[Construct validation study of the Relationship Scales Questionnaire (RSQ) on an adult sample]. / La version française du Relationship Scales Questionnaire de Bartholomew (RSQ, Questionnaire des échelles de relation): étude de validation du construit.

INTRODUCTION: The authors present the construct validity of the French version of the Relationship Scales Questionnaire (RSQ) designed by Griffin and Bartholomew (1994), which is the most widely-used self-report concerning adult attachment. OBJECTIVES: To improve knowledge on the psychometric properties of the RSQ by studying the construct validity on a sample of adults. METHOD: Subjects were recruited in a primary social care setting in Paris, France, and asked to fill in the RSQ twice: the first time just before meeting the social worker in charge, the second time, at home, with a prestamped form, two days later. A questionnaire on sociodemographic and economic variables was also filled in during the first time. Statistical analyses were conducted using Exploratory Factor Analysis with orthogonal rotation. The reliability was studied using Cronbach's coefficient for each new scale from the factor analysis. The test-retest reliability was studied for the prototypic scales and for the scales from the factor analysis, using the intra-class correlation method. RESULTS: One hundred and twenty-six subjects were recruited and completed the two forms (mean interval: 2.16 days). The factor analysis gives a three-factor structure explaining 48% of the total variance. The three factors were: factor 1 "Avoidance" with seven items explaining 21% of the total variance; factor 2 "Anxiety in the relationships" (five items) explaining 14% of total variance and factor 3 "Security" (five items) explaining 11% of the total variance. Cronbach's coefficient was low for the prototypical scales (0.41 for "secure", 0.54 for "fearful", 0.22 for "preoccupied", and moderate for "dismissive" (0.64). It was moderate for the scales designed from the factor analysis (0.66 for F1, 0.69 for F2 and 0 .60 for F3). The Intraclass Coefficients (ICC) were modest for the four prototypical scales (ICC<0.70) and were good for the scales designed from the factor analysis (F1: ICC=0.80; F2: ICC=0.85 and F3: ICC=0.78). DISCUSSION: The construct validity studied on an adult sample confirms the good psychometric properties of the RSQ considering the factor analysis, the test-retest short time reliability and the internal consistency. The factor analysis with three factors provides a different structure of classical descriptions with only two factors, but confirms the most recent results on Attachment Self-Reports that find a factor concerning security and two factors concerning management of insecurity (avoidance and anxiety in relationships). To be confirmed, the results require further research (confirmatory factor analysis, larger sample, other type of population).

Caribbean nurses migrating to the UK: a gender-focused literature review.

BACKGROUND: International nurse recruitment is an integral part of government health care strategy in many countries. However, the gendered implications of nurse migration have been little explored despite the fact that the nursing workforce is predominantly made up of women. AIM: Based on the migration of nurses from the English-speaking Caribbean region to the UK, this paper explores the significance of gender at both the macro and micro levels. METHODS: Four strands of inquiry were explored: nurse migration, impact on development, work experiences and family life. Key terms were used to search the electronic databases SSCI, EBSCO and JSTOR. An interpretative framework based on the feminist theory of intersectionality was used to systematically review the 15 studies that met the inclusion criteria. FINDINGS: Gender issues are significant across all aspects of the migratory process. Migrant nurses contribute to social progress through remittances and knowledge gained abroad although overall, nurse migration negatively impacts development and there are hidden implications for women. For some Caribbean nurses, migration reflects increased economic freedom; however, for others, gender inequality lies at the centre of the decision to relocate. Gender inequality also permeates the lives of many migrant nurses even in countries where economic and work conditions are improved. CONCLUSIONS: The ramifications of nurse migration cannot be fully understood without attention to gender inequalities and the specific socio-economic contexts in which they exist. There is need for a gender-centred approach to international nursing recruitment policy that takes account not only of the impact on developing countries, but also of the well-being of migrant nurses themselves.

The childhood experience of care and abuse questionnaire (CECA.Q): validation in a community series.

BACKGROUND: Childhood neglect and abuse, as measured by retrospective interview, is highly predictive of psychiatric disorder in adult life and has an important role in aetiological models. However, such measures are labour-intensive, costly, and thus restricted to relatively modest sample sizes. A compact self-report assessment of childhood experience is invaluable for research screening purposes and large-scale survey investigation. METHOD: A self-report questionnaire (CECA.Q) was developed to mirror an existing validated interview measure: the childhood experience of care and abuse (CECA). The questionnaire assessed lack of parental care (neglect and antipathy), parental physical abuse, and sexual abuse from any adult before age 17. A high-risk series of 179 London women were interviewed using the CECA together with the PSE psychiatric assessment, and completed the CECA.Q at later follow-up. Repeat CECA.Qs were returned for 111 women and 99 women additionally completed the parental bonding instrument (PBI; Parker, Tupling, & Brown, 1979). RESULTS: Satisfactory internal scale consistency was achieved on the CECA.Q for antipathy (alpha = .81) and neglect (alpha = .80) scales. There was satisfactory test-retest for both care and abuse scales. Significant associations were found between CECA.Q scales and the parallel interview scales with cut-offs determined for high sensitivity and specificity. CECA.Q neglect and antipathy scales were also significantly related to PBI parental care. CECA.Q scales were significantly related to lifetime history of depression. Optimal cut-off scores revealed significant odds ratios (average of 2) for individual scales and depression. When indices were compiled to reflect peak severity of each type of adversity across perpetrator, odds-ratios increased (average 3). A dose-response effect was evident with the number of types of neglect/abuse and rate of lifetime depression. CONCLUSION: The CECA.Q shows satisfactory reliability and validity as a self-report measure for adverse childhood experience. The merits of having parallel questionnaire and interview instruments for both research and clinical work are discussed.

Contextual Assessment of the Maternity Experience: development of an instrument for cross-cultural research.

BACKGROUND: There is evidence that stressors may trigger the onset of a depressive episode in vulnerable women. A new UK interview measure, the Contextual Assessment of the Maternity Experience (CAME), was designed to assess major risk factors for emotional disturbances, especially depression, during pregnancy and post-partum. AIMS: With in the context of a cross-cultural study, to establish the usefulness of the CAME, and to test expected associations of the measure with characteristics of the social context and with major or minor depression. METHOD: The CAME was administered antenatally and postnatally in ten study sites, respectively to 296 and 249 women. Affective disorder throughout pregnancy and up to 6 months postnatally was assessed by means of the Structured Clinical Interview for DSM-IVAxis I Disorders. RESULTS: Adversity, poor relationship with either a partner or a confidant, and negative feelings about the pregnancy all predicted onset of depression during the perinatal period. CONCLUSIONS: The CAME was able to assess major domains relevant to the psychosocial context of the maternity experience in different cultures. Overall, the instrument showed acceptable psychometric properties in its first use in different cultural settings.

Maternal attachment style and depression associated with childbirth: preliminary results from a European and US cross-cultural study.

BACKGROUND: Insecure attachment style relates to major depression in women, but its relationship to depression associated with childbirth is largely unknown. A new UK-designed measure, the Attachment Style Interview (ASI), has potential for cross-cultural use as a risk marker for maternal disorder. AIMS: To establish there liability of the ASI across centres, its stability over a 9-month period, and its associations with social context and major or minor depression. METHOD: The ASI was used by nine centres antenatally on 204 women, with 174 followed up 6 months postnatally. Interrater reliability was tested and the ASI was repeated on a subset of 96 women. Affective disorder was assessed by means of the Structured Clinical Interview for DSM-IV. RESULTS: Satisfactory interrater reliability was achieved with relatively high stability rates at follow-up. Insecure attachment related to lower social class position and more negative social context. Specific associations of avoidant attachment style (angry-dismissive or withdrawn) with antenatal disorder, and anxious style (enmeshed or fearful) with postnatal disorder were found. CONCLUSIONS: The ASI can be used reliably in European and US centres as a measure for risk associated with childbirth. Its use will contribute to theoretically under pinned preventive action for disorders associated with childbirth.

The Vulnerable Attachment Style Questionnaire (VASQ): an interview-based measure of attachment styles that predict depressive disorder.

BACKGROUND: The Vulnerable Attachment Style Questionnaire (VASQ) was developed to provide a brief self-report tool to assess adult attachment style in relation to depression and validated against an existing investigator-based interview (Attachment Style Interview--ASI). This paper describes the development and scoring of the VASQ and its relationship to poor support and major depression. METHOD: Items for the VASQ reflected behaviours, emotions and attitudes relating to attachment relationship style, drawn directly from the ASI. The VASQ was validated against the ASI for 262 community-based subjects. Test-retest was determined on 38 subjects. RESULTS: Factor analysis derived two factors, labelled 'insecurity' and 'proximity-seeking'. The VASQ insecurity dimension had highest mean scores for those with interview-based Angry-dismissive and Fearful styles and was significantly correlated with degree of interview-based insecurity. The proximity-seeking VASQ scores had highest mean for those with Enmeshed interview attachment style and was uncorrelated with ASI insecurity. VASQ scores were highly correlated with a well-known self-report measure of insecure attachment (Relationship Questionnaire) and text-retest reliability of the VASQ was satisfactory. The total VASQ score and the insecurity subscale proved highly related to poor support and to depressive disorder. This was not the case for the proximity-seeking subscale. CONCLUSION: The VASQ is a brief self-report measure that distinguishes individuals with attachment styles vulnerable for depressive disorder. The use of the measure for screening in research and clinical contexts is discussed.

Childhood adversity, parental vulnerability and disorder: examining inter-generational transmission of risk.

BACKGROUND: An investigation of intergenerational factors associated with psychiatric disorder in late adolescence/early adulthood was undertaken to differentiate influences from maternal disorder, maternal poor psychosocial functioning and poor parenting, on offspring. METHOD: The sample comprised an intensively studied series of 276 mother-offspring pairs in a relatively deprived inner-city London area with high rates of lone parenthood and socio-economic disadvantage. The paired sample was collected over two time periods: first a consecutively screened series of mothers and offspring in 1985-90 (n = 172 pairs) and second a 'vulnerable' series of mothers and offspring in 1995-99 (n = 104 pairs). The vulnerable mothers were selected for poor interpersonal functioning and/or low self-esteem and the consecutive series were used for comparison. Rates of childhood adversity and disorder in the offspring were examined in the two groups. Maternal characteristics including psychosocial vulnerability and depression were then examined in relation to risk transmission. RESULTS: Offspring of vulnerable mothers had a fourfold higher rate of yearly disorder than those in the comparison series (43% vs. 11%, p < .001). They were twice as likely as those in the comparison series to have experienced childhood adversity comprising either severe neglect, physical or sexual abuse before age 17. Physical abuse, in particular, perpetrated either by mother or father/surrogate father was significantly raised in the vulnerable group. Analysis of the combined series showed that maternal vulnerability and neglect/abuse of offspring provided the best model for offspring disorder. Maternal history of depression had no direct effect on offspring disorder; its effects were entirely mediated by offspring neglect/abuse. Maternal childhood adversity also had no direct effect. CONCLUSIONS: Results are discussed in relation to psychosocial models of risk transmission for disorder. Maternal poor psychosocial functioning needs to be identified as a factor requiring intervention in order to stem escalation of risk across generations.

Adult attachment style. I: Its relationship to clinical depression.

BACKGROUND: Although there are an increasing number of studies showing an association of adult attachment style to depressive disorder, such studies have rarely utilised epidemiological approaches with large community-based series and have relied heavily on brief self-report measurement of both attachment style and symptoms. The result is a wide inconsistency in the type of insecure style shown to relate to disorder. The present study examined adult attachment style in a high-risk community sample of women in relation to clinical depression. It utilised an interview measure of adult attachment which allowed for an assessment of both type of attachment style and the degree of insecurity of attachment. A companion paper examines its relationship with other depressive-vulnerability (Bifulco et al. 2002). METHOD: Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. A global scale of attachment style based on supportive relationships (with partner and very close others) together with attitudes to support-seeking, derived the four styles paralleling those from self-report attachment assessments (Secure, Enmeshed, Fearful, Avoidant). In order to additionally reflect hostility in the scheme, the Avoidant category was subdivided into 'Angry-dismissive' and 'Withdrawn'. The degree to which attitudes and behaviour within such styles were dysfunctional ('non-standard') was also assessed. Attachment style was examined in relation to clinical depression in a 12-month period. For a third of the series this was examined prospectively to new onset of disorder. RESULTS: The presence of any insecure style was significantly related to 12-month depression. However, when controls were made for depressive symptomatology at interview, only the 'non-standard' levels of Enmeshed, Fearful or Angry-dismissive styles related to disorder. Withdrawn-avoidance was not significantly related to disorder. CONCLUSION: The relationship of attachment style to clinical depression is increased by differentiating the degree of insecurity of style and differentiating hostile and non-hostile avoidance.

Adult attachment style. II: Its relationship to psychosocial depressive-vulnerability.

BACKGROUND: A range of studies show adult attachment style is associated with depressive-vulnerability factors such as low self-esteem, poor support and childhood adversity. However, there is wide inconsistency shown in the type of insecure style most highly associated. Few studies have examined attachment style in relation to clinical depression together with a range of such factors in epidemiological series. The present study uses an interview measure of adult attachment which differentiates type of attachment style and degree of insecurity of attachment, to see: (a) if it adds to other vulnerability in predicting depression and (b) if there is specificity of style to type of vulnerability. METHOD: Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. The Attachment Style Interview (ASI) differentiated five styles (Enmeshed, Fearful, Angry-dismissive, Withdrawn and Standard) as well as the degree to which attitudes and behaviour within such styles were dysfunctional ('non-standard'). Attachment style was examined in relation to low self-esteem, support and childhood experience of neglect or abuse, and all of these examined in relation to clinical depression in a 12-month period. RESULTS: The presence of any 'non-standard' style was significantly related to poor support, low self-esteem and childhood adversity. Some specificity of type of style and type of vulnerability was observed. Logistic regression showed that non-standard Enmeshed, Fearful and Angry-dismissive styles, poor support and childhood neglect/abuse provided the best model for clinical depression. CONCLUSION: Non-standard attachment in the form of markedly Enmeshed, Fearful or Angry-dismissive styles was shown to be associated with other depressive-vulnerability factors involving close relationships, self-esteem and childhood adversity and added to these in modelling depression.

Childhood Experience of Care and Abuse Questionnaire (CECA.Q). Validation of a screening instrument for childhood adversity in clinical populations.

BACKGROUND: Interview measures for investigating adverse childhood experiences, such as the Childhood Experience of Care and Abuse (CECA) instrument, are comprehensive and can be lengthy and time-consuming. A questionnaire version of the CECA (CECA.Q) has been developed which could allow for screening of individuals in research settings. This would enable researchers to identify individuals with adverse early experiences who might benefit from an in-depth interview. This paper aims to validate the CECA.Q against the CECA interview in a clinical population. METHODS: One hundred and eight patients attending an affective disorders service were assessed using both the CECA interview and questionnaire measures. A follow-up sample was recruited 3 years later and sent the questionnaire. The questionnaire was also compared with the established Parental Bonding Instrument (PBI). RESULTS: Agreement between ratings on the interview and questionnaire were high. Scales measuring antipathy and neglect also correlated highly with the PBI. The follow-up sample revealed the questionnaire to have a high degree of reliability over a long period of time. CONCLUSIONS: The CECA.Q appears to be a reliable and valid measure which can be used in research on clinical populations to screen for individuals who have experienced severe adversity in childhood.

Predicting onset of depression: the Vulnerability to Depression Questionnaire.

OBJECTIVES: The development of a self-report questionnaire capable of assessing cognitive and interpersonal vulnerability factors for clinical depression is described. The Vulnerability to Depression Questionnaire (VDQ) was developed to provide a brief, economical alternative to the Self-Evaluation and Social Support interview (SESS; O'Connor & Brown, 1984), assessing negative evaluation of self, negative interaction with partner or child and lack of a support figure. DESIGN: The VDQ was tested in a prospective study of community-based women who were contacted on three occasions over the course of approximately 1 year, to: (i) compare the VDQ's capacity to categorize vulnerability compared with the SESS interview, and (ii) to test the VDQ's prediction of onset of clinical depression during the follow-up. METHOD: Selected nondepressed respondents completed the VDQ and were interviewed to determine their vulnerability using the SESS. They were re-interviewed on two further occasions during the follow-up period, and the VDQ was also re-administered at the time of first follow-up. Onset of clinical depression during the follow-up was assessed by interview at each contact. RESULTS: Comparison of VDQ and SESS interview classification of participants' vulnerability at first contact indicated that the questionnaire had good sensitivity and specificity. Test-retest scores for the VDQ indicated satisfactory levels of reliability. VDQ scores also predicted onset of clinical depression in the follow-up period. CONCLUSIONS: Results suggest that the VDQ is an economical and effective means of screening large populations for the purposes of risk assessment, to aid future research into clinical depression and to facilitate the implementation of intervention strategies.

Lifetime stressors and recurrent depression: preliminary findings of the Adult Life Phase Interview (ALPHI).

BACKGROUND: The well-established association between stress and depression is explored in a lifespan context in relation to adverse childhood experience. A new retrospective interview instrument, the Adult Life Phase Interview (ALPHI) examined the number of chronic stressors (or 'adversities') experienced over the adult life course in relation to chronic or recurrent clinical depression. The role of such lifetime adversity in mediating the relationship between childhood neglect/ abuse and adult disorder was examined. METHOD: The ALPHI uses an investigator-based, contextual approach suited to retrospective and time-linked enquiries. Reliability of the instrument was found to be satisfactory. Its association with both lifetime clinical depression and childhood neglect or abuse was examined in a community series of 198 women, consisting of 99 sister pairs, where one-half of the series was selected for having had adverse childhood experience and the other for comparison. RESULTS: Adult adversity, both at settled/fixed times and at times of major life change, was significantly higher among those with prior childhood neglect or abuse. Both a high adult adversity score and childhood neglect or abuse were related to chronic or recurrent episodes of clinical depression, with logistic regression indicating both indices contributed independently to disorder. The same results held when controls were made for sister status, given possible familial bias in experience, and for age, since women under age 25 had fewer adult phases and less adversity. CONCLUSIONS: Characteristics of adult life phases and change-points are described and the relevance of the measure for intensive survey work seeking to investigate relationships between lifespan experience and depression is discussed.

Predicting depression in women: the role of past and present vulnerability.

BACKGROUND: A prospective study, covering just over a 1-year period, sought to confirm an earlier finding that around 40% of women who experience a severe life event in the presence of two ongoing psychosocial vulnerability factors, (negative close relationships and low self-esteem) will develop a major depressive episode. Distal risk factors were examined to see if they improved prediction. METHODS: A population sample of 105 mainly working-class mothers with vulnerability and without depression were interviewed three times over a 14-month period to date the occurrence of severe life events and onset of major depression. Degree of vulnerability was assessed at first contact together with distal risk in terms of childhood neglect/abuse and any earlier episodes of depression. RESULTS: Thirty-seven per cent of these vulnerable women became depressed in the study period. The majority experienced a severe life event, and of these, 48% had onsets. Contrary to expectation, risk was only a little less among those with just one of the two vulnerability factors. Two-thirds of women with an onset had been depressed in previous years. Although this was associated with increased risk, the effect was greatest for those who had experienced an episode before age 20. A relationship between childhood neglect/abuse and onset was entirely accounted for by such early depression. CONCLUSION: An aetiological model of depression outlined in earlier research was confined with a new factor of teenage depression shown to increase risk of onset.

Memories of childhood neglect and abuse: corroboration in a series of sisters.

Reports from 87 community-based sister-pairs, selected for high rates of neglect or abuse in childhood, have been used to establish validity of the CECA, a retrospective interview measure of childhood experience. Corroboration was based on independent assessments of sisters' accounts of what happened to each other in childhood. Corroboration of scales assessing parental neglect, physical abuse in the household and sexual abuse (either household or nonhousehold) was satisfactory, with a mean correlation for the three experiences of .60 (weighted kappa [Kw]). Concordance reflected the degree to which experience was shared and was judged by comparing the sisters' accounts of their own experience. Among sisters with shared (concordant) experience for neglect or abuse, corroboration was high (mean of .74), but for those with nonshared (nonconcordant) experience it was largely absent (mean of .01). The degree to which the experiences of neglect or abuse were concordant was related to whether the perpetrator was a member of the household. Neglect and physical abuse were by definition from household members (mainly parents) and involved high concordance of experience. Sexual abuse occurred from many sources and in practice was commonly from an adult living outside the household and such experiences were less likely to be shared by sisters. An overall index indicating the presence of at least one abusive experience before the age of 17 showed a concordance of .64 with corroboration between sisters as high as .70. Issues involving retrospective recall and measurement are discussed.

Cognitive coping response to crises and onset of depression.

This paper consider the relationship between cognitive coping responses to severe life events and related difficulties and the risk of onset of case depression in a sample of 150 mothers living in Islington, North London. A period between a first interview and a followup interview 12 months later was covered, and any onset in the follow-up period examined. Three types of 'negative' cognitive response to a severe life event/difficulty complex were related to an increased risk of depression. These were inferred denial, self-blame and pessimism. One 'positive' cognitive factor, that of downplaying, was inversely related to onset. A negative cognitive response to crises was found to be associated with the most serious of the events, defined by their match with an ongoing marked difficulty. However, both matching severe events and a negative cognitive response were required to model onset of depression. Negative cognitive coping responses were also related to type of event: all were related to crises involving partners. In addition, self-blame was associated with crises involving children's behaviour, and there was some evidence that denial was related to pregnancy/birth crises, and pessimism, to health/death crises. A negative cognitive response was also associated with other risk factors such as prior vulnerability and failure to receive support in the crisis. However, when these were taken into account a negative response to a crisis was still required in modelling onset of depression. Issues of possible bias are addressed.

Childhood Experience of Care and Abuse (CECA): a retrospective interview measure.

The development of a retrospective, investigator-based interview measure of Childhood Experience of Care and Abuse (CECA) used with two community samples of adults in London is described. The component ratings are shown to have satisfactory inter-rater reliability and also validity as determined by agreement between sisters' independent accounts. The association between the different childhood scales is explored as well as the relationship of childhood experiences to adult depression. Methodological issues concerning investigator-based versus respondent-based measures of childhood are discussed and a case made for use of the former. Advantages of using the CECA, a retrospective, time-based measure of childhood, are outlined.

Social factors and recovery from anxiety and depressive disorders. A test of specificity.

Analysis of 33 instances of recovery or improvement among 92 women with anxiety, and 49 instances of recovery and improvement among 67 episodes of depression, showed that recovery and improvement, when compared with conditions not changing, were associated with a prior positive event. Such events were characterised by one or more of three dimensions: the 'anchoring' dimension involved increased security; 'fresh-start', increased hope arising from a lessening of a difficulty or deprivation; and 'relief', the amelioration of a difficulty not involving any sense of a fresh start. Events characterised by anchoring were more often associated with recovery or improvement in anxiety, and those characterised as fresh-start were associated with recovery or improvement in depression. Recovery or improvement in both disorders was more likely to be associated with both anchoring and fresh-start events. The study involved the reworking of some social and clinical material, and although done blind should be seen as exploratory.

Early sexual abuse and clinical depression in adult life.

Sexual abuse in childhood and adolescence was studied in 286 working-class mothers living in Islington, who were contacted on three occasions over a two-year period. The sample was collected primarily to study current vulnerability factors in the onset of depression, but childhood measures were also included to look at longer-term risk factors. Twenty-five women - 9% of the sample - reported sexual abuse involving physical contact before age 17 and, of these, 64% had case depression in a three-year period (which included the year before first interview). While such abuse was related to other earlier stressful experiences such as parental indifference, violence to the child and institutional stay, it was associated with an increased risk of depression over and above these factors. Sexual abuse before age 17 also related to having been divorced/separated or never having married/cohabited.

Self-esteem and depression. II. Social correlates of self-esteem.

The Self-Evaluation and Social Support Schedule (SESS), an interview-based instrument, is described, which aims to give a comprehensive description of a person's social milieu in terms of 'objective' and 'subjective' measures. On the basis of a population survey of 400 largely working-class women, a tentative causal model is developed which relates both the quality of current interpersonal ties and childhood experiences to current negative and positive measures of self-esteem. A major purpose of the exercise is to develop positive and negative indices of the social environment that can be used to elucidate the aetiological role of self-esteem in the development of depression. This is the task of a third paper.

Self-esteem and depression. III. Aetiological issues.

This is the last of a series of three papers dealing with the role of self-esteem in the onset of clinical depression. On the basis of a longitudinal population enquiry a comprehensive psychosocial model of depression is developed. It is concluded that self-esteem (primarily in terms of a negative measure) does play a significant role. However, this can be only properly interpreted in the light of the full model. This highlights: 1. the importance of the occurrence of both a negative environmental factor (negative interaction with children or husband for married or negative interaction with children or lack of a very close tie for single mothers) and a negative psychological factor (low self-esteem or chronic subclinical condition); and 2. how a relatively small group of high risk women in these terms (23% of total at risk based on measures collected well before any onset) contain three-quarters of all instances of onset of depression occurring over a 12 month period.