1. Depression is not an illness, but a psychobiological reaction which can be provoked in anyone.

2. It is much more easily provoked in some people than in others.

3. Vulnerability to depression is partly dependent upon social factors, as George Brown has demon strated. It is also determined by internal factors in the personality.

4. There is increasing evidence to show that the child's attachment to his mother is an important determinant of future mental health.

5. It will be argued that children who make ‘anxious attachments’ to the mother, as described by Bowlby, are less likely to incorporate her as a ‘good object’ within the psyche, and that this renders them more vulnerable to later depression than children who form ‘secuartetachments.’

6. Many features of depression in adults resemble or are related to ‘anxiouatstachments.’

7. The way in which psychotherapy can alleviate vulnerability to depression is described in terms of this hypothesis.

8. Reference is also made to the fact that effective action can be a source of self-esteem as well as love. Many of the great creators were partially effective in dealing with vulnerability to depression by work.

9. Freud affirmed that mental health depended upon the capacity to love and the capacity to work. It will be argued that the former capacity has been over-emphasized at the expense of the latter.

Psychotherapy, like any other effective treatment in medicine, may lead to negative effects either in the patient or those around him. The source of these unwanted effects may be in the patient's or the therapist's personality, in the patient-therapist interaction, in faulty therapy technique or in the patient's unresolvable social situation. The possibility of negative effects should be anticipated during the descriptive and psychodynamic assessment of the patient and before establishing the therapeutic contract. The technique of a trial of psychotherapy should be more frequently used than it is in cases where the therapist is in doubt. If negative effects do develop, these should be minimized by decreasing the frequency of psychotherapy sessions and depth of exploration. This may be done by allowing greater therapist “transparency”, by making fewer psychodynamic interpretations and by altering the focus of therapy from problems of early development to problems of current living.

A study on the Standardized Assessment of Depressive Disorders (SADD) in collaboration with WHO Headquarters, Geneva, is reported in this paper. The instruments used for the study were screening forms and the SADD schedule, both of which were supplied by WHO. Fifty depressed patients were selected from the outpatients and inpatients of the Accra psychiatric hospital by experienced specialist psychiatrists using the screening forms. The two investigators then carried out a clinical assessment on each selected patient using the SADD schedule. The data collected were subjected to computer analysis. Findings were similar to those from previous WHO/SADD studies in different cultures. Specifically, the investigators found a “core” of depressive symptomatology among African patients in Ghana. An interesting finding was the change in the presentation of depression in African patients over the past 30 years. Broad diagnostic groupings like endogenous depression and psychogenic depression could easily be applied to the study patients. There is a great need for more SADD studies in Africa.

A follow-up enquiry was carried out after two years on 54 patients who had earlier participated in a controlled experiment on home-care through a community nurse in Bangalore. Thirty seven of these patients could be contacted, of whom 21 had undergone the experimental care (home care) and 16 were from the control group, which had been treated by hospital admission. It was found that the experimental subjects had maintained a significantly better clinical status than the controls, and had been readmitted less often.

A new problem-oriented cross-cultural method has been developed to identify the appropriate management of mental health problems in primary-care settings. It is designed to be used by multipurpose health workers in out-patient clinics in many developing countries. Presenting mental health problems in many cultural settings can be placed into one or more of eight behaviourly determined categories. After this initial categorization an algorithmic process is used to determine the sequence of observations which must be made in order to identify the appropriate management. The system allows for variations in available resources and local constraints. We outline the design principles of this algorithmic method and the rules for using it, and describe a training programme developed to teach people to adapt it and use it effectively. The evaluation studies that have been done in different developing countries confirm that the method is acceptable and efficient, and gives management decisions with a high degree of repeatability.

Two thousand three hundred and ninety consecutive visits to a walk-in psychiatric emergency service were studied to examine issues relevant to service provision. Only a third of patients were from the catchment area. Psychotic patients and those admitted or kept overnight (guests) were more frequent after hours and among non-medical referrals, especially family and police referrals; but suicidal patients often came from other hospitals. At index visit a third of patients were offered follow-up, but attendance was poor. Factors influencing attendance were examined. Keeping overnight avoided unnecessary admissions. There was little evidence that patients abused the service.

The findings suggest that a psychiatric emergency service should be available to all referrals 24 hours a day.

In a prospective study of a community sample, we examined changes in social relationships accompanying the onset and remission of neurotic symptoms. For those who developed symptoms in the course of 12 months, no decrease was found in the availability or reported adequacy of either close or diffuse ties, compared to those who remained symptom-free. For those having a remission, an increase in the adequacy of social relationships and a decrease in rows was observed only in those who improved later on, at the 12-month interview. But with either the onset or remission of symptoms, the availability of relationships remained unchanged. These observations cannot establish the direction of causality, but suggest that neurotic symptoms are more associated with the perception of social relationships than with the structure of personal networks.

A large sample of women (n = 899) from Dunedin, New Zealand, completed a self-report questionnaire on depressive symptoms. On this basis, about 8 per cent of the sample were identified as having major depressive disorder. These women tended to have a history of previously reported psychological symptoms and formal treatment for depression. A significantly high proportion of the depressed group had been young at first pregnancy and had since been separated from their partners. The depressed women also reported more behaviour problems in their children, but these reports were not confirmed by teachers' reports or by the children's self-reports, suggesting a response bias in depressed women towards reporting problems.

When subjects act as their own controls in drug experiments there is a risk of asymmetrical transfer between treatment conditions, with the result that treatment effects are determined largely by order of administration. In such cases the effect of a drug may be reduced or exaggerated, and prior treatment with a drug may affect placebo conditions. Asymmetrical transfer is probably much more common than is generally realized. Suggested causes include inadequate wash-out between treatments, state-dependent learning, adoption of learning strategies, and practice effects. The problem is illustrated by the re-analysis of a paper on the effects of benzhexol on memory, published recently in this journal (Potamianos and Kellet, 1982). The advantages of separate-group experimental design are reconsidered.

Several coefficients have been suggested for the measurement of agreement between raters. Recently Maxwell (1977) has proposed, and Janes (1979) has extended, a new coefficient, which they have termed the random error coefficient (RE). This paper criticizes their proposal and suggests that Cohen's (1960) coefficient kappa (K) is still the measure of choice.

Different patterns of personality in old age were examined in an aged community sample of 82 subjects (mean age 79.6 years). Four personality patterns in old age were identified using multivariate techniques. They were the normal, the introverted, the perturbed and the matured integrated. The clinical implications of personality types in old age are discussed; the perturbed group are most likely to develop psychiatric disorder.

In a survey of training in child psychiatry in Great Britain, all senior registrars were sent questionnaires; the response rate was 69 per cent. We describe background factors of the trainees, details of the clinical and academic experience available to them, and their attitudes towards their training.

Most trainees had had extensive previous experience in adult psychiatry and the predominant orientation was psychoanalytic. In general, they approved of the guidelines for training issued by the Joint Committee for Higher Psychiatric Training. Family therapy was the most popular treatment method. We comment on their training experience where the interest expressed was not matched by adequate availability of the training facilities.

Over a 25 year period, 2.4 per cent of Birmingham medical students developed psychiatric disorder which was severe enough to cause loss of time from the course; 1 per cent of the total required hospital admission. One-third of the psychiatrically ill students did not graduate, but those who did were as likely as graduates who had not been ill to remain on the Medical Register.

A young man aged 23 made contact and asked to talk about an adverse drug reaction. He had been puzzled and frightened by what had happened to him and although he was a very experienced drug-user he had not fully realized that a drug could cause such consequences—he had feared that he was going mad. He came along not as ‘a patient’ but because he believed that he had something to tell which might add to medical insights.

The authors conducted a preliminary trial of a 5-day course of diphenoxylate in the treatment of out-patients with methadone withdrawal symptoms. Diphenoxylate provided substantial relief from detoxification symptoms with no drug-associated adverse effects.

Two cases are described where auditory hallucinations persisted, in spite of medication, in two schizophrenic patients, one with acute onset and one with a severe chronic illness. The hallucinations were treated successfully by methods derived from Green's theory that auditory hallucinations are represented in the non-dominant hemisphere.

Very few patients with ulcerative colitis are likely to be referred or to refer themselves for psychotherapy for their condition. Recently I was asked by a gastro-enterologist to see Caroline, a young woman in her early thirties, who had ulcerative colitis, with a view to her discussing having psychotherapy. This was because she had caused him and a social worker in this hospital to be concerned about her emotional state.

A previous paper in this series with the same title (Lipowski, 1979) described the history and recent developments in the organisation of consultation liaison psychiatry. I therefore cover two other aspects, the nature of the psychological reactions to physical illness and the clinical role of the psychiatrist working on general surgical and medical wards. Lipowski remarked on the “generally mediocre quality of research” and on the lack of a “single fully adequate textbook”. These deficiencies remain all too apparent and the increasingly large literature is still mainly “clinical and anecdotal”. However straightforward clinical descriptions do provide an essential background to understanding the practical impact on patients' and families' lives of illnesses and of their treatment. A good knowledge of medicine is also essential and the liaison psychiatrist requires an up to date textbook and should try and read review papers and editorials in the general medical journals.