The signal honour and distinction you have conferred upon me has set me wondering how and why I have merited your selection at this time. It is true that I have worked and spoken for having our own College. I have always profoundly believed in the reality of psychiatry's claim to be the other half and an equal partner of internal medicine, to speak from the position of its own self-respecting identity. It next occurred to me that this sense of identity and personal autonomy is consolidated around the phase of development we call “coming of age”. The hitherto sharp and often painful internal conflicts of adolescence now merge into a greater sense of integration. That means a tolerance of doubt, of ambivalence and of inner contradictions which strengthen where earlier they seemed to threaten stability. So, I reflected, as our rather young discipline has matured to the point of achieving its sense of assured identity—in the space of months or a few years—this Association could accept and wanted to recognize a representative of its own hitherto underprivileged “other half”—the frankly and explicitly “subjectivist” psychotherapeutic or “dynamic” viewpoint.

This study, in two parts, compares the immediate and more long-term outcome of two groups of schizophrenic patients admitted to hospital before and after the introduction of pharmacotherapy in the form of reserpine and the phenothiazines. There have been differences of opinion as to whether the undoubted improvement which has occurred in the prognosis of schizophrenia, at least in the short term, since the introduction of chemotherapy has been due to the use of these drugs, to changes of administrative treatment, or to both. There has been evidence from mental hospital statistics (Shepherd et al., 1961) that changes in outcome began before the introduction of the drugs and were almost certainly related to the changes of administrative treatment or institutional management which have occurred in the mental hospitals over the same period. It may well be that the use of drugs has facilitated these changes as well as having a more direct effect oh prognosis, but the relative importance of these two factors is difficult to assess from mental hospital statistics. Comparison between results obtained in different hospitals is also of limited value because of the number of uncontrolled variables. There would seem, therefore, to be an advantage in the more detailed examination and comparison of a smaller number of patients admitted to the same hospital, and the present investigation is of this type. The material consists of two groups, of 50 patients each, admitted to the Professorial Unit at the Maudsley Hospital in the years 1952/53 and 1956/57 respectively. Since the policy throughout has been to admit only non-compulsory patients for relatively short-term treatment, administrative changes in this hospital between the two periods are likely to have been minimal. The aim was to compare both immediate and long-term outcome in the two groups and to examine the effect of a number of variables on this. The short-term outcome will be considered in the first and the long-term outcome in the second paper.

In the previous paper a comparison was made between short-term outcome of two groups of 50 schizophrenic patients each, admitted to the Professorial Unit of the Maudsley Hospital before and after the introduction of reserpine and phenothiazines into treatment. It was shown that patients admitted in 1956/57 (Group B) had a better prognosis in terms of condition on discharge and length of stay in hospital than those admitted in 1952/53 (Group A).

This is the first of a series of papers reporting studies of various cognitive disorders in schizophrenia. The present paper deals with the validity of certain tests as measures of thought-process disorder: subsequent papers will relate type of disorder to various sub-categories of schizophrenia, as diagnosed clinically and by the Symptom-Sign Inventory (Foulds, 1965).

Several workers have suggested that important differences exist in the cognitive disorders shown by patients in the various sub-groups of schizophrenia (Shakow, 1962, Lothrop, 1961). In this report the cognitive disorders investigated are those measured by the following tests: the Bannister-Fransella test (1966), which aims to measure “looseness and inconsistency in the use of constructs (concepts)” and two tests from the Payne-Friedlander (1962) battery intended to measure “over-inclusive thinking”—the Payne Object Classification test (Payne, 1962) and a modification of Benjamin's Proverbs (Benjamin, 1944). The differences among the schizophrenics which are considered are those between the acute and chronic stages of the illness and between paranoid schizophrenia and the non-paranoid varieties of the illness—hebephrenia, catatonia and simple schizophrenia.

The occurrence of psychotic episodes indistinguishable from schizophrenia in epileptic patients has long been recognized, and Slater, Beard and Glithero have recently published their findings in sixty-nine such cases.

In recent years there has been a considerable shift towards the treatment of psychiatric patients outside hospital; and although progress in the expansion of such services as hostels, day centres and social work has in many places been slow, the idea of a Community Service based on home care whenever possible has become a popular one and forms the basis of official planning in this country (16). Doubts have, however, been expressed as to the wisdom of so great an emphasis on this untried method of management (13, 34, 39); the proper evaluation of Community Care is therefore of great importance.

Maddison and Mackey, in their review article “Suicide, the Clinical Problem” (1966), emphasize “the interpersonal significance of suicide, a viewpoint which is complementary and not alternative to an intensive study of the patient's intrapsychic life.” They continue: “More than usual attention needs to be given to the specially significant individual to whom the suicidal patient is often ambivalently bound in a symbiotic relationship, for highly relevant psychopathology will very frequently be found in this person …”.

An ecological study by Philip and McCulloch (1966) demonstrated very high correlations between the incidence of attempted suicide and the rates of incidence for repeated attempted suicide, overcrowding, having been taken into care by the local authority, having had contact as a child with the Royal Scottish Society for the Prevention of Cruelty to Children, and juvenile delinquency. McCulloch and Philip (1968) showed that persons admitted to hospital following a suicidal attempt manifested these variables to a high degree. In this latter study “juvenile delinquency” was replaced by “all offences” as a variable. The present paper reports on the relationships between a scale based on these variables and a number of psychological measures gathered from 84 of the 95 patients in the latter study.

There is growing evidence of a connection between the metabolism of monoamines and severe depressive illness, but the exact role of these substances in affective disorders has yet to be defined. We know that reserpine depletes the brain of monoamines and that a proportion of patients treated with this compound develop a depressive illness. Conversely a number of compounds which raise the levels of amines in the brain by blocking the enzyme monoamine oxidase have been used in antidepressant therapy. The knowledge that loss of amines may be associated with depression, and that their replenishment in the brain may induce recovery, immediately leads to the question as to which of the biogenic amines is responsible for the affective changes. Pollin, Cardon and Kety (1961) observed the effect of giving various amino acids together with a monoamine oxidase inhibitor (M.A.O.I.) to patients suffering from chronic schizophrenia. They found that only tryptophan, the precursor of the monoamine 5-hydroxytryptamine (5HT), produced an elevation of mood. On the basis of their results, Coppen, Shaw and Farrell (1963) treated a number of patients suffering from severe depressive illness with M.A.O.I. and half of this group also received an oral dose of a suspension of D L-tryptophan (214 mg./kg. body weight) for one week. The patients taking tryptophan and M.A.O.I. recovered more rapidly than those receiving M.A.O.I. alone both while they were on tryptophan and also subsequently. One explanation for these findings was that the combination of M.A.O.I. and tryptophan increased the amount of amines derived from tryptophan in the brain, and that it was this which was responsible for the therapeutic effect. If this were so, then there were several possibilities. The first was that the level of 5HT in the brain was low in depression and the combination of amine precursor and enzyme inhibitor brought it back to normal. Alternatively it may be that recovery occurred as a result of the presence of abnormally large quantities of 5HT in the central nervous system or even following the production of tryptamine, another amine derived from tryptophan.

In 1957 Krantz, Truitt, Ling and Speers found that the inhalation of small amounts of hexafluorodiethyl ether (Indoklon) produced convulsions in animals, and it was later used as a therapeutic convulsant for the treatment of psychiatric patients (Krantz, Truitt, Speers and Ling, 1957).

There is a growing body of evidence that oxypertine (Win. 18,501), a recently developed indolylalkyl-phenyl-piperazine (1, 9), is of value in the treatment of schizophrenia (6). Oxypertine has been described as superior to trifluoperazine in its effect on certain aspects of schizophrenic behaviour (2, 5).

Since the introduction of chlorpromazine in the early 1950's, various phenothiazine tranquillizers have become established as standard treatment in schizophrenia. However, it is recognized that these drugs have their limitations; every mental hospital contains a large group of schizophrenics whose illness is unaffected or only partially modified by phenothiazines, and some patients develop side-effects sufficiently severe to preclude these drugs being given in fully effective doses.

It has been shown by Parkes (1) and other workers that about 45 per cent. of out-patient schizophrenics are unreliable at taking their phenothiazine medication. It is in this group that many relapse and require readmission to hospital. Kline (2) quotes that 20 per cent. of in-patients are also unreliable in this regard. With the advent of a long-action phenothiazine injection fluphenazine enanthate, control of these difficult patients may well prove more effective.

Previous assessments of nortriptyline (Bennett, 1962; Rose and Leahy, 1964) have suggested that it has useful anti-depressant properties, and a preliminary trial in which the present authors were involved (Rose et al., 1965) found that it compared sufficiently favourably with amitriptyline to merit further controlled study.

In a previous study (Willcox et al., 1965), we reported the results of urine tests on a series of psychiatric out-patients, done with the aim of determining whether the patients were taking their pills as prescribed. We now report a similar study on in-patients. It is a matter of clinical experience that some psychiatric in-patients avoid taking their pills as prescribed, for in-patients who take an overdose in a suicidal gesture often say that they 'saved up’ their prescribed pills in order to do this. There are many other reasons, such as the occurrence of unpleasant side-effects or a belief that the pills are not doing any good, which might lead in-patients to avoid swallowing their pills at medicine-time, and though we should not expect to find this happening as often in in-patients as in out-patients yet the proportion of cases in which this occurs and whether it occurs more often with one type of drug than another are matters of general concern.

The ancient Greeks likened people who withdrew into themselves, were slow, and had a distant and frowning expression, to those who had consulted the holy oracle of Trophonius in Lebadeia about what was to happen to them in the future. King Croesus of Lydia consulted it about his expedition against the Persians (Herodotus I), Mardonius about his war against the Athenians (Herodotus VIII), the Thebans in the war against the Spartans (Pausanias IV) before the battle of Leuctra. Others consulted the oracle about their spiritual and mental state. There is evidence that among them were men who were concerned with psychological or metaphysical problems, a preoccupation which sometimes indicates the presence of psychological disorder. Timarchus, to whom we shall refer later, belongs to this category.