors. Andrews78 has drawn attention to what he calls the ‘bane of depression outcome research’, the combination of high spontaneous recovery (at least for episodes of 2 months or less) and placebo response, which mean that high recovery rates within RCT control groups often obscure the interpretation of the effects of the targeted treatments. Introducing some of the psychosocial measures detailed earlier could perhaps illuminate the mechanism of spontaneous recovery (perhaps via fresh start experiences) and the process of the placebo response (perhaps some form of social support). Certainly incorporating such measures could serve to monitor the oft repeated finding that the effect size of drug and psychological treatments is not dissimilar and that combinations of drug and psychological do not add over and above one treatment alone. Does each act through a different initial route towards a final common pathway to remission1 which if reached through one path cannot further facilitate the attainment of recovery through another? Certainly notions concerning the preventive role of social support have been the prime inspiration of the various social, as opposed to psychological therapy, interventions reported. Translated into more communitarian life-span versions, they have also underpinned a number of recent government initiatives in the Health Action Zones, such as Sure Start, which targets children under 4 years and their mothers living in disadvantaged areas as an investment in the mental health of its future citizens. It aims to use health visitors to promote support and positive parenting groups to halt the intergenerational spiral whereby maternal depression promotes child disturbance which in turn exacerbates maternal depression. Many such schemes are too recent for serious evaluation here, but evaluations of similar interventions deserve attention not only for their contribution to understanding depression but also for their promise in defeating it.
One RCT with a chronically depressed elderly group in London suggested that regular visits from a community nurse providing emotional support had contributed substantially to remission79. Another RCT in an adjacent London borough with 86 chronically depressed women, using volunteer befrienders given minimal supervision by social-worker counsellors, found an effect of similar size (65% versus 39%)80. The latter study specifically measured the degree of support offered throughout the period by the volunteers, from the perspective of both befriendee and befriender, for which there was high agreement. This was indeed identified as a mediating factor81, but absence of any new severe stressor and presence of fresh-start events during follow-up, as well as baseline attachment style, were also needed to model remission82.
Another set of interventions with postnatally depressed mothers, explicitly targeted at different components of the correlations between maternal and infant moods, behaviours and interactions, came up with the surprising finding that all interventions, whether focused on the depression or the mother–child interaction, were equally effective at relieving depression but equally ineffective in influencing mother–child interaction or infant behaviour61. This ‘Cambridge Treatment Trial’ included two groups identical to an earlier trial that had identified 8 weekly non-directive counselling sessions by health visitors as a significant improvement over routine primary care (69% versus 38% remission), but added two extra intervention groups involving 42 with CBT and 48 with a form of dynamic psychotherapy in which an understanding of the mother's representation of her infant and her relationship with him was promoted by exploring aspects of the mother's own early attachment history. A later intervention by all health visitors working in the Cambridge National Health Service sector with a 6 half-day training in basic counselling skills and basic cognitive-behavioural strategies essentially replicated the Cambridge controlled trial83. Murray and Cooper61 comment that ‘a common feature of all the treatments was that they provided women with an opportunity to discuss their problems managing their infants and it is conceivable that this opportunity enabled therapeutic change of this dimension’. However, it is important to mention here one negative result for depression in Canada, a comparison of 8 social support group therapy sessions with a no-intervention group, although there was some evidence of an effect on mother–infant interaction84.
Another set of interventions, focused on children in contexts liable to promote childhood depression or behavioural problems, such as bereavement (24 intervention families and 31 controls) or parental separation (34 and 36), also provided theoretical insights85. For the first, the intervention consisted of a family grief workshop followed by a highly structured 12-session adviser programme targeted on each of four putative mediators defined by the aetiological model, parental warmth, parental demoralisation, promoting stable positive events and coping with negative stress events. This programme led to parental ratings of decreased depression problems and conduct disorder in the older children, and increased warmth in relationships with their children, satisfaction with social support and maintenance of family discussion of grief-related issues. The second programme (parental separation) involved 10 weekly group and 2 individual sessions. It indicated the following changes in the five targeted mediators: higher quality mother-child relationships, and discipline, and fewer negative divorce events for programme participants than for controls, along with better mental health outcomes, although the latter were more notable by mothers' than by children's reports. (Mothers were only rated on a scale of demoralisation whereas children were assessed for depression and conduct disorder.) Analyses revealed that improvements in the mother–child relationship partially mediated the effects on mental health outcomes.
|
Biopsychosocial investigations |
|---|
It would be misleading to end without paying due tribute to work which has made the effort to incorporate the biological part of the tripartite model in the range of its variables. Such work falls into two broad groups – that concerned with genetic factors and that relating biological measures such as hormone levels to depression in combination with the key psychosocial predictors.
Genetic models
Unfortunately, space precludes the lengthy exposition owed to the work of Kendler and his colleagues who have used the Virginia Twin register to incorporate genetic analyses along with a full range of psychosocial measures, including independent and dependent events86,87. His recent examination of monozygotic twin pairs discordant for major depression88 confirms his previous reports that both genetic and environmental effects are involved in major depression, giving additional insights, for example distinguishing the largely genetically mediated role of neuroticism from the environmentally mediated role of low self-esteem. This work, seemingly inspired by a ‘genetic’ perspective, has also confirmed the recent elaborations of the life-span psychosocial model, the link between childhood and current adversity along with the roles of self-esteem and social support86.
Integrating hormone measures
Strickland and colleagues used a range of Brown's psychosocial measures along with a range of biological measures to predict onset one year later89. Results were essentially negative. Goodyer and colleagues collected data among adolescents on cortisol and the key psychosocial predictors identified by their team90, and more recently Herbert encouraged Harris and Brown to combine his team's measures of cortisol with their psychosocial instruments91. The results of investigating depressive onset among adult women specially selected for psychosocial vulnerability and followed up after 12 months provided an encouraging parallel to the adolescents followed up by Goodyer and colleagues90. High baseline levels of cortisol at 8 am, although unrelated to any of the psychosocial measures, did independently predict subsequent onset.
|
Concluding comments |
|---|
This resumé has covered a wide range of pathways to depression which have emerged repeatedly in recent research on the psychosocial aetiology of affective disorder. What stands out is the complex interweaving of social and psychological strands throughout the developmental history: how the severe humiliation entrapment events which precede onset issue not only from an inclement environment but are sometimes produced by the subjects themselves; that the lack of any supportive relationship which might protect against onset issues not always from the hostile networks into which life has currently thrust them but sometimes from their own attachment styles which have led them to avoid intimacy or to alienate potentially supportive figures by their needs for enmeshment. Moreover, such behavioural styles involving event-production or attachment tendencies in adulthood can repeatedly be traced to early adverse interpersonal experiences involving neglect and abuse in childhood, with their acknowledged impact on subsequent personality. Such a developmental perspective has echoes of psychodynamic explanatory models, particularly since the amendments introduced by Attachment Theory have rendered these more amenable to empirical test. Certainly the time is ripe for a rapprochement between psychodynamic psychotherapists and evidence-based practice, medical or other, with depressed patients. There is much to learn, but also much to unlearn, on both sides, especially an appreciation of the impact of social context for the mechanisms by which other biological or psychological factors exert their influence upon depression.
|
Key points for clinical practice |
|---|
- An understanding of a depressed person's on-going problems, particularly interpersonal difficulties, can afford clinicians the opportunity to promote fresh start experiences, such as reconciliations, which have emerged as so important for remission
- An understanding of patients' childhood experiences may alert clinicians to those needing help to avoid producing more humiliating events for themselves in the current period
- Fresh-start experiences in one domain, for example a housewife embarking on a part-time training, can often prove therapeutic despite continuation of severe difficulties in another domain, such as a poor marriage
- Confirmation of the positive role of social support, not only as protection against depressive onset but also as promoting recovery, suggests clinicians should routinely assess patients' support networks and encourage their utilisation and development
- The psychosocial role of the consultation itself, both as listening support and as potential fresh-start, should not be underestimated: if during consultation, attention is paid to the social context of a depressive episode, including any adversity in childhood, this supportive role will be preserved and adherence to prescribed medication may thus be increased
|
Footnotes |
|---|
Correspondence to: Dr Tirril Harris, Socio-Medical Research Centre, Academic Department of Psychiatry, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK
|
References |
|---|
- Akiskal HS, McKinney Jr WT. Depressive disorders: towards a unified hypothesis. Science 1973; 182: 20–9
[Abstract/Free Full Text] - Beck AT. Depression: Clinical, Experimental and Theoretical Aspects. London: Staples, 1967
- Eaton WW, Harrison G. Epidemiology, social deprivation and community psychiatry. Curr Opin Psychiatry 2000; 13: 185–7[Web of Science]
- Andrade L. Surveys of morbidity and psychiatric comorbidity. Curr Opin Psychiatry 2000; 13: 201–7[Web of Science]
- Van Os J. Social influences on risk for disorder and natural history. Curr Opin Psychiatry 2000; 13: 209–13[Web of Science]
- Brown GW, Harris TO. Social Origins of Depression: A Study of Psychiatric Disorder in Women. London: Tavistock, 1978
- Prudo R, Harris TO, Brown GW. Psychiatric disorder in a rural and an urban population: 3. Social integration and the morphology of affective disorder. Psychol Med 1984; 14: 327–45[Web of Science][Medline]
- Gaminde I, Uria M, Padro D et al. Depression in three populations in the Basque country – a comparison with Britain. Soc Psychiatry Psychiatr Epidemiol 1993; 28: 243–51[Web of Science][Medline]
- Paykel ES. Life events, social support and depression. Acta Psychiatr Scand Suppl 1994; 377: 50–8[Medline]
- Brown GW, Harris TO, Hepworth C. Loss humiliation and entrapment among women developing depression: a patient and non-patient comparison. Psychol Med 1995; 25: 7–21[Web of Science][Medline]
- Gilbert P, Andrews B., Shame: Interpersonal Behaviour, Psychopathology and Culture. Oxford: Oxford University Press, 1998
- Price J, Sloman L, Gardner Jr R et al. The social competition hypothesis of depression. Br J Psychiatry 1994; 164: 309–15
[Abstract/Free Full Text] - Brown GW, Adler Z, Bifulco A. Life events difficulties and recovery from chronic depression. Br J Psychiatry 1988; 152: 487–98[Abstract]
- Brown GW, Lemyre L, Bifulco A. Social factors and recovery from anxiety and depressive disorders: a test of the specificity hypothesis. Br J Psychiatry 1992; 161: 44–54
[Abstract/Free Full Text] - Leenstra AS, Ormel J, Giel R. Positive life change and recovery from anxiety and depression. Br J Psychiatry 1995; 166: 333–43
[Abstract/Free Full Text] - Oldehinkel AJ, Ormel J, Neeleman J. The effect of positive life change on time to recovery from depression: some people benefit more than others. J Abnorm Psychol 2000; 109: 299–307[Web of Science][Medline]
- Brown GW, Harris TO. The origins of life events and difficulties. In: Brown GW, Harris TO. Life Events and Illness. New York: Guilford, 1989
- Harris TO, Brown GW. The origins of the life events preceding onset of depression: 1. Independence and humiliation/entrapment in a general population series. 2001; Submitted
- Harkness LL, Monroe SM, Simons AD, Thase M. The generation of life events in recurrent and non-recurrent depression. Psychol Med 1999; 29: 135–44[Web of Science][Medline]
- Xing-jia C, Vaillant GE. Antecedents and consequences of negative life events in adulthood: a longitudinal study. Am J Psychiatry 1996; 153: 21–6
[Abstract/Free Full Text] - Adrian C, Hammen C. Stress exposure and stress generation in children of depressed mothers. J Consult Clin Psychol 1993; 61: 354–9[Web of Science][Medline]
- Poulton RG, Andrews G. Personality as a cause of adverse life events. Acta Psychiatr Scand 1992; 85: 35–8[Web of Science][Medline]
- Fergusson DM, Horwood LJ. Vulnerability to life events exposure. Psychol Med 1987; 17: 739–49[Web of Science][Medline]
- Kendler KS, Neale M, Kessler R et al. A twin study of recent life events and difficulties. Arch Gen Psychiatry 1993; 50: 789–96
[Abstract/Free Full Text] - Breslau N, Davis GC, Andreski P. Risk factors for PTSD-related traumatic events: a prospective analysis. Am J Psychiatry 1995; 152: 529–35
[Abstract/Free Full Text] - Champion L, Goodall G, Rutter M. Behaviour problems in childhood and stressors in early adult life: 1. A twenty year follow-up of London school children. Psychol Med 1995; 25: 231–46[Web of Science][Medline]
- Harris TO, Brown GW. The origins of the life events preceding onset of depression: 2 Personality disorder and contingent events in a patient series. 2001; Submitted
- Plomin R, Perdersen NL, Lichtenstein P et al. Genetic influence on life events during the last half of the life span. Psychol Aging 1990; 5: 25–30[Web of Science][Medline]
- Putnam R. Bowling alone: America's declining social capital. J Democracy 1995; 6: 65–78
- Kawachi I, Kennedy BP, Glass R. Social capital and self-rated health: a contextual analysis. Am J Public Health 1999; 89: 1187–93
[Abstract/Free Full Text] - Schwartz S, The fallacy of the ecologic fallacy: the potential misuse of a concept and the consequences. Am J Public Health 1994; 84: 825–9
[Abstract/Free Full Text] - Prince MJ, Harwood RH, Thomas A et al. A prospective population-based cohort study of the effects of disablement and social milieu on the onset and maintenance of late-life depression. The Gospel Oak Project VII. Psychol Med 1998; 28: 337–50[Web of Science][Medline]
- Paykel ES. Recent life events and clinical depression. In: Gunderson EKE, Rahe RH. (eds) Life Stress and Illness. Springfield, IL: CC Thomas, 1974
- Bebbington P, Tennant C, Hurry J. Adversity and the nature of psychiatric disorder in the community. J Affect Disord 1981; 3: 345–66[Web of Science][Medline]
- Bebbington P, Brugha T, MacCarthy B et al. The Camberwell Collaborative Depression Study I. Depressed probands: adversity and the form of depression, Br J Psychiatry 1988; 152: 754–65
[Abstract/Free Full Text] - Frank E, Anderson B, Reynolds CF et al. Life events and the research diagnostic criteria endogenous subtype. Arch Gen Psychiatry 1994; 51: 519–24.
[Abstract/Free Full Text] - Brown GW, Harris TO & Hepworth C. Life events and ‘endogenous’ depression: a puzzle re-examined. Arch Gen Psychiatry 1994; 51: 525–34
[Abstract/Free Full Text] - Post RM, Rubinow DR, Ballenger JC. Conditioning and sensitisation in the longitudinal course of affective illness. Br J Psychiatry 1986; 149: 191–201
[Abstract/Free Full Text] - Brewin CR. Scientific status of recovered memories. Br J Psychiatry 1996; 169: 131–4
[Free Full Text] - Tennant C, Bebbington P, Hurry J. Parental death in childhood and risk of adult depressive disorders: a review. Psychol Med 1980; 10: 289–99[Web of Science][Medline]
- Parker G. Parental ‘affectionless control’ as an antecedent to adult depression: a risk factor delineated. Arch Gen Psychiatry 1983; 40: 956–60
[Abstract/Free Full Text] - Birtchnell J, Kennard J. How do the experiences of the early separated and early bereaved differ and to what extent do such differences affect outcome? Social Psychiatry 1984; 19: 163–71[Web of Science][Medline]
- Harris T, Brown GW, Bifulco A. Loss of parent in childhood and adult psychiatric disorder: a tentative overall model. Devel Psychopathol 1990; 2: 311–28
- Bifulco A, Brown GW, Harris TO. Childhood experience of care and abuse CECA: a retrospective interview measure. Child Psychol Psychiatry 1994; 35: 1419–35
- Hill J, Pickles A, Burnside E. Child sexual abuse, poor parental care and adult depression: evidence for different mechanisms. Br J Psychiatry 2001; In press
- Tousignant M, Habimana E, Biron C et al. The childhood experience of care and abuse (CECA), an exploration with adolescent refugees. In: Harris TO. (ed) Where Inner and Outer Worlds Meet: Psychosocial Research in the tradition of George W. Brown. London: Routledge, 2000; 195–209
- Pathare S, Craig TKJ. Cross-gender sib-pair study of childhood adversity, substance use disorders. 2001: Submitted
- Craig TKJ, Hodson S. Homeless youth in London: I. Childhood antecedents and psychiatric disorder. Psychol Med 1998; 28: 1379–88. II Accommodation, employment and health outcomes at 1 year. Psychol Med 2000; 30: 187–94[Web of Science][Medline]
- Herman DB, Susser ES, Struening L et al. Adverse childhood experiences: are they a risk factor for adult homelessness? Am J Public Health 1997; 87: 249–55
[Abstract/Free Full Text] - Mullen PE, Martin JL, Anderson JC et al. The long-term impact of the physical, emotional and sexual abuse of children: a community study. Child Abuse Neglect 1996; 20: 7–21[Web of Science][Medline]
- Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse and psychiatric disorders in young adulthood. Part II. Psychiatric outcomes of sexual abuse. J Am Acad Child Adolesc Psychiatry 1996; 35: 1365–74[Web of Science][Medline]
- Briere J, Runtz M. Differential adult symptomatology associated with three types of child abuse histories. Child Abuse Neglect 1990; 14: 357–64[Web of Science][Medline]
- Brown J, Cohen P, Johnson JG et al. A longitudinal analysis of risk factors for child maltreatment: findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse Neglect 1998; 22: 1065–78[Web of Science][Medline]
- Brown GW, Moran P. Clinical and psychosocial origins of chronic depressive episodes. I: a community survey. Br J Psychiatry 1994; 165: 447–56
[Abstract/Free Full Text] - Brown GW, Harris TO, Hepworth C, Robinson R. Clinical and psychosocial origins of chronic depressive episodes. II: a patient enquiry. Br J Psychiatry 1994; 165: 457–65
[Abstract/Free Full Text] - Bifulco A, Brown GW, Lillie A et al. Memories of childhood neglect and abuse: corroboration in a series of sisters. J Child Psychol Psychiatry 1997; 38: 365–74[Web of Science][Medline]
- Brewin CR, Andrews B, Gotlib IH. Psychopathology and early experience: a reappraisal of retrospective reports. Psychol Bull 1993; 113: 82–98[Web of Science][Medline]
- Andrews B, Brown GW, Creasey L. Intergenerational links between psychiatric disorder in mothers and daughters: the role of parenting experiences. J Child Psychol Psychiatry 1990; 31: 1115–29[Web of Science][Medline]
- Rutter M, Madge N. Cycles of Disadvantage: A Review of Research. London: Heinemann, 1976
- Radke-Yarrow M. Children of Depressed Mothers: From Early Childhood to Maturity. Cambridge: Cambridge University Press, 1998
- Murray L, Cooper PJ. Post-partum Depression and Child Development. New York: Guilford, 1997 for cited references see pp 202, 217–20
- Brown GW, Andrews B, Harris TO, Adler Z, Bridge L. Social support, self-esteem and depression. Psychol Med 1986; 16: 813–31[Web of Science][Medline]
- Bifulco A, Brown GW, Moran P et al. Predicting clinical depression in women: the role of past and present vulnerability. Psychol Med 1998; 28: 39–50[Web of Science][Medline]
- Brown GW, Hepworth C. Launching from Adolescence to Adulthood: A Study of the Impact of Family Life. Report to the ESRC, Ref R000 23 2042, 1993 [mimeographed report]
- Nazroo JY, Edwards AC, Brown GW. Gender differences in the onset of depression following a shared life event: a study of couples. Psychol Med 1997; 27: 9–19[Web of Science][Medline]
- Edwards AC, Nazroo J, Brown GW. Gender differences in marital support following a shared life event. Soc Sci Med 1998; 46: 1077–85[Web of Science][Medline]
- Brown GW, Moran P. Single mothers poverty and depression. Psychol Med 1997; 27: 21–33[Web of Science][Medline]
- Sheppard M. Social work practice in child and family care: a study of maternal depression, Br J Social Work 1997; 27: 814–5
- Brugha T. (ed) Social Support and Psychiatric Disorder: Research Findings and Guidelines for Clinical Practice. Cambridge: Cambridge University Press, 1995
- Okasha A, El Akabawi AS, Snyder AS et al. Expressed emotion, perceived criticism and relapse in depression: a replication in an Egyptian community. Am J Psychiatry 1994; 151: 1001–5
[Abstract/Free Full Text] - Leff J, Vearnals S, Brewin CR. The London Depression Intervention Trial: randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcome and costs. Br J Psychiatry 2000; 177: 95–100
[Abstract/Free Full Text] - Hayhurst H, Cooper Z, Paykel ES et al. Expressed emotion and depression: a longitudinal study. Br J Psychiatry 1997; 171: 439–43
[Abstract/Free Full Text] - Bifulco AT, Moran PM, Ball C et al. Adult attachment style and depression: a new measure of the ability to make supportive relationships. 2001; Submitted
- Parry G. Social support processes and cognitive therapy. In: Brugha T. (ed) Social Support and Psychiatric Disorder: Research Findings and Guidelines for Clinical Practice. Cambridge: Cambridge University Press, 1995
- Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised controlled trial comparing problem solving treatment with amitryptyline and placebo for major depression in primary care, BMJ 1995; 310: 441–5
[Abstract/Free Full Text] - Mynors-Wallis LM, Davies I, Gray A, Gath DH, Barbour F. Randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders by community nurses in primary care. Br J Psychiatry 1997; 170: 113–9
[Abstract/Free Full Text] - Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000; 320: 26–30
[Abstract/Free Full Text] - Andrews G. Placebo response: boon of therapy, bane of research. Br J Psychiatry 2001; 178: 192–4
[Free Full Text] - Blanchard MR, Waterreus A, Mann A. The effect of primary care nurse intervention upon older people screened as depressed. Int J Geriatr Psychiatry 1999; 10: 289–98
- Harris TO, Brown GW, Robinson R. Befriending as an intervention for chronic depression among women in an inner city. I: Randomised controlled trial. Br J Psychiatry 1999; 174: 219–25.
[Abstract/Free Full Text] - Harris TO, Brown GW, Robinson R. Befriending as an intervention for chronic depression among women in an inner city. III: The role of support: the befriending process and characteristics of the volunteers. 1999; In preparation
- Harris TO, Brown GW, Robinson R. Befriending as an intervention for chronic depression among women in an inner city. II: Role of fresh-start experiences and baseline psychosocial factors in remission from depression. Br J Psychiatry 1999; 174: 225–33
[Abstract/Free Full Text] - Seeley S, Murray L, Cooper PJ. The outcome for mothers and babies of health visitor intervention. Health Visitor 1996; 69: 135–8
- Fleming AS, Klein E, Corter C. The effects of a social support group on depression, maternal attitudes and behaviour in new mothers. J Child Psychol Psychiatry 1992; 33: 685–98[Web of Science][Medline]
- Sandler IN, Wolchik SA, MacKinnon D et al. Developing links between theory and intervention in stress and coping processes. In: Wolchik SA, Sandler IN. (eds) Handbook of Children's Coping: Linking Theory and Intervention. New York: Plenum, 1997; 4–40
- Kendler KS, Kessler R, Neale M et al. The prediction of major depression in women: toward an integrated etiologic model. Am J Psychiatry 1993; 150: 1139–48
[Abstract/Free Full Text] - Kendler KS, Karkowski LM, Prescott CA. The assessment of dependence in the study of stressful life events: validation using a twin design. Psychol Med 1999; 29: 1455–6[Web of Science][Medline]
- Kendler KS, Gardner CO. Monozygotic twins discordant for major depression: a preliminary exploration of the role of environmental experiences in the aetiology and course of illness. Psychol Med 2001; 31: 411–23[Web of Science][Medline]
- Strickland P, Deakin W, Percival P, Dixon J, Gater R, Goldberg D. The bio-social origins of depression in the community: Interactions between social adversity, cortisol and serotonin transmission. Submitted
- Goodyer I, Herbert J, Tamplin A et al. Recent life events, cortisol, dihydroepisandrosterone and the onset of major depression in high-risk adolescents. Br J Psychiatry 2000; 177: 499–504
[Abstract/Free Full Text] - Harris TO, Borsanyi S, Messari S. Morning cortisol as a risk factor for subsequent major depressive disorder in adult women. Br J Psychiatry 2000; 177: 505–10
[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  M. S. Webb and M. P. Carey The early health consequences of smoking: Relationship with psychosocial factors among treatment-seeking Black smokers Nicotine Tob Res, May 1, 2009; 11(5): 564 - 571. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Walters, M. Ashworth, and A. Tylee Ethnic density, physical illness, social deprivation and antidepressant prescribing in primary care: ecological study The British Journal of Psychiatry, September 1, 2008; 193(3): 235 - 239. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M Virtanen, S Koskinen, M Kivimaki, T Honkonen, J Vahtera, K Ahola, and J Lonnqvist Contribution of non-work and work-related risk factors to the association between income and mental disorders in a working population: the Health 2000 Study Occup. Environ. Med., March 1, 2008; 65(3): 171 - 178. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. J. Waldinger, G. E. Vaillant, and E. J. Orav Childhood Sibling Relationships as a Predictor of Major Depression in Adulthood: A 30-Year Prospective Study Am J Psychiatry, June 1, 2007; 164(6): 949 - 954. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Wieclaw, E. Agerbo, P. B. Mortensen, H. Burr, F. Tuchsen, and J. P. Bonde Work related violence and threats and the risk of depression and stress disorders. J Epidemiol Community Health, September 1, 2006; 60(9): 771 - 775. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Cohen, P. R. Houck, K. Szanto, M. A. Dew, S. E. Gilman, and C. F. Reynolds III Social Inequalities in Response to Antidepressant Treatment in Older Adults Arch Gen Psychiatry, January 1, 2006; 63(1): 50 - 56. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. H. Ice and J. Yogo Measuring Stress Among Luo Elders: Development of the Luo Perceived Stress Scale Field Methods, November 1, 2005; 17(4): 394 - 411. [Abstract] [PDF]
|
|
|
|
 |
|
 C. Muntaner, W. W. Eaton, R. Miech, and P. O'Campo Socioeconomic Position and Major Mental Disorders Epidemiol. Rev., July 1, 2004; 26(1): 53 - 62. [Full Text] [PDF]
|
|
|
|
 |
|
 K. M. Mehta, K. Yaffe, K. M. Langa, L. Sands, M. A. Whooley, and K. E. Covinsky Additive Effects of Cognitive Function and Depressive Symptoms on Mortality in Elderly Community-Living Adults J Gerontol A Biol Sci Med Sci, May 1, 2003; 58(5): M461 - M467. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||