The social causation of depression: a critique of the work of Brown and his colleagues

Epidémiologie de la dépression : données récentes I. Epidémiologie descriptive

Les auteurs font la revue des études récentes concernant l’épidémiologie de la dépression. Les études épidémiologiques de la dépression dans la population générale sont difficiles à interpréter, du fait de différences dans l'identification des cas et de variations dans les procédures de diagnostic entre les études. Mais il y a eu un progrés considérable avec le récent développement des méthodes d’identifications de cas, fiables et valides, comme les RDC et le DSM-III. D’autres problémes méthodologiques concernent le choix de la population et le choix des différentes mesures du risque.

Des données examinées, on peut tirer les estimations suivantes : la prévalence sur six mois de la dépression majeure est de 1% à 3% chez l’homme, et 3% à 5% chez la femme; la prévalence sur la vie entiere (proportion des sujets qui ont déjà présenté le trouble) est de 3% à 6% chez l’homme et 5% à 10% chez la femme. L’estimation du risque morbide (ou risque sur la vie entiére) est plus difficile. Le principal probléme provient de l’effet de cohorte de naissance: il semble que les taux de troubles affectifs majeurs sont en train d’augmenter dans les cohortes nées apres la Seconde Guerre mondiale.

Aussi, les auteurs proposent une estimation des risques sur la vie entiére qui ne peut être que prudente: 6 à 10% chez l’homme, 12 à 20% chez la femme. Ils envisagent aussi l’épidemiologie de la dépression sous l’angle de la mortalité: les troubles affectifs sont associés non seulement à un haut risque de suicide mais aussi à une mortalité générale augmentée.

Epidémiologie de la dépression: données récentes. II — Epidémiologie analytique et épidémiologie d’évaluation

Les données provenant d’études récentes concernant l’épidémiologie analytique et l’épidémiologie d’évauation de la dépression sont examinées.

Au sujet de l’épidémiologie analytique, il peut être conclu de la littérature actuellement disponible que les principaux facteurs de risques pour la dépression majeure sont : a) Sociodémographiques, à savoir : être une femme, être jeune, séparé, divorcé, ou avoir des problèmes conjugaux (les auteurs soulignent en particulier que les différences entre les sexes, concernant la dépression, sont réelles et ne sont pas un artefact lié à la façon de relater les troubles ou au comportement vis-à-vis des soins), b) Environnementaux: facteurs prédisposants (les événements de vie qui surviennent durant l'enfance peuvent prédisposer un individu à la dépression à l’âge adulte) et facteurs précipitants (il y a relation entre la survenue d’événements de vie pendant la vie adulte et le début de la dépression), c) Familiaux: il y a une multiblication par 2 à 5 du taux de dépression majeure chez les parents de premier degré de sujets témoins par rapport à es témoins non malades. L’influence de l’hérédité génétique est supportée par des études de jumeaux et des études adoption, mais une large part de la variance ne peut être expliquée, d) Divers: qui concernent le cycle de reproduc- 10n de la femme (la période du post partum entraîne une augmentation du taux de dépression) et les variations saisonneres (pics au printemps et en automne).

En ce qui concerne l'épidémiologie d’évaluation, il est habituel de distinguer prévention primaire, secondaire et teriaie. Leur dessein est respectivement de diminuer l’incidence de la dépression, la prévalence de la dépression et les isques de chronicité et de la récurrence. Les efforts concernant la prévention primaire ne peuvent avoir qu’un effet imité. Dans le domaine de la prévention secondaire, il peut être conclu que beaucoup de dépressifs ne sont pas diaglostiqués ou ne sont pas traités. La prévention tertiaire a pour dessein de limiter deux risques: la chronicité et la récurence. Le premier pourrait être évalué à 15-20% à chaque épisode. Les facteurs de risques principaux seraient la présence un trouble psychiatrique non affectif ou d’une affection physique, une personnalité névrotique et un faible niveau le traitement. Pour le risque de récurrence, on peut considérer qu’entre 50 et 85% des patients ayant fait un épisode lépressif majeur feront au moins un autre épisode de dépression ultérieurement. Les facteurs de risques pourraient re un Stand nombre d’épisodes antérieurs, un antécédent d’épisode maniaque ou d’hypomanie, l’association à un ésordre psychiatrique non affectif ou à une affection physique, une histoire familiale de maladie affective ou un âge e début tardif.

How do age and major risk factors for mortality interact over the life-course? Implications for health disparities research and public health policy

A critical question in life-course research is whether the relationship between a risk factor and mortality strengthens, weakens, or remains constant with age. The objective of this paper is to shed light on the importance of measurement scale in examining this question. Many studies address this question solely on the multiplicative (relative) scale and report that the hazard ratio of dying associated with a risk factor declines with age. A wide set of risk factors have been shown to conform to this pattern including those that are socioeconomic, behavioral, and physiological in nature. Drawing from well-known principles on interpreting statistical interactions, we show that evaluations on the additive (absolute) scale often lead to a different set of conclusions about how the association between a risk factor and mortality changes with age than interpretations on the multiplicative scale. We show that on the additive scale the excess death risks posed by key socio-demographic and behavioral risk factors increase with age. Studies have not generally recognized the additive interpretation, but it has relevancy for testing life-course theories and informing public health interventions. We discuss these implications and provide general guidance on choosing a scale. Data from the U.S. National Health Interview Survey are used to provide empirical support.

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Studies often conclude that the effect of demographic and behavioral risk factors on mortality weakens with age.

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We show that this conclusion is premature as studies often fail to interpret their findings on the additive scale.

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We show empirically that on the additive scale the excess death risks posed by key risk factors strengthens with age.

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The general pattern of increasing susceptibility by age on the additive scale has not been previously recognized.

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We argue that the pattern has critical implications for sociological theory and public health policy.

Vulnerability, life events and depression amongst Moslem Malaysian women: comparing those married and those divorced or separated

INTRODUCTION

The experiences of married and single mothers were compared in an investigation of psychosocial vulnerability, stress and depression in a community-based study of Moslem mothers in Malaysia. For the first time, a model of vulnerability-provoking agent originally developed by Brown et al. in the UK was tested in a Malaysian context.

METHODS

A cross-sectional study was carried out in the district of Johor Bahru, Malaysia. Of the 1,200 women approached from membership of community associations, 1,002 (84%) completed the questionnaires. Severe life events Recent Life Events Questionnaire (Brugha and Cragg in Acta Psychiatr Scand 82:77-81, 1990) and psychosocial vulnerability (VDQ) (Moran et al. in Br J Clin Psychol 40:411-427, 2001) were used to measure vulnerability factors. Depression was measured by the General Health Questionnaire (GHQ-30) (Havenaar et al. in Soc Psychiatry Psychiatr Epidemiol 43:209-215, 2008).

RESULTS

Single mothers had significantly higher rates of depression than those married (60.5 vs. 39.5%), as well as higher rates of severe life events and Negative Elements in Close Relationships (lack of support and conflict with children). However, married mothers had greater Negative Evaluation of Self. The two vulnerability factors were correlated to each other and to severe life events and social adversity. Logistic regression showed an interaction between severe life events in the material and relationship domains and joint vulnerability for depression outcome. The results are discussed in relation to the low recognition of psychosocial risks for depression in single mothers in Malaysia, as well as lack of appropriate services.

Psychiatric epidemiology

Statisticians working in psychiatric epidemiology regularly confront a variety of problems that are rare in other branches of epidemiology. These problems range from the frequent absence of 'objective' biological markers and consequent reliance on informant and self-reports of considerable fallability, to the perhaps corresponding frequent use of multivariate statistical methods such as latent variable modelling. Equally, such difficulties can be regarded as challenges that offer the statistician a critical role.

Social networks and service utilisation in patients with severe mental illness

In a seminal study, Elizabeth Bott (1957) investigated relationships between family roles and social networks in a small group of families in London. The author was an anthropologist, and the field of social network research, in psychiatry, has received major input from methods of social anthropology. Tolsdorf (1976) investigated social networks of patients with schizophrenia. Since then, many studies have focused different aspects of social networks and social support in patients with psychotic disorders.

Confiding in crisis: gender differences in pattern of confiding among cancer patients

Social support has been identified as a key predictor of psychological morbidity following adverse life-events. However, the majority of the research has focused exclusively on women, despite evidence of significant gender difference in the utilisation and role of social support. To examine gender differences in patterns of confiding crisis, 520 subjects were interviewed within 8 weeks of a cancer diagnosis. Men were as likely as women to have confided their main concern in others (61% mainly or fully confided vs 67% of women, P = 0.308) but were much more likely to have used only one confidante (45% vs 25% of women, P < 0.001) while women made use of a wider circle of family, friends and partner and used more confidantes overall. The results confirm marked gender differences in the utilisation of social support at times of crisis and call into question the extent to which support research using exclusively female samples can be generalized.

Psychiatric morbidity among New Zealand Cambodians: the role of psychosocial factors

A community survey of the relationship between minor psychiatric morbidity and life events, chronic post-migration stressors, social support and coping style among adult Cambodians living in Dunedin was conducted using the 28-item version of the General Health Questionnaire (GHQ-28) as the case identification instrument. Chronic post-migration stressors, life events, poor coping style and poor social support were all associated with minor psychiatric morbidity. Social support or coping style did not moderate the relationship between life events/post-migration stressors and GHQ caseness, but had an independent relationship with the latter.

The neo-Kraepelinian revolution in psychiatric diagnosis

New revisions of diagnostic categories have produced the most recent classification systems, namely DSM-IV and ICD-10. The diagnostic approaches exemplified by these two nomenclatures are very similar to one another and represent a return to descriptive psychiatry in which careful observation of symptoms, signs, and course of mental diseases become the diagnostic criteria themselves. In many ways, these newest classification schemata can be considered a return to phenomenological psychiatry perhaps best exemplified at the start of this century by Emil Kraepelin. Thus, recent developments in psychiatric diagnosis can be thought of as "neo-Kraepelinian". Because they represent a relatively radical change from psychodynamic approaches to evaluation and diagnosis, they can also be called "revolutionary." This paper traces the roots of current diagnostic systems and compares and contrasts these systems to the classification schema described by Kraepelin. Diagnostic criteria for schizophrenia are used as an example of how diagnostic conventions have changed dramatically over the past 50 years. Discussion of the implications of this neo-Kraepelinian revolution in psychiatric diagnosis is included.

Statistics and the nature of depression

A critical examination is made of the role that statistical methods have played in the understanding of depression. The development of instruments for measuring depression is illustrated by reference to the Beck Depression Inventory and the Hamilton Rating Scale. The controversy over the existence of one or two types of depression is examined from the perspective of the statistical tools used. Some of the problems in studies of the heritability of depression are outlined. The development of clinical trials of depression is examined, with particular reference to ECT and maintenance therapy, and the role of meta-analysis is discussed.

Life stress, social support and clinical depression: a reanalysis of the literature

In recent years, theorists and researchers have disagreed about the relationship between social support and mental health. Some believe that support is a direct provoking agent (i.e. lack of support constitutes strain), whereas others maintain that support is a vulnerability factor moderating the effect of life stress. Focusing on clinical depression, the article reviews the arguments and evidence supporting a strain hypothesis of social support versus a vulnerability hypothesis. Reanalyzing cross-classified data from 12 community studies of clinical depression, the study shows that the choice of model depends on the specification of functional form of the stress-clinical depression relationship. The linear probability specification suggests a vulnerability hypothesis, whereas the logit and probit specifications support a strain hypothesis. However, theoretical and statistical arguments tend to favor a logit or probit specification, and an additional analysis of data from Brown and Harris [Social Origins of Depression: A Study of Psychiatric Disorder in Women. The Free Press, New York, 1978] supports these arguments. Thus, the study concludes that the strain hypothesis of social support is more consistent with the available data.

Personality, stress, smoking, and genetic predisposition as synergistic risk factors for cancer and coronary heart disease

Risk factors for cancer have been found in the past to act synergistically in a number of studies. However, these studies were not always designed to test the hypothesis of synergism, and have sometimes failed to equate for important variables, which might influence the results. The present study tests the hypothesis that psychosocial variables and physical ones (personality/stress, smoking, and genetic predisposition) interact in a synergistic fashion in the causation of lung cancer and coronary heart disease (CHD).

The Ryle Marital Patterns Test as a predictor of symptoms of anxiety and depression in couples in the community

The associations between marital relationships, as measured by the Ryle Marital Patterns Test, and symptoms of anxiety and depression as measured by the Interval General Health Questionnaire (I-GHQ), were assessed in 98 married couples in the community. Logistic regression analyses showed that symptoms of anxiety and depression in wives were best predicted by low ratings of affection exchange. Occupational class interacted with husbands' affection ratings, suggesting that in the nonmanual class only lower affection ratings were significantly associated with more symptoms. Anxiety in men was best predicted by low affection ratings while depression was best predicted by unemployment, by an affection discrepancy score indicating that more affection is given than received, and by a marriage which was rated as relatively more wife-dominated by wives and as relatively more husband-dominated by husbands.

In sickness and in health: associations between physical and mental well-being, employment and parental status in a British nationwide sample of married women

Many studies have been published which have examined the relationship between paid employment and women's health. As employment outside the home is likely to have differential effects for women with different family commitments, further analysis taking account of the association between paid employment and household circumstances is necessary. Using data from a large, representative British sample, this paper examines the effects of interactions between paid employment, social class, and parental status on women's health. The results show differential effects of these variables on physical and mental health. The most important influence on women's mental health (as measured by the 30-item General Health Questionnaire) is the age of their youngest child; women with children under five are most likely to show signs of psychological disturbance. With respect to physical health, age of the youngest child has no significant effect, but there is an interaction between employment status and social class. Paid employment, particularly full-time work, is associated with good physical health for middle-class women but not for working-class women.

AIDS survey methodology with black Americans

Unique substantive and methodological issues are involved in conducting survey research on sexual and HIV risk related behaviors among Americans of African descent. Problem conceptualization, sampling, design of instruments, mode of data collection, interviewer/respondent characteristics, community resistance, and data analysis and interpretation are discussed. The lack of survey research on sensitive health issues is noted. Possible methods for addressing these issues are drawn from the experiences of the authors in conducting national research on the general and at risk Black community populations. It is concluded that attention to these issues can substantially improve the quality of research on AIDS related behaviors on Black communities. Finally, it is suggested that behavioral theories and sophisticated methodological and analytic approaches, sensitive to the special cultural dimensions of racial/ethnic life in the United States, would contribute substantially to the scientific armamentarium needed to successfully meet the challenge of the AIDS epidemic.

Models of stress, vulnerability and affective disorder

The concept of vulnerability indicates predisposition to affective disorder; characterised by greater sensitivity to stress but with no added risk in its absence. Mastery, self-esteem and attributional style may be involved but exogenous factors can also act as markers of vulnerability. A follow-up study of a national cohort of 36-year-olds was used to identify endogenous and exogenous vulnerability factors. Financial hardship and childhood risk were implicated for women, and financial hardship and unemployment for men. However, low rates of symptoms for 'stress-free' vulnerable individuals were only observed when chronic cases were excluded from analysis. Two alternative models are suggested: (i) a conditional vulnerability effect with an additional component to account for inception of long-term disorders; (ii) an additive burden model with vulnerability represented as a continuum from 'resilience' to 'susceptibility'. Their differentiation will require greater attention to the measurement of vulnerability and a fuller consideration of the significance of chronic disorders.

The similarities and dissimilarities between community and clinic cases of depression

It has been hypothesised that community cases of depression compared with clinic cases: (a) have fewer symptoms; (b) have milder symptoms; (c) have different symptoms; (d) are of shorter duration; (e) are less incapacitating; (f) are more environmentally and less biologically caused; and (g) respond better to psychological than pharmacological intervention. A review of the literature indicates that some of these hypotheses have not been tested, others have not been adequately tested, and none has been unequivocally confirmed. Further investigations of these important issues are required.

Hosts to adversity. II. Psychiatric sequelae

This article examines the relationship between event rates, demographic and psychosocial factors and the onset of psychiatric disorder according to Research Diagnostic Criteria in the context of a longitudinal general population survey of women. Life events were classified according to ratings of their severity and dependence. Analyses revealed the extent to which case inception was associated with risk factor status, as determined from respondents when psychiatrically well, and the complex interrelationship between the factors according to powerful statistical modelling techniques.

The relationship between depression and hopelessness. Implications for current theories of depression

In both Beck's cognitive theory of depression and Brown & Harris's sociopsychological model, hopelessness is given unwarranted universality and centrality. Empirical evidence contradicting this element of the two theories has been ignored, and two new investigations are presented which suggest the existence of 'non-hopeless' depression. A more complete account of the heterogeneous nature of depression is now required.

Method and technique of life events research in depression and anxiety

Methodological aspects still have a decisive impact on the putative etiological role of life events in clinical research. Questions of a diagnostic nature also serve to complicate this kind of research still further, in this present review in particular, when it deals with depression and/or anxiety. The relationship between life events and disturbed behavior also depends on additional variables, such as personality factors and social support. It is for this reason that detailed specification of the concepts used in life events research would seem to be necessary. And finally--when more than two variables are present--the simultaneous application of a number of statistical models is worthy of recommendation.

Social functioning in community residents with depression and other psychiatric disorders: results of the New Haven Epidemiologic Catchment Area Study

Social functioning was compared among 4913 community participants with current depression, past depression, other psychiatric disorders and no psychiatric history, from the New Haven Epidemiologic Catchment Area Wave I survey. Respondents with current major depressive disorder (1.5%) (based on the Diagnostic Interview Schedule) reported significantly poorer intimate relationships and less satisfying social interactions than respondents with past depression or other current disorders. Respondents with no psychiatric history (77%) reported significantly more active and satisfying social interactions than persons with any psychiatric disorder. These social functioning and depression associations were similar among males and females, and corroborated results from patient samples.

Base-rates, cut-points and interaction effects: the problem with dichotomized continuous variables

On the background of the recent discussion about the appropriateness of linear difference and ratio models for testing interaction effects of social support and stress, it is argued that interaction effects are basically unstable when dichotomized continuous variables are analysed. A data set with known interrelationships of the continuous variables 'stress', 'social support', and 'depression' was simulated and analysed in tabular format. It is shown that the choice of cut-points for the independent variables crucially determines the size and presence of interaction effects in ratio analysis models.

Limitations on the use of scales in psychiatric research

This paper discusses some issues involved in the construction and interpretation of scales in psychiatric research. The issues covered include scale construction, measures of scale homogeneity, the logic of factor analysis and the interpretation of effects manifesting in scale-data, especially interaction effects. The aim of the paper is to "de-mystify" some of the psychometric techniques commonly available, and to emphasize that their appropriate use depends on both a firm understanding of the content area to which they are applied and a rudimentary knowledge of what the methods purport to do.

Childhood loss of parent, lack of adequate parental care and adult depression: a replication

A study of women living in Islington has confirmed earlier findings that the loss of a mother before the age of 17 (by death or separation) is associated with an increase in clinical depression in adulthood. Lack of adequate parental care following the loss accounted for the increase in disorder and there was some evidence that it acted as a 'vulnerability factor' increasing risk of onset of depression during a 1-year follow-up period, in the presence of a severe life event or major difficulty. Premarital pregnancy, marital separation/divorce and negative evaluation of self were identified as factors intervening between childhood lack of care and adult depression.

The buffer theory of social support--a review of the literature

The buffer theory postulates that social support moderates the power of psychosocial adversity to precipitate episodes of illness. In this paper, we review the theory as applied to minor affective disturbances. Research in this area suffers because of the many disparate conceptualizations of social support and the resulting difficulty of deciding on the content of measures. Moreover, the meaning of the term buffering is itself unclear. These problems have not, however, inhibited research, and many cross-sectional and longitudinal studies have now been carried out. Our review leads to the conclusion that evidence for a buffering role of social support is inconsistent, reflecting methodological differences between studies but probably also indicating that buffering effects are not of dramatic proportions. Moreover, it is possible that the observed relationships are the result of spurious association or contamination of measures.

Social support, self-esteem and depression

A prospective study of 400 largely working-class women with children living at home has used measures of self-esteem and 'social support' to predict the risk of depression in the following year once a stressor had occurred. Actual support received at the time of any crisis in the follow-up year was also measured. Self-esteem was correlated quite highly with some of the measures of support. A core tie was defined as a husband, lover or someone named as very close at first contact. Negative evaluation of self (i.e. low self-esteem), and various indices of lack of support from a core tie at the first interview, were associated with a greatly increased risk of subsequent depression once a stressor occurred. Lack of support from a core tie at the time of the crisis was particularly highly associated with an increased risk. There was also a high risk among those who were 'let down' - that is, for those who did not receive the support which they might have expected in terms of the first interview material. It is concluded that it is essential for prospective enquiries to take account of the actual mobilization of support in the follow-up period.

Simultaneous multiple comparison procedures for categorical data

Methods are outlined for performing simultaneous multiple comparisons between groups when the dependent variable is one in which subjects are assigned to one of two or more categories. These methods provide tests which are analogous to Scheffe- and Bonferroni-adjusted tests of contrasts in the analysis of variance. Examples are provided of each of these procedures.

Psychosocial variables and the life event/anxiety-depression link. A community study

Attention has shifted from the simple association between life events and psychological disturbance towards more complex models. Additional variables which may modify this simple association include personality factors, the nature and extent of social relationships, "vulnerability" factors and general coping skills. Four hypotheses concerning the influence of additional variables were described and their clinical relevance discussed. A general population study of 408 individuals was described. The influence of additional variables on the simple association between stressful life events and "anxiety-depression" was examined, using a hierarchical regression model. A range of demographic, personality, "vulnerability" and social relationship variables were considered in these analyses. The relevance of these results for our understanding of life events was discussed.

Self-esteem, vulnerability and psychiatric disorder in the community

One hypothesis concerning the nature of the link between negative self-appraisal and certain psychological disorders is that low self-esteem may be a consequence of both early and current experiences, and may predispose to breakdown. An alternative view is that the negative self-concept is only to be found in the presence of illness, which is the primary cause. Results are reported from a community survey, confirming the influence of certain biographical factors on self-esteem in the absence of illness, whereas other factors appear to operate only after the onset of illness. Anxiety as well as depression, has effects on self-esteem.

Social origins of major depression: the rôle of provoking agents and vulnerability factors

An examination of the Brown-Harris etiological model of depressive disorder was accomplished by analyzing data from a community study of 800 middle-aged urban Swedish women. The sample included 53 onset cases of major depressive episode (DMS-III) in a 1-year period. In the analysis, interaction was defined according to the additive model employed by Brown & Harris. Occurrence of provoking agents was not significantly related to onset of depressive episode. None of the four vulnerability factors of the model showed significant interaction with provoking agents as expected from the model. One of them, lack of intimacy, increased significantly the risk of major depression in its own right, i.e. in the absence of provoking agent. Possible explanations for the major discrepancies of results between the original Camberwell study and the present one are briefly discussed.

Social support and stressful life events during mid-life

Life events have been shown to produce psychological distress in women during mid-life. It has been argued that social relationships may modify the detrimental effects of life events and/or have a direct influence on psychological well-being. This paper examined the influence of eight social relationship variables on 'psychological' and 'somatic' distress in a general population sample of women at mid-life. Several of the social relationship variables were shown to be important. The availability of individuals in whom the subject could confide was of particular importance. It is argued that the results confirm the importance of psychosocial factors in producing psychological distress during mid-life.

Interpreting data in aetiological studies of affective disorder: some pitfalls and ambiguities

Although recent research in social psychiatry has produced an encouraging congruence of findings and conclusions, puzzling inconsistencies continue to be reported. One explanation which is often overlooked is that subtle differences in the way seemingly identical variables are grouped can produce sizeable, and sometimes dramatic, differences in the patterning of the same data. Re-examination of existing results can therefore often better clarify confusing inconsistencies than collection of new data. This is illustrated by examples from recent studies of affective disorder where the grouping of variables is discussed in three broad areas: parental loss in childhood, precipitating stress, and social support. Until the aetiology of affective disorder is more fully understood, it will often be clearer if data are analysed more than once, so that several combinations of variables are systematically examined.

Life events and physical illness

This paper reviews research on the role of stressful life events in the aetiology of physical illness. Particular attention is given to the methodological problems involved in the identification and measurement of life events. There has been insufficient sound research for firm conclusions to be drawn but prospective studies make it clear that assessment of life events will lead to a more complete understanding of how psychosocial factors interact with bodily functioning. Future research studies will need to be based on an interactional model.

Marital intimacy and depression

Recent research has suggested that the absence of an intimate, confiding relationship may be a vulnerability factor in the development of depression in women living under adverse circumstances. This study demonstrates a significant association between severity of depression and deficiencies of marital intimacy; depressed patients with the lowest levels of marital intimacy failed to improve at one month follow-up, while 36% of the spouses of the depressed patients had symptoms of non-psychotic emotional illness. The depressed patients and their spouses' perception of their marital intimacy differ, but these differences appear not to be solely related to the spouse's depression.

Family therapy with the elderly mentally ill. Some strategies and techniques

Over a six month period, 142 consecutive referrals of patients over 65 to a community-orientated psycho-geriatric service in North London were studied. The psycho-social factors determining referral were quantified and their relationship to diagnosis analysed. Therapeutic strategies are described, devised to deal with the presenting psycho-social problems. It is suggested that a family-centred approach is of some value in the management of the elderly mentally ill.