The assessment of change in psychiatric patients is never easy. The problem is accentuated in the chronic inhabitants of psychiatric hospitals, since the period of treatment and observation may have to be prolonged, and the changes found may be small and gradual. A rating scale can be of value, in recording findings in a uniform manner and in preserving the observations from selective amnesia, so making comparison possible over a long period. In the present communication we report a scale devised by two of us (F.J.J.L. and A.D.H.) for use with chronic patients. This scale summarizes the relevant parts of the examination of mental state found in standard text books of psychiatry, and we have tried to avoid presuppositions about the meaning or distribution of symptoms.

Although chlorpromazine was the first of the phenothiazine drugs to be used in psychiatry, and has since been the subject of an extensive literature, there is a surprising dearth of information about the nature of its effect in chronic schizophrenia. Some early reports indicated that it produced a beneficial change, but before this could be examined and documented the attention of most psychiatrists was diverted to newer and supposedly more potent analogues. The present trial was undertaken with three factors in mind, which had not been fully taken into account of in previous studies. These were:

The factors leading to the fall in the mental hospital population which started in England in 1954 are not fully agreed. By some, the introduction of the phenothiazine drugs was held to be of first importance: other writers have stressed the role of social and administrative factors—of energetic rehabilitation and discharge policies together with measures to provide community services for discharged patients.

In previous communications (6, 9) we have presented data indicating that affective disorder (manic depressive disease, involutional depressive reaction, neurotic depressive reaction, psychotic depressive reaction) is more frequent in females than in males. More specifically, in a total sample of 366 affective disorder probands there was a ratio of 1·9 females to every male; and in the parents of the probands a statistically significant excess of mothers as compared to fathers was found to have suffered from the same illness. Calculations done on the same proband group revealed that alcoholism was significantly more prevalent in the fathers and siblings of the affective disorder group than in a matched control series. It appeared that if one added the alcoholic fathers to the affectively disordered fathers one found a prevalence of psychiatric illness in fathers which was similar to the prevalence of affective disorder itself in the mothers. Thus, it seemed that the deficiency in affective disorder diagnoses in fathers was made up by alcoholism.

Symptoms of depression as a clinical entity have been the object of factor analyses by Hamilton (1960) and by Overall (1962). In each of these studies data consisted of observations of male in-patients whose hospital diagnosis was depression. Subjects were rated on the basis of interview behaviour in sets of items considered relevant to clinical concepts of the disorder. Dimensions obtained in Overall's analysis agreed very closely with factors which had previously been identified in psychiatric ratings of schizophrenic patients (Lorr, 1953; Lorr, McNair, Klett, and Lasky, 1962; Overall and Gorham, 1962). This finding was interpreted as evidence that “certain basic factor dimensions appear in various different types of patients” (Overall, 1962). Hamilton felt that a single word-label might describe qualitatively different behaviours, depending on diagnosis; he therefore insisted on the importance of context (nosological category) in assessing the significance of any given symptom.

Quite a number of reports have been published on serum lipids and especially serum cholesterol in manic-depressives. The results, however, are contradictory, and the experimental designs have not been satisfactory. Altschule (1953), and Hoch and Zubin (1954) have reviewed this field, but little original work of importance has been published recently.

Many patients with depressive illness also show considerable anxiety and agitation and often require a tranquillizer in addition to an anti-depressant drug. A new combination—Ro 4-6270 or Limbitrol Forte (Roche)—consisting of amitriptyline 25 mg.+chlordiazepoxide 10 mg. has recently become available for clinical trial. Both amitriptyline and chlordiazepoxide are widely used as an anti-depressant and a tranquillizer respectively. Clinical trials by Harris (1960), Jenner et al. (1961) and Hordern et al. (1963) have confirmed the efficacy of these drugs. Karabanow (1962), Poldinger (1963), Tietzen (1964) and Haider (1967a) have reported the usefulness of the combination of amitriptyline and chlordiazepoxide in depressive states, but none of these studies was adequately controlled. In a previous study (Haider, 1967b) I reported the efficacy of a combination of an anti-depressant and a tranquillizer in improving anxiety and agitation in depressive illness, more than one would expect with an anti-depressant alone. As the combination was compared with a placebo, it was not possible to state with any certainty what was the role of the tranquillizer in improving these symptoms.

In the clinical evaluation of psychopharmacological agents there are many factors which operate simultaneously with the pharmacological effects. These other factors may independently have an effect on the patient's symptomatology. In uncontrolled studies, therefore, these “non-drug” factors may frequently lead to erroneous clinical conclusions in regard to drug efficacy as well as side reactions.

Nitrazepam (Mogadon), a benzodiazepine compound, chemically related to diazepam (Valium) and chlordiazepoxide (Librium) is a recently introduced sleep-inducing agent. Other studies (Baum et al., 1965; Fraser and Shepherd, 1966), found it to be both safe and effective. It is thought to induce sleep by “shielding the brain centre responsible for waking from emotioned stimuli”, and is therefore of particular interest for psychiatric illness. This study is a clinical comparison with sodium amylobarbitone, using a double-blind cross-over technique.

An initial report on this study (Sheldon, 1964) demonstrated a significant positive relationship between psychiatric after-care and reduction of readmissions to mental hospital in the six months following hospital discharge when patients were randomly allocated to psychiatric after-care or to the general practitioner. The present paper demonstrates that this effect, although diminished, is still apparent for a similar group of patients allocated to after-care by their discharging psychiatrist and followed up for three years. It attempts to clarify the factors operating in psychiatric selection for after-care, and to explore the relative importance of after-care and of the nature and severity of illness in determining outcome, at least as measured by the number, duration, and time after discharge of rehospitalizations.

In view of the important implications of the subject, it is surprising that there have been so few studies of psychiatric illness within the medical profession, except specifically in regard to drug addiction. Indeed, we could find only two papers on the overall psychiatric morbidity in the profession published during the last decade (Duffy and Litin, 1964; Pearson and Streker, 1960). In Great Britain there have been no published studies of this kind as far as we can discover.

In 1876 the Danish physician, Julius Thomas Thomsen, described the disease entity of myotonia congenita, from which he himself and some members of his family suffered. This muscular disorder is now accepted as a clinical and genetic entity, distinct from other forms of myotonia, viz. dystrophia myotonica and paramyotonia (De Jong, 1955).

Tropical neuropathies have been causally related to disturbances of pyruvate metabolism (Monekosso, 1963); like the neuropathy described by Wernicke, they are thought to be due to vitamin B deficiency. The clinical picture includes mental disturbances of the organic type, such as disturbance of memory, confabulation, apathy, disorientation, etc. Reports do not mention symptoms suggestive of functional psychosis.

There can be no more urgent or conspicuous problem in psychiatry, as a scientific discipline, than that it lacks a generally agreed theoretical framework on which to base practice and teaching.

The essential function of the clinical psychologist, from the point of view of society as a whole, must be to make available to the Health Service the contribution of the science of psychology. This means much more than the kind of sophistication which stems from an experience of psychiatric disorder and from a study of the psychiatric literature. We will now consider the implications of such an approach for the three main aspects of clinical work: assessment, modification, and research.