Stupor is an unusual but striking phenomenon, generally recognized but difficult to define in precise clinical terms. A large literature exists on the diverse conditions in which it may occur, but there is little information on differentiating one cause from another, or on the prevalence of these causes. This insufficiency extends to the phenomenology of stupor, where descriptive criteria are not always adequate for separating stupor from allied states. Such difficulties are reflected in a current text book by Merskey and Tonge (1965). The authors only recognize stupor if there is total akinesis, where it is assumed that the diagnosis is schizophrenia. Depressive stupor is not recognized as an entity.

An association between certain persistent oral dyskinesias and medication with phenothiazines has been observed in middle-aged and elderly women for several years. In most of the published reports it is held that the phenothiazines are an important cause of the abnormal movements, since phenothiazines are known to exert a selective action on the basal ganglia. Other possible causes, however, are almost invariably present. These are brain damage from disease, leucotomy or electroconvulsive therapy (Hunter, Earl and Janz, 1964; Hunter, Earl and Thornicroft, 1964; Uhrbrand and Faurbye, 1960), and buccal factors such as ill-fitting dentures or the edentulous state (Joyston-Bechal, 1965; Evans, 1965). Similar dyskinesias are also said to occur with brain damage when phenothiazines have not been given (Rosin and Exton-Smith, 1965).

The evidence that potent tranquillizers are useful in the long-term treatment of elderly patients with dementia in psychiatric hospitals is conflicting.

Seager (1955), in a double-blind, controlled trial involving 48 elderly women, 29 of whom suffered from dementia, found a highly significant improvement of social adjustment associated with chlorpromazine therapy. Schulsinger (1961), Exton-Smith (1962) and Post (1963) claimed promazine to be of particular value for agitated elderly patients. Robinson (1959), on the other hand, compared the effects of prolonged administration of chlorpromazine, reserpine, leptazol and a placebo upon 84 senile female patients in a double-blind trial and found no statistically significant improvement associated with the active drugs. Indeed, in the case of chiorpromazine, he found a significant lowering of the level of functioning. Abse and Dahistrom (1960), in a double-blind controlled trial involving 8o patients over 60 years of age with various symptoms (including some with confusion), found that chlorpromazine did not give better results than placebo.

Depressive illness is a major medical problem among psychiatric out-patients (Davies, 1964). Most of the recent investigations of depression have been related to the use of antidepressive drugs and electroplexy, but a deeper understanding of the condition quite apart from the efficacy of treatment is necessary (Lewis, 1964). The importance of cultural factors in mental illness is well recognized (Myers and Roberts, 1959), but their study has been neglected in Britain in spite of the variety of ethnic groups in many British cities, especially London. Many of the cultural groups in London consist of recent immigrants in whom the factors connected with immigration are difficult to separate from cultural influences. However, Anglo-Jews form a long established though distinct group which has been fully accepted in Britain for over a hundred years (Roth, 1964). They are predominantly British-born and English-speaking and number about 450,000, more than half of these living in London (Brotman, 1964). One of the older areas of settlement is the East End of London, but with economic advancement there has been a drift away from there to better class areas (Krausz, 1964). It was felt that a cross-cultural study in the East End of London comparing Jewish and non-Jewish patients suffering from depression might provide some insight into intercultural differences as well as the dynamics of depressive illness.

In 1954 a programme of “occupation and liberalization” was started at this hospital. Attempts to assess this programme were made and have been reported (Clark and Hoy, 7; Clark and Oram, 8). As a result of these surveys, we possess a complete list of the male patients in the hospital in October 1954 and February 1961, showing the work they were doing at these times; many men's names appear in both lists. This paper reports the analysis of these lists and some interesting facts that emerged.

Many mental hospitals are practising some form of group treatment either intra- or extra-murally or both. (Martin, 1962; Clark, 1964; Freeman and Farndale, 1961). Thus, ward meetings with as many as 60 patients and staff (Jones and Hollingsworth, 1963), small therapeutic groups of selected patients limited to 8 or 10 individuals (Foulkes and Anthony, 1965), family groups involving single families or several families taken as one group, follow-up groups with ex-patients and many other patterns are being developed. Most of the literature available and most of the training is based on the classical model (Bion, 1961) of the psychoanalytically-orientated group of selected patients, mainly cases of psycho-neurosis and character disorders, who have been suitable for this type of therapy.

Saxondale Hospital was one of the first in the Sheffield Region to start Industrial Therapy. Since June 1960 the unit has grown, more patients are employed, and we hope for further expansion in the near future. From our experience it seemed that Industrial Therapy was useful in the management of the chronic psychiatric patient. However, we felt that a more objective assessment could be obtained if we surveyed eight comparable hospitals. A personal survey has certain advantages over postal questionnaires, and we decided to conduct a complete survey of one region. All visits were made between November 1964 and January 1965.

Reorientation of the mental health services towards community care was one of the main recommendations contained in the report of the Royal Commission on Mental Health Law (1957) and accepted as Government policy. It was implied that there would be a considerable expansion in the services provided by local health and welfare authorities for the benefit of the mentally disordered, and local authorities were asked to draw up a proper order of priorities and plan their activities accordingly (Ministry of Health, 1959). The priorities depended upon an assessment of needs and time had to elapse before these became apparent. Since four complete years have passed since the coming into operation of the Mental Health Act, 1959, detailed assessment has become possible and this has revealed the difficulties experienced in the community by two special groups of patients, namely mentally abnormal offenders and patients of no fixed abode (N.F.A.s).

The demonstration by previous investigators (Table I), that more schizophrenics have experienced death of a parent in childhood than have control populations, suggests that the bereavement may be of aetiological importance. Gregory (1958) has criticized the methods of such studies, particularly in regard to their difficulty in obtaining well-matched control groups or data relating to the normal population, and the validity of these findings is therefore uncertain. The investigation described in this paper tries to overcome this methodological difficulty by comparing data on ages at bereavement of schizophrenics with those relating to their non-schizoohrenic sibs.

Introductory View

Bereavement is only the most measurable of many possible traumata in childhood; it is fortunately not the commonest and its frequency is still diminishing.

It has long been recognized that deprivation in childhood could be related to subsequent crime. Bunyan, in The Life and Death of Mr. Badman, takes for granted that orphanhood renders a girl liable to early seduction. Dickens, writing of Newgate Prison in his Sketches by Boz, says: “Barely past her childhood, it required but a glance to discover that she was one of those children, born and bred in neglect and vice, who had never known what childhood is; who have never been taught to love and court a parent's smile, or to dread a parent's frown. The thousand nameless endearments of childhood, its gaiety and its innocence, are alike unknown to them. They have entered at once into the stern realities and miseries of life, and to their better nature it is almost impossible to appeal in after times ….” In 1944, Bowlby outlined the concept of the affectless and affectionless psychopath produced by deprivation and repeated change of parent figure. The Gluecks, in 1950, found an increase of incidence of broken family in young male delinquents. Analysis of their figures (Fig. 1) suggests that loss of mothers in the childhood of these male delinquents was significant. In 1961 we made an examination of 200 women prisoners and concluded that loss of fathers in childhood was a significant factor in female delinquents.

The accidental event of childhood bereavement by death of a parent, and its possible importance in the later development of psychiatric illness, has been under study in recent years. It is a truism to state that, in the present organization of European society, such an event is a catastrophe, but whether bereavement is an event of aetiological importance in mental illness has not yet been decided.

The Royal Medico-Psychological Association believes that certain courses of action in relation to therapeutic abortion should be permissible by law because they contribute, according to the best available knowledge, to the promotion of health and the prevention of disease. In this belief they do not presume to dictate to those of their members who cannot personally adopt this pragmatic view of medical ethics, and who must clearly be free to adhere to the ethical standards prescribed by their religion or philosophy. Indeed, the Association would be opposed to legislation which might bring pressure on an individual doctor to act contrary to his conscience.