In recent years several factor analytic studies of the depressive states have referred to the problem of the so-called endogenous and neurotic varieties of depression. Some authors (Hamilton and White, 1959; Kiloh and Garside, 1963; Carney et ai, 1965) have found a bipolar factor corresponding to the supposed endogenous—neurotic dichotomy or to an anxious retarded dichotomy (Hamilton, 1967) while others have not (McConaghy et al., 1966). Rosenthal and Gudeman (1967a, b) found two orthogonal factors which they felt described an endogenous (or autonomous) depressive syndrome and a self-pitying syndrome. Differences in selection of patients or in interpretation of results, and unconscious bias in recording clinical data (Oswald, 1966) have been held to be responsible for these discrepancies.

In a previous paper (Kay et al., 1969) the mode of selection and composition of a sample of 104 depressed patients was described. The present article concerns the follow up of this sample, 5–7 years after the index admission (which was always a first admission). The aims were: (i) To examine and compare outcome in three groups of patients, “endogenous”, “neurotic”, and “undifferentiated”, (ii) The second aim was to study the power of various individual features to predict the course and outcome of the illness. The patients' groups were defined by the factor scores on a first (bipolar) factor which was identifiable in many though not all respects with the “endogenous-neurotic” factor previously described by Kiloh and Garside (1963) and by Carney, Roth and Garside (1965). A full account of the symptoms defining the factor, which was obtained by principal components analysis, and of the method of allocating patients to the diagnostic groupings, was given in the previous paper.

There has been a great deal of argument during the past 30 years about the symptomatic differences between anxiety and depressive states. Mapother (1926) thought that anxiety states should be regarded merely as one of the numerous sub-divisions of the manic-depressive illnesses, since they merged through a series of patients into agitated depression. Lewis (1966) too saw no sharp division between anxiety states and depression and classified agitated depression and anxiety states together as one sub-division of the affective disorders. Garmany (1956, 1958) and Mayer-Gross, Slater and Roth (1960), however, felt that anxiety states and depression were basically different forms of illness.

The purpose of this paper is to report on therapeutic measures which have been used on my Unit at the Maudsley Hospital for several years and have been gradually elaborated with the help of registrars who have learned to apply them under my general supervision. The measures are derived from the therapeutic technique Freud recommended. In 1913, when he reviewed the development of his technique, he said: “In the earliest days of analytic technique we took an intellectualist view of the situation. We set a high value on the patient's knowledge of what he had forgotten, and in this we made hardly any distinction between our knowledge of it and his…. We hastened to convey [it] to the patient in the certain expectation of thus bringing the neurosis and the treatment to a rapid end.

“But surely, in the third act when the father sends the son from his home, your intent is to probe the unresolved oedipal strivings of both men?” The man from the Sunday Review of the Creative Arts looked up from his note-pad, a faint air of well-bred surprise on his manicured face.

To an analytically oriented psychiatrist a neurotic symptom is a meaningful expression or result of an unconscious conflict. To a behavioural therapist it is maladaptive, learned behaviour. The psychotherapist sees his task as a joint venture in which patient and therapist explore the patient's life history in order to determine how the trauma of the past manifests itself in the distortions of the present. Behavioural therapists contend that analytical theory, of whatever sort, is invalidated by their successes and by the fact that successful treatment of a symptom or set of symptoms has not, in their experience, led to substitution of some other symptom or to more serious pathological consequences. The claimed success rate for behaviour therapy is very high. Journals of recent years abound in reports of spectacular cures, especially of individual patients with traditionally refractory conditions (Clark, 1963; Cooper, A. J., 1963, 1965; Raymond and O'Keefe, 1965). The psychotherapist's aim is to help his patient to understand his problems and find his own solutions for them. Would he be better advised to use his authority to reward “acceptable” and punish “unacceptable” behaviour; or his imagination and inventive skill to figure out ever more ingenious procedures of deconditioning? Is the time-consuming process of intensive psychotherapy not only wasteful but inferior in results to techniques based on conditioning? It seems to me, to judge by recent reports, that some of the results of behaviour therapy are less impressive than a cursory reading would suggest.

For a long time it has been thought that deviations from the average in certain body measurements might be associated with an increased expectation of mental illness. The features to attract most interest have been size, linearity, and masculinity.

Klinefelter, Reifenstein and Albright (13) in 1942 collected and described nine cases of a new clinical syndrome, later given the eponym Klinefelter's Syndrome, which appeared at puberty in males and was characterized by gynaecomastia, hypogonadism, aspermatogenesis, increased follicle-stimulating hormone (F.S.H.) and normal or low 17-ketosteroid urinary excretion.

This paper reports a study of first admissions to psychiatric facilities in Dublin. It forms part of a survey whose objects were to investigate the extent and characteristics of hospitalized psychiatric illness in Dublin, to make comparisons between mental illness in Dublin and in other cities, to observe the outcome of a first-admitted cohort of patients followed up for five years and to examine the differences, on admission and in outcome, between those receiving Local Authority and those receiving private care.

The pressures and difficulties of the clergyman's life are in many ways similar to those to which the doctor is subject (a'Brook, Hailstone and McLauchlan, 1967). Like the doctor, the clergyman occupies a special role in the community and is “surrounded by a sacred aura which sets him apart from his fellow man” (McAllister and Vanderveldt, 1965). Society, too, exacts much the same price from the minister of religion as it does from the doctor; it gives them both privileged positions, but demands from them exemplary behaviour and often superhuman qualities.

The decade following the end of World War II saw a progressive rise in the admission rate to mental hospitals in this country. The population of mental hospitals rose to a peak of 152,000 in England and Wales in 1954, since when there has been a steady decline. These fluctuations have been analysed by such authors as Norton (1961) and Tooth and Brooke (1961). The latter attributed the more recent decline to increased efficiency of treatment and rehabilitation, and predicted a continued fall so reducing the mental hospital patients by about 1970 that they would be covered by an allocation of 1 · 8 beds per thousand population. Maclay (1963) believed this prediction to err if anything on the conservative side and the Ministry of Health (1962) based its plans for psychiatric beds upon this ratio. In these plans the Ministry accepted the thesis that short-stay psychiatric patients should preferably be treated in general hospital units near to their homes whilst patients needing a longer hospital stay should be catered for in specialized hospitals for that purpose. The prediction in the Ministry of Health's Hospital Plan (1962) that there would be a steadily declining mental hospital population has been severely criticized by Gore and Jones (1961) but supported by Orwin and Sim (1965) in their analysis of the effects of the provision of acute general hospital psychiatric units in the Birmingham area. The importance of accurately assessing the psychiatric hospital bed needs over the next twenty years, given a full range medical and ancillary services, is vital to future planning and has been much in the author's mind when writing this paper.

Burgess and Harrington (1964), Hoenig and Ragg (1965), and Errera et al. (1965) studied failure to keep initial appointments at psychiatric clinics. The present study is concerned with non-attendance at a follow-up clinic.

Research relating brain stem stimulation and cortical selectivity by Lindsley (1957) led Venables (1963) to utilize a score from a perceptual discrimination task (two-flash fusion threshold, T.F.T.) to examine hypotheses relating arousal level to perceptual dysfunction and schizophrenic symptoms. Other work failed to confirm the results (Hume and Claridge, 1965), possibly due to the unsuitable method of determining T.F.T., a method of constant stimuli. The following experiments were based on the proposition that perceptual functioning is related to arousal level, and also attempted to resolve confusions arising from earlier studies by control of possible sources of error in the experimental situation.

Few studies of this type concentrating on young people have been published. Comparison of results is almost impossible, since different age ranges have been involved and in some cases the sex factor has been ignored. During the calendar year 1965, 20 patients were referred to our Child Psychiatric Unit having intentionally damaged themselves, and were seen by one or other of the four psychiatrists. This survey was made retrospectively from their notes because we were impressed by the number who had “broken homes”, or whose parents were chronically mentally or physically ill.

Staffing patterns are a major concern in the planning and administration of psychiatric facilities. The cost of professional and sub-professional personnel are the largest expense on psychiatric institution operating budgets. Trained professionals are in short supply and for the foreseeable future will not be available in adequate numbers to staff existing and developing programmes. Such considerations make important the development of more efficient methods for deciding upon staffing levels. At present, clinical experience and uncontrolled comparison of differently staffed clinical programmes are the usual justifications for improved staffing. This study was undertaken to investigate whether a relationship existed between staff time spent in treatment of patients and outcome for a patient group.

It is appreciated that the National Health Service already makes substantial contributions towards the training of doctors. Nevertheless, the view expressed in the Royal Commission Report (paragraph 195) that the N.H.S. should accept a broad responsibility for the cost of postgraduate medical training is endorsed. Moreover, a distinction between ‘academic’ and ‘vocational’ training is somewhat artificial as far as medical education is concerned: both are important, and it seems inevitable that much of the postgraduate training as psychiatrists will fall upon the universities, whose staff, on the whole, are more experienced in teaching. More teachers will be needed to implement the proposals of the Royal Commission, and their training will be largely the responsibility of the universities. At present, very few of the university departments of psychiatry are equipped for the increasing demands made for postgraduate education, nor do they receive any grant for this purpose. The future training of psychiatrists must be more intensive and better organized. While it is agreed that much of this training will be provided by the ‘non-teaching’ hospitals and by tutors at the periphery, the university departments will need to be actively involved in these teaching programmes. Moreover, there will have to be an increase in the courses organized by university departments for general practitioners, medical officers of health, school medical officers, etc. Such an expansion of university departments does not run counter to the principle of the N.H.S. financing the professional training of doctors. Finally, consideration should be given to establishing parity in the salaries of university clinical teachers and N.H.S. consultants, whose responsibilities are usually very similar.

A questionnaire on postgraduate teaching and training facilities was prepared and circulated by the Education Committee late in 1965, and, after approval by Council, the report on this survey has been published (R.M.P.A., 1968). To find out what changes in teaching and training facilities had taken place in up to 21/2 years, a second questionnaire was circulated to all psychiatric hospitals in the United Kingdom approved by the Conjoint Board as providing training for the D.P.M. The second questionnaire was shorter and simpler than the first, some questions of doubtful value being eliminated and others re-phrased to make them less ambiguous.