The extent to which psychiatric disability after head injury depends upon the brain damage which has occurred remains a problem of considerable practical and theoretical interest. In 1904 Adolf Meyer saw the need for caution in approaching this question since there was “no direct measure of the damage of a concussion”; similarly in 1945 Denny-Brown saw that the most serious obstacles to better understanding still lay in the difficulty of obtaining a reliable estimate of the severity of injury to the brain and in the impossibility of differentiating clinically between simple skull fracture, laceration or contusion of the brain.

In December, 1965, a patient was admitted to the wards at Parkside Hospital, Macclesfield, with a Korsakoff syndrome which had appeared following a suicidal hanging attempt. Strangulation as a cause of the Korsakoff syndrome appears in all surveys of the numerous causes of the disorder, from Bonhoeffer (1904) to Lewis (1961), but only one case (Whiteley, 1958) has been described in the English literature and this only briefly. Indeed, the whole subject of the neuropsychiatric sequelae of attempted hanging has received scant attention in the English literature, yet according to statistics of the Registrar-General (Stengel, 1964), hanging is the second commonest method of suicide in males in this country. Moreover, Bokonjic (1963) has collected 19 cases admitted to hospitals in Aarhus and Copenhagen between 1948–1958 suffering from the anoxic effects of attempted hanging, whilst Berczeller and Nowotny (1935) claimed to have dealt with 100 hanging survivors in the Vienna University Clinic over a ten-year period. Possibly of greater importance in justifying a review of this subject is the fact that the neuropsychiatric sequelae of attempted hanging are really those of cerebral anoxia. In this age, when surgical techniques involving interruption of the cerebral circulation are growing more frequent and when methods of anaesthesia and particularly dental anaesthesia are evoking a good deal of attention and contention, it is important that the psychiatrist should have some acquaintance with the psychological and neurological symptoms and signs that are caused by cerebral anoxia.

Many investigators have studied the relationship between life events and psychiatric illness to discover whether certain events predispose to some disorders or precipitate them, and to discover the effect of illnesses already in progress on subsequent life events and the effect of events on established illnesses. The validity of such studies depends, among other things, on the selection of suitable controls. For example, if adult patients with depression differ from a group of controls in that they had a higher incidence of parental death, it might indicate that bereavement had made them more susceptible to the development of the illness. But if the depressed patients were from a lower social class than their controls, the greater incidence of bereavement might be explained by the fact that there is a higher death rate in that stratum of society. This would then cast doubt on a conclusion about a causal relationship in that group between childhood bereavement and depression in adult life.

Schizophrenia still offers the psychiatrist one of his greatest challenges, in spite of the volume of research that has been lavished on it, and the many important therapeutic improvements that have been achieved.

Psychiatrists have frequently pointed out that in a high proportion of individuals who commit suicide it is apparent that there is pre-existing psychiatric illness. It has been further shown that many of these people have received medical care and have been attending their doctor within four weeks of their death (Motto and Greene, 1958; Seager and Flood, 1965). The implication of these findings is that doctors do not always recognize psychiatric illness in their patients and are certainly not attuned to the possibility of suicide, even when the patient frankly states that he finds life is not worth living and that he has considered ending his life. Such straightforward information is not accepted at its face value. The doctor may hold the mistaken view that people who talk about suicide do not in fact commit the act. This statement is manifestly incorrect. It has been shown (Robins et al., 1959) that 70 per cent. of suicides have declared their intention of committing the act days or weeks beforehand.

Claims have been made that thyroid hormone treatment benefits some schizophrenic patients. Earlier studies reported the use of dried thyroid in a dose of 48 gr. (2·9G) daily in a schizophrenic (Hoskins and Sleeper, 1929) and in other psychiatric states up to 60 gr. (3·6G) daily (Minski, 1927), but recent papers describe the use of l-triiodothyrgnine in place of dried thyroid in treating schizophrenics (Lochner, Scheuing and Flach, 1963; Flach, Celian and Rawson, 1958). Huxley, Mayr, Osmond and Hoffer (1964) believe that schizophrenics are more resistant to the effects of some physiological substances, including thyroxine, as part of a genetic polymorphism.

Electroconvulsive therapy (E.C.T.), first introduced in 1937, rapidly became accepted as playing an important part in the treatment of depression. Since its introduction, there have been few modifications of the technique that have stood the test of time. The most important has been the use of muscular relaxants to modify the convulsion. Most recent advances have been directed towards the development of reliable criteria for the selection of patients most likely to respond to treatment, but little attention has been paid to improvements in the method of treatment as such.

Mandrax is a combination of methaqualone 250 mg. and diphenhydramine 25 mg. Burke and Mahadevan (1966) have found it to be as potent in this dosage as 200 mg. of butobarbitone.

Seven drugs of the imino-dibenzyl group are now generally available in Great Britain (imipramine, amitriptyline, desipramine, nortriptyline, protriptyline, trimipramine and opipramol). All are similar in their actions and side-effects. Imipramine, the first to appear, has been shown to be more effective than placebo in the treatment of depression, though with much better results in men than in women (M.R.C. Clinical Trial, 1965). Desipramine, a metabolite of impramine, was introduced with the claim that its action was quicker than that of imipramine, though this has never been clearly demonstrated. Trials of desipramine against imipramine (Waldron and Bates, 1965; Rose and Westhead, 1964) showed no significant difference between these drugs. Comparison of amitriptyline and imipramine (Burt, Gordon, Holt and Hordern, 1962), showed amitriptyline to be at least as effective as imipramine and significantly superior in the treatment of endogenous depression. Comparisons of nortriptyline and amitriptyline (Forrest, Affleck, Gibb and Priest, 1964; Rose, Leahy, Martin and Westhead, 1965) showed no significant difference between these drugs.

Metronidazole (‘Flagyl’) has recently been said to be of value in treating alcoholism (Taylor, 1964). The drug is, of course, better known for its use against trichomoniasis. Three main claims have been made about it: (a) that it has an effect like disulfiram (Taylor, 1964; Bonfiglio and Donadio, 1966; Lehman, Ban and Nalchayan, 1966); (b) that it cuts short withdrawal symptoms (Lehman et al., 1966); (c) that it reduces craving and thereby allows return to normal drinking (Lehman, et al., 1966; Elosuo, 1966; Bonfiglio and Donadio, 1966). It is this last claim that is particularly important, since other well-tried preparations are in use for the first two purposes. We report a double-blind controlled trial directed to the possible disulfiram-like effects of the drug, and to its ability to reduce craving.

Obsessional neurosis is generally considered to have a poor prognosis (Farr and Stewart, 1942; Müller, 1953; Rüdin, 1953; Ingram, 1961; Noyes and Kolb, 1963; Kringlen, 1965). Factors adversely affecting prognosis include early onset of symptoms, premorbid obsessional personality and the emergence of complications.

A patient, S., voiced the opinion that subnormals, the blind, anyone with physical or mental imperfections should be exterminated. This included the psychiatrically ill and consequently himself. He had attempted suicide, and said that when he thought it appropriate he would attempt suicide again. In projective tests and interviews he expressed the wish to kill his father, and showed much sado-sexual fantasy and racial prejudice. Psychological tests showed that he was of average intelligence, non-retarded and abnormally overinclusive. He was diagnosed initially as “paranoid schizophrenic”. Such bizarre and macabre features are not necessarily dangerous, but S. was married with two young children. He believed his children to be highly intelligent. Another baby was expected shortly. This study attempted to predict whether these attitudes were potentially dangerous should the patient discover some imperfection in his family.

Much confusion has resulted in recent years from the use of the word “community” to mean merely “outside hospital”. Community psychiatry is not just extramural work or a means of avoiding hospitalization. A community mental health service is a comprehensive psychiatric service of care and treatment for a defined population, including full hospital facilities (Freeman, 1963). The hospital is in fact part of the community, and provides one of its services. The size of population base that can most efficiently support a comprehensive service is probably between 150,000 and 200,000 in urban areas, judging by experience in Lancashire (Smith, 1965). This is large enough to contain all the basic services that are needed, and small enough to allow all key professional workers to remain in constant face-to-face contact. Within its defined area, the service must have continuous and final responsibility, whatever the clinical state of individual patients. It must offer a continuous spectrum of integrated services, from full-time, permanent care in an institution on the one hand, to occasional support for a patient or family at home on the other. Since the demand for services is potentially infinite, an essentially ideological choice must be made in assessing priorities for the resources that exist. I believe that if we try to act primarily on the basis of human needs within the total community, the first call on these resources must be for the three great problems of schizophrenia, subnormality and old age. Concentration on psychotherapy would make it more likely that these greater social needs remained unmet, and it may well be that any large-scale treatment of neurosis or personality problems would have to be outside psychiatric—or even medical—channels (Ryle, 1967).

In the United States considerable emphasis is at present being placed upon emergency psychiatric services. This is part of a national drive to provide a high level of care for the total population and not just those who can afford the services of private psychiatrists. Investigations have been conducted in various centres in the U.S.A., and subsequent discussion and documentation (e.g. 5) suggest that emergency care is best given by a centre which also provides full in-patient and out-patient services. This echoes and reinforces the recommendations of the “Community Mental Health Centers Act”, which promises Federal matching funds to American states setting up community mental health centres, provided the services are comprehensive. The term “comprehensive” is defined in some detail, and comprises in-patient and out-patient services, partial hospitalization (e.g. day-care), emergency services for 24 hours in the day, and consultation and educational services to professional personnel and to the community at large.

An analysis has been reported of the in-patient case-load of a comprehensive psychiatric department (Queen's Park Hospital, Blackburn) for the twelve months ending 28 February, 1961 (Silverman, 1961). This analysis showed that a department of 99 beds was coping with virtually 95 per cent. of the total in-patient problem from a population of approximately 250,000. However, the criticism has not uncommonly been made that, although a department of this kind might appear to function with reasonable success at the outset, the nature of the psychiatric case-load is such that, sooner or later, an excessive number of beds would become blocked by long-stay patients and the service would become unworkable in its original form. It was therefore decided to report and analyse admissions and discharges over a much longer period, and the statistics for the four years ending 31 December, 1965, were utilized for this purpose.

The term “psychoanalysis” has a triple usage. First, it describes a connected body of observations about unconscious mental processes, systematically classified and more or less colligated and brought under general laws. This first meaning places psychoanalysis among the sciences, but a difficulty at once arises; for the phenomena with which psychoanalysis is concerned, and the methods used to study them, are so different from those upon which our tradition of science was first based that the question arises whether it is science at all.

To describe the role of the consultant psychotherapist in the mental health services, we must start from the situation in regard to psychotherapeutic needs in the community and the kinds of resources that can be mobilized to meet them. I should make it clear that when referring to consultant psychotherapists in the psychotherapeutic clinic I assume that optimally these specialists would be part of a comprehensive psychiatric service. For convenience I shall use the term “psychotherapeutic centre” to allow for the location of the psychotherapeutic services to vary according to circumstances in any one area. Also, although I shall speak often of the psychotherapist as though his was a rather separate contribution, I want to stress that this is partly a reflection of the present situation. Much of what I have to say about his role must become increasingly a part of the work of all psychiatrists.

While there are reports from the United Kingdom of the use of closed-circuit TV in medical education, most of those relating specifically to psychiatry appear to have come from North America. There is also one from the U.K. (Stafford-Clark, 1964) and a few others from elsewhere. But even in the U.S.A. there has been no rush to use television. According to Ramey, by 1964 only 179 of 1,500 departments of various kinds in U.S. medical schools were using closed-circuit TV, and only 141 to any substantial extent. Departments of physiology and pharmacology were found to be the prime users, with psychiatry coming a close third.