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Introduction
Depression and anxiety are common following diagnosis of breast cancer (Burgess et al. 2005) and this has led to a search for ways to identify patients at risk and for the underlying, and potentially modifiable, psychological processes contributing to the risk. Breast cancer usually occurs in middle-aged and older women but depression and anxiety commonly have onset in adolescence and early adult life (Jaffee et al. 2002). It is possible, therefore, that much of the depression and anxiety seen following breast cancer occurs in women who have experienced previous episodes, and may result from mechanisms associated with recurrent psychopathology. Although several reports have implicated pre-morbid psychiatric history as a risk factor in anxiety or depression after breast cancer treatment, the findings have not been consistent (Dean, 1987; Maunsell et al. 1992; Pinder et al. 1993; Grassi et al. 1997; Morasso et al. 2001; Gallagher et al. 2002; Burgess et al. 2005). Moreover, psychiatric history was assessed in most studies by methods that did not use research psychiatric interview schedules; for example, relying on clinical records or patients' reports of having received treatment for emotional problems (Dean, 1987; Pinder et al. 1993; Grassi et al. 1997; Morasso et al. 2001; Gallagher et al. 2002; Burgess et al. 2005).
The question of whether psychiatric disorders following diagnosis of cancer are recurrences of previous episodes is important for understanding causal mechanisms and hence for designing treatments to reduce risk of post-diagnosis psychopathology. In the absence of measurement of previous episodes, predictors of post-diagnosis psychiatric disorder might be assumed to reflect causal processes that could be targeted to reduce subsequent psychopathology. However, if previous episodes are assessed and are shown to be associated with post-diagnosis episodes, then such predictors may turn out to be mediators between previous and subsequent episodes, or they might be merely markers of vulnerability arising from previous episodes. In this study we therefore first examined whether depression and anxiety in the year following breast cancer diagnosis were likely to be recurrences of previous psychopathology. Then we examined three possible predictors of psychopathology after breast cancer - low social support, self-blame, and shame - in order to determine whether they mediated the relationship of previous psychopathology to the psychopathology...