Eugene Stern Paykel, one of the most influential psychiatrists of the past century, died in 2023 after a brief illness. He was born in Auckland, New Zealand, in 1934. He received his medical degree at the University of Otago Medical School, and he then travelled to the UK via the Panama Canal as a doctor on a cargo ship. Once in London, he first chose internal medicine, followed by psychiatric training at the Maudsley Hospital in London. He then moved to Yale University where he performed landmark and seminal research in depression. He went back to England to St. George’s Hospital Medical School in London, where he became full professor. From 1985 to 2001, he was Head of the Department of Psychiatry at the University of Cambridge. In 1979, with George Winokur, he founded the first journal specifically devoted to mood and anxiety disorders (the Journal of Affective Disorders), which he edited until 1993. The following year, he became editor-in-chief of Psychological Medicine, and he continued in that role until 2006. After his retirement, he joined the editorial board of Psychotherapy and Psychosomatics and provided valuable advice to the journal (Fig. 1).

Fig. 1.

Eugene S. Paykel

His contributions and personal mentorship were an important part of my career. My correspondence with him started in the mid seventies, when I was a medical student who was assigned an MD thesis on life events and ulcerative colitis. I wrote to him because I had read his study on life events and depression [1], and I was hoping to get some advice about addressing the topic. I received a big envelope with his comments, reprints of several publications, and his life event scale [1]. I started using his scale and studying (not simply reading) his reprints, which had beautiful covers that demanded respect and humility. I wrote back, and we started a correspondence that lasted nearly 50 years. He became one of my mentors. When in the late nineties he invited me to give a lecture in Cambridge. I started my talk by saying that I considered myself as one of his students, even though I never received formal training from him. He smiled (and his smile was always so warm and enlightening) and consented.

Eugene Stern Paykel (Gene for his friends) created a revolution in life event research. He developed, at a time when the field was dominated by self-rated methods, the Interview for Recent Life Events (IRLE) [2], covering 63 recent life changes related to work, education, finance, health, bereavement, migration, family, and social relationships. Events were categorized as entrances/exits from the social field, desirable and undesirable events, controlled and uncontrolled events. The rater was also called to judge the objective negative impact of an event (the degree of impact the event would be expected to bring to bear on someone when its full nature and particular circumstances are taken into account), that is the contextual threat of the event [2]. By using the IRLE as a young psychiatrist in the eighties, both in clinical investigations and in my practice, I became aware of the fact that a simple open question (“Did anything happen to you recently?”) was insufficient to get adequate information about a person’s life setting. Collecting the various events allowed me to have an idea of what was going on in a person’s life. I also learned to pay attention to the symptomatic development of psychiatric and medical disorders (which symptom occurred first?) since the area to be explored had to be concerned with the time preceding illness onset. Use of IRLE allowed to substantiate a link between life events and vulnerability to medical or psychiatric illness in a number of well-controlled investigations [2]. Indeed, the findings of Paykel’s original study [1] were fully replicated in other investigations, to an extent that is seldom found in psychiatric research [2]. In my clinical practice, instead of using the full interview, I often chose the items that seemed to be relevant to the individual case.

In addition to his original investigation on life events and depression [1], two studies were particularly influential to me. One was concerned with the causative role of life events in relapse of depression [3]. In a controlled investigation, antidepressant drugs were not found to provide protection. From that study, I learned to pay attention to the life setting before relapse and to the fact that in many cases, a recurrence does not occur out of a clear sky. It is astonishing how research on treatment resistance in depression today completely neglects the psychosocial context of individuals, and, not surprisingly, therapeutic efforts are likely to yield limited, if any, lasting relief [4]. Another important investigation he authored was concerned with life events, social support, and postpartum depression, that were found to be strongly associated [5]. From that investigation, I learned that in postpartum depression we need to pay attention to what went on during pregnancy in terms of life events and social support. The key to understanding the development of depression is there, and treatment should address those stressful life circumstances.

In 1993, McEwen and Stellar [6] introduced the concept of allostatic load as the cost of chronic exposure to fluctuating or heightened neural or neuroendocrine responses resulting from repeated or chronic environmental challenges that an individual reacts to as being particularly stressful. The notion of allostatic load provided a synthesis of the cumulative effects of experiences in daily life that involve chronic stress, life events, as well as work, unemployment, adverse living conditions, social and educational experiences, and income inequality throughout the life span [7]. It was then clear to me that allostatic load was an expansion and refinement of the concept of objective negative impact of Paykel’s IRLE [2]. Its initial determination however was restricted to biomarkers that express a state of body systems and ignore the environmental circumstances [8, 9]. Paykel’s IRLE was developed before the definition of the field of clinimetrics, the science of clinical measurements [10, 11]. Yet, it had all characteristics that pertained to a clinimetric index instead of a psychometric tool [11]. Clinimetrics provided a leading direction for research on allostatic load [12]. A first step was the development of the Psychosocial Index (PSI) [13, 14]. This is a short self-rated questionnaire, tailored to a busy clinical setting, for the assessment of stress and related psychological distress. It was found to fulfill the clinimetric criteria for patient-reported outcome measures [15]. Clinimetric criteria for the determination of allostatic overload (when stress exceeds the coping resources of an individual) by interview methods were introduced in 2010 [16]. They were subsequently incorporated in the Diagnostic Criteria for Psychosomatic Research [17] under a specific diagnostic rubric and supplemented by a semi-structured research interview [18]. These clinimetric methodologies that are achieving increasing importance in research on allostatic load [8, 9, 12, 14] would have not been developed without Paykel’s seminal work [1‒3, 5] and my clinical experience in using his IRLE [2]. A recent review concerned with the role of stress in endocrinology [19] illustrates the interaction of life events studies using the IRLE scale [2] in a number of endocrine disorders with the new insights provided by clinimetric criteria for allostatic overload [14, 16‒18].

There was also another scale that Gene had sent to me while being a medical student that I treasured over the years. It was the Clinical Interview for Depression (CID) [20, 21]. He developed the scale in the Yale years [22] and refined it in 1975 [20]. It started as an expansion and modification of the Hamilton Rating Scale for Depression [23], but Gene introduced completely innovative features compared to what was then available. It was developed on the basis of clinimetric, and not psychometric, principles [21]. The scale included 36 items that explored the full range of symptomatology of mood and anxiety disorders [20, 21]. For instance, he introduced the item “reactivity to social environment” (changes in mood and symptomatology in the direction of either improvement or worsening, as a result of environmental circumstances). Each item was carefully defined and could be rated on a 1–7 scale, with specification of each anchor point based on severity, frequency, and/or quality. A semi-structured research interview, as in the case of IRLE [2], provided the information that was necessary for scoring [20, 21]. When I started personally assessing patients with the interview in research studies, I particularly appreciated certain features. First, how the questions were formulated; they did not yield yes/no answers but provided opportunities for appreciating the patient’s personal experience of symptoms. The fact that the interview was semi-structured allowed to reformulate questions when patients had trouble understanding. Further, each item was not rated in the 1–7 point scale as a simple matter of intensity or frequency, but there was room for separating mild, subclinical symptoms from severe distress and devastating experiences. I soon memorized the entire interview and started using it in my clinical practice, in its full version or selecting specific items that followed the flow of the interview. I am convinced that the CID substantially improved my clinical performance, whenever I wanted to be sure to understand the nature and characteristics of symptoms. I learned that not all symptoms are the same for a patient: you could have the diagnosis of a major depressive disorder with few, but severe and invalidating, symptoms (not sufficient to fulfill the diagnostic criteria), while it was better to avoid such diagnosis with 5 or more symptoms of mild intensity (the limitations of a checklist use of diagnostic criteria) [11].

When in the late eighties I developed an interest in subclinical (prodromal and residual) symptoms that culminated in the introduction of the staging method in psychiatry [24], Gene encouraged me to pursue that innovative line of research. He had given me the CID, the perfect instrument for exploring subclinical symptomatology in mood and anxiety disorders [20, 21]. When I found that residual symptoms could progress to become prodromal symptoms of relapse, a new approach, the sequential model, opened up: treating with a psychotherapeutic approach residual symptomatology after pharmacotherapy might prevent relapse in depression [25]. Not surprisingly, Gene’s research group confirmed the results of our pilot study [25] in demonstrating the long-term benefits of the sequential model in preventing relapse in depression [26]. These findings were later replicated by a number of investigators around the world [27]. The suitability of the CID for detecting subclinical symptomatology was also essential for exploring mood disturbances in the setting of medical disease [21], with particular reference to the clinical state of demoralization [28] and the interaction between euthymia and dysthymia [29].

Gene shared with me the fact that the immersion in clinical practice which occurred in his early years at Yale, when he personally examined most of the patients who were included in studies, provided the basic research questions that required many years to be developed and addressed. The methods for assessment that he devised were derived from real-life clinical challenges. They provided a picture of what was going in the life of a person and derived from his careful and empathic listening, his capacities of elaboration, and his creative mind. His broad approach allowed him to split his interests between psychopharmacology, psychopathology, and psychosocial research, including psychotherapy. His contributions to the literature always had the mark of the methodological excellence and of the clinical factor, the degree and extent to which an article provides information to the clinician that may improve his/her practice [30]. His first book, a monograph on the depressed woman and her social relationships, written with Myrna Weissman in 1974 [31], could still teach more to a resident in psychiatry than 100 recent articles by researchers who have no familiarity with the clinical process and who therefore produce studies that are devoid of any clinical implications. His biopsychosocial approach made him an outstanding editor not only of the Journal of Affective Disorders and Psychological Medicine but also of books. The two editions of his Handbook of Affective Disorders [32, 33] remain unsurpassed monographs in the field.

His most important legacy probably consists in the assessment of life setting for understanding what is going on during a specific phase of an individual’s life [34]. Gene’s work emphasized the complex interaction of life events with chronic stress, social support, individual vulnerability to the event (e.g., personality, previous experiences), specific illness vulnerability (genetic and/or environmental), and treatment-seeking factors [35]. It was more geared into psychological medicine, defined as the clinical application of the psychosomatic approach [36], than traditional psychiatry. In clinical medicine, there is increasing awareness that a strictly biological model that ignores a patient’s life setting is unable to identify all of the factors that make individual susceptible to disease, resilient when disease occurs, and variably responsive to treatment [37]. Consideration of life setting may lead to unique individual profiles that take into account both biology and biography, both in patients [17‒19] and in physicians [38]. Curiously, psychiatry, that pioneered the psychosocial approach in the sixties and seventies [1‒3], currently neglects such approach, with the net result of biological reductionism that clashes with clinical reality and produces very modest therapeutic results [36]. Not surprisingly, treatment in psychiatry was recently found to be associated with subsequent socioeconomic deterioration [39]. As a result, I believe that the legacy of Eugene Stern Paykel is more timely than ever and may contribute to overcoming the current intellectual crisis in psychiatry. Thank you for your insights and wisdom, Gene, and all you have taught to us.

Giovanni A. Fava is indebted to Lynet Smith for her comments and suggestions.

Giovanni A. Fava has no conflicts of interest to declare.

The study did not receive any funding.

Giovanni A. Fava conceived and wrote the entire manuscript.

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