A reappraisal is offered of the precise sense in which the introduction of moral treats ment at the end of the eighteenth century marked a decisive shift in our characteristic ways of responding to and coping with the mentally disturbed. Some connections are explored between this new approach to the ‘mad’ and larger social movements and processes.

Thirty patients were selected for a prospective study according to two criteria: (i) an irresistible urge to overeat (bulimia nervosa), followed by self-induced vomiting or purging; (ii) a morbid fear of becoming fat. The majority of the patients had a previous history of true or cryptic anorexia nervosa. Self-induced vomiting and purging are secondary devices used by the patients to counteract the effects of overeating and prevent a gain in weight. These devices are dangerous for they are habit-forming and lead to potassium loss and other physical complications. In common with true anorexia nervosa, the patients were determined to keep their weight below a self-imposed threshold. Its level was set below the patient‘s healthy weight, defined as the weight reached before the onset of the eating disorder. In contrast with true anorexia nervosa, the patients tended to be heavier, more active sexually, and more likely to menstruate regularly and remain fertile. Depressive symptoms were often severe and distressing and led to a high risk of suicide.

A theoretical model is described to emphasize the interdependence of the various symptoms and the role of self-perpetuating mechanisms in the maintenance of the disorder. The main aims of treatment are (i) to interrupt the vicious circle of overeating and self-induced vomiting (or purging), (ii) to persuade the patients to accept a higher weight. Prognosis appears less favourable than in uncomplicated anorexia nervosa.

Morning and evening plasma cortisol levels were checked in 123 consecutively newly admitted psychiatric patients with a variety of diagnoses. Questions asked were whether there were differences among groups with more severe illness, type of depression, alcohol abuse, or particular symptoms. Morning cortisol elevation was found in 33% of patients and was not associated with any particular diagnostic category. Evening cortisol elevation occurred in 85% of the subjects. It was significantly higher in those with unipolar depression and organic brain syndrome, also in those patients who abused alcohol regardless of diagnosis. Evening cortisol elevation was twice as common in patients with diagnoses of more severe psychiatric illness than in those with minor disorders. Further study is suggested to see if these patterns of cortisol elevation are sustained beyond the stress-of-admission period.

Non-esterified fatty acid and total and free tryptophan were determined in the plasma of psychiatric patients unselected with respect to psychiatric diagnosis and in the plasma of normal subjects before and after physiological and psychiatric tests. Retarded patients had significantly low total and free tryptophan values which correlated negatively with agitation. Total tryptophan fell significantly after testing in the non-retarded subjects. The only biochemical abnormality significantly associated with a diagnosis of primary depression was the rise of plasma non-esterified fatty acid after testing. Thus, tryptophan abnormalities were associated more with psychiatric rating scores than with diagnoses.

A study of attentional deficit in the relatives of schizophrenics and in a matched control group is reported, in which the relatives are found to have poorer scores on a vigilance test and on a choice reaction time test. It is concluded that this deficit points to one of the primary symptoms of schizophrenia, and suggestions for further research are made

Between 1968 and 1975 there was a marked, non-artefactual rise in the numbers of young female parasuicides admitted to the Regional Poisoning Treatment Centre in Edinburgh. The greatest increase in rates occurred among girls aged 15–19 (for events, persons and ‘first-ever’ episodes). Among teenagers the most marked increase occurred for those who were married: this group also reported a greater increase than did the non-married in the frequency of physical violence and Serious debt. ‘Marginal’ social-sexual roles have also become progressively more common in this age group. The 20- to 24-year group showed a more modest increase in rates, similar for the married and the non-married. In this age group there was no consistent pattern of change for reported violence or debt over the study period, nor were changes in these variables related to marital status. An increase in consumption of alcohol before parasuicide was noted for both age groups.

In Sheffield 544 consecutive cases of attempted suicide (parasuicide) were seen at 2 large hospitals over a 12-month period, and allocated in sequence to the junior and senior psychiatric staff, of British and foreign origin. During the follow-up period of 12 months, 31 patients had a further episode of parasuicide and 5 patients committed suicide.

The outcome (as measured by repeat parasuicide or suicide) was not significantly affected by the country of origin of the psychiatrist, nor his length of training in psychiatry

A series of 80 patients who had deliberately but not fatally harmed themselves and had been admitted to hospital was examined with special reference to their use of available services during the period of distress prior to the episode. They were followed up for 4 months and the ways in which they subsequently made use of helping agencies were also monitored.

Three broad groups of patient attitudes to help and its utilization are described. ‘General practitioner help-seekers’ (29) defaulted least often and appeared to have more positive attitudes towards seeking help for their problem. The ‘psychiatric help-seekers’ (17) appeared to be a chronically disorganized group who, though previously often in treatment, seemed unable to cooperate: they defaulted frequently and apparently gained little. ‘Non-help-seekers’ (34) had been reluctant to ask for help concerning psychological problems and subsequently defaulted just as frequently as did the ‘psychiatric help seekers’.

The need to take into account variation in patient attitude to help and its utilization in designing services for the primary prevention of non-fatal deliberate self-harm is emphasized.

Self-poisoning patients admitted to hospital were studied for persistence of psychiatric symptoms over a 3-month period and evaluated at 3 points in time with the General Health Questionnaire and the Present State Examination. Symptoms were identified which had a high or low prevalence at 3-month follow-up. GHQ and PSE scores correlated at 0·8. The implications of the study are discussed, particularly the earlier need for out-patient help in those who had a moderate or high number of symptoms at initial interview.

The Present State Examination was administered to 539 patients who attended a casualty department after an act of self-poisoning during the course of a year. Computer analysis by means of the Catego program showed that 30% of the patients had insufficient symptoms to be considered as psychiatric ‘cases’. Fewer than 4% had symptoms of functional psychosis. About 60% of the patients were classed as depressed: on several indices this group was less severely ill than a group of depressives receiving psychiatric treatment. It is suggested that psychiatric treatment is essential for only a small proportion of self-poisoning patients. The effectiveness of psychiatric treatment for the large group of patients with depressive disorders of minor severity and probably short duration has still to be evaluated.

An entire population of 32 patients on regular dialysis treatment (RDT) in their own homes were ranked according to their present mental state as assessed by a standardized semi-structured interview. The point-prevalence of psychiatric morbidity was 31 % which compares closely with that of patients attending a general practitioner's surgery who were assessed by the same method. The 10 patients who were psychiatrically ill had more organic symptoms and their spouses were less able to tolerate RDT in the home.

An entire group of 32 home dialysis patients from one hospital renal unit was assessed for psychiatric morbidity on a standardized interview of proven reliability. A rating of physical symptomatology and an enquiry into the childhood and psychosocial background were made at the same time. Psychiatric morbidity, physical symptomatology and a history of good relationships with both natural parents in childhood were inter-related. They were all related to survival on haemodialysis 3½ years later. Survival was also associated with a coping spouse and full-time employment or housework by the patient. These findings are discussed in the light of current concepts of the psychosocial setting for physical illness.

The reliability of Brown's contextual measure of threat is assessed and found to be highly satisfactory. Previously inexperienced raters achieve highly reliable ratings after only brief training. The implications for the concept of the threat of life events are discussed.

Two hundred and eighty-two schizophrenics discharged from St John's Hospital, Stone, were followed-up. The reliability of the diagnosis was measured by the extent of agreement among the hospital clinicians. The number of readmissions and the time spent in hospital were ascertained and correlated with the sex, civil state and age at first admission of the subjects.

It was found that a higher proportion of males than of females was readmitted; that the proportion of single persons among male schizophrenics is higher than among comparable age groups in the general population; that single males are more frequently admitted than single females; that the peak age of first admission for males is 10 years earlier than for females and that men whose age at first admission is below the median are more frequently readmitted than those whose age at first admission is above it.

Women are more frequently married than men at the onset of schizophrenia, giving rise to the suggestion that marriage has a protective effect in schizophrenia. This hypothesis was not supported by our findings. The bearing of these findings on the course, genetics and marital handicap of schizophrenia is discussed.

A neighbourhood health centre in the US is compared with the mental health services in an area of the UK.

Patients with severe, but long-standing psychiatric illnesses, or patients with transient emotional problems are likely to be treated by a general practitioner in London and by non-medical mental health specialists in Boston. These patients receive more overall care, more specialist, non-medical care but make as many visits to a medical provider, other than a psychiatrist, in Boston as they do in London. Psychiatrists see more acutely ill patients for a shorter time than non-medical specialists in both places, and in both Boston and London there is a highly selective referral process which results in psychiatrists from both areas seeing approximately the same proportion of the population of their catchment areas.

The integration of these findings with community attitudes in planning services is discussed.

The numbers of long-stay patients in Danish psychiatric hospitals were studied, based on information from the Danish cumulative psychiatric register and from the census studies of patients in Danish psychiatric hospitals, performed at 5-year intervals since 1957.

In 1977, 2079 (20%) of the in-patient population which had been admitted before 1957 were still in hospitals. This ‘old long-stay’ group has diminished exponentially, with an annual reduction of 7%.

During the period 1972–6, the number of patients who, on any given day, had been in-patients or attending as day-patients for more than 1 but less than 2 years (the ‘new long-stay’) varied between 847 and 1089: an average of 20 per 100000 total population. The ratio of in-patients to day-patients was approximately 4:1.

Data derived from a psychiatric case-register are presented on the accumulation of new long-stay cases in Salford from 1967 to 1976. The analysis supports the general decline reported in an earlier shorter-term study except for the over 65s, where the trend was reversed. The implications of the findings are discussed.