During the last two years, the medical profession in Britain has been participating in a public debate – perhaps in a more exposed way than for some time. Eminent Presidents have been writing letters to The Times, and less eminent ones demonstrating in Downing Street. This can all be seen as contributions to the discussion on the state of the National Health Service. But there is, I believe, a wider and in my view a more long-lasting change going on, namely the relationship between the medical profession and the public – the citizens of this country. You may feel that the basic premise is based on a false dichotomy, rather like the sterile debates on community care. Hospitals are part of the community. Doctors are citizens. Yet there is an implicit or explicit contract, social if not financial, between a country's medical profession and its citizens. As we are in the era of negotiating or inventing or specifying contracts, I wanted to consider this.

The Holocaust under the Nazi regime is probably the most traumatic catastrophe of our century and even of history in the civilised world. Its deepest abyss consumed the lives of one-third of the world's Jewish population, who were selected and murdered in a cold-blooded industrialised machinery of death in this their ‘Shoa’. The Jewish people represent the victims of the Holocaust more than any other group of human beings who suffered this iniquity. The Holocaust has left in its wake few survivors, and many invalids in body and in mind, who remain compelled to live with a trauma that surpasses any other deliberately caused by fellow humans: and it has left in its wake an entire nation in shame and bewilderment, stigmatised and traumatised by the horrifying crimes that were committed in its name, faced with the task of analysing what happened, so that it may never be repeated, forbidden by the enormity of the horrors from repressing the past, and obliged to integrate deeds that cannot be undone.

Political change in Eastern Europe has its catchwords: democracy, pluralism, human rights. Taken at face value, they seem to convey convincingly that a steady and consistent transition has been set in motion, with a clear purpose in mind: the de-structuring of stagnated totalitarian regimes and their replacement with more viable and flexible systems. I do not intend to discuss political change at this macro level, not because it lacks importance or interest, but because the events in question so directly affect my immediate human world and me as an individual that attempting to step out of their stream and judge them impartially is impossible for me.

“I think you ought to leave your head to the College of Surgeons to ascertain what wonderful impressionable substance it contains instead of brains” (G. B. Shaw to a correspondent, 1926).

Whereas the history of the Royal College of Psychiatrists has been reasonably well documented, that of its journal, under its various titles, has received little attention. What follows is an attempt to redress the balance, but this could not have come about if my attention had not been drawn to the existence in the College library of the original, handwritten minutes dating from 1841 of the Association of Medical Officers of Asylums and Hospitals for the Insane and the succeeding body, the Medico-Psychological Association. This historic treasure, to steal a line from one of its pages, written in immaculate handwriting and expressed in elegant Victorian Gothic prose, “contained an unworked mine of golden wealth”.

In the 18th century the main varieties of nervous illness – hypochondria, hysteria, the spleen, the vapours and dyspepsia – became included under the general term ‘nervous disorders'. When no physical disorder of the nerves could be detected in such conditions, the hypothesis of nervous disorder was replaced by the more vague concept of ‘nervous temperament’. The fact that there is still no evidence of pathological change in such cases continues to expose physicians to the alternative hypothesis of a purely psychological cause. The modern era in our understanding of the nervous system may be said to date from 1843 when Du Bois Reymond showed the electrical nature of nervous conduction. The publication of Jordan's Briefe Discourse in 1603 may be taken to represent the start of a discrete period (1600 to 1840) in the history of neurotic illness.

The first national training scheme for attendants upon the insane began in 1891. The Medico-Psychological Association considered this initiative as essential if asylums were to have therapeutic credibility and recruit high-quality attendants. The initiative failed because poor pay and conditions of service were obstacles to recruitment and better standards of care. The Association then sought to integrate asylum and general nursing, leading to a double sense of betrayal on the part of the asylum nurses. They felt betrayed by the failure of the training scheme to improve their career structure and by the threat to their jobs posed by the proposed merger with general nurses. They responded by unionisation, so that two decades after the introduction of training, its only major effect had been to politicise nurses and engage them in disputes with their hospital superintendents and employing authorities. Training raised expectations in the attendants which neither the Association nor the institutions had intended to satisfy, and it was not seen by attendants as of benefit either to them or to patients.

Modern comprehensive multidisciplinary mental-health services for children and adolescents have four origins: psychology from 1890, psychoanalysis from 1906, the child-guidance movement from 1920, and the children's departments of psychiatric teaching hospitals from 1930. Post-war changes in society and reform, especially the NHS Act 1946, contributed to rapid development of services and an increasingly wide range of sophisticated therapeutic interventions; professional and interdisciplinary associations and trans-Atlantic exchange were also influential. In the last three decades a succession of official inquiries, reports, legislation and reorganisations have had a damaging effect. Children and their services have been prey to causes célèbres, fashion and the exaggerated fads and foibles of the media and politicians; they have thrived best when society and their carers were tolerant, and loving, sought good qualities to augment, not evil to exorcise, and succeeded in balancing structure and control with flexibility and freedom to grow. Planners should review the past before acting.

In the mid-19th century, the Commissioners in Lunacy continued the direction of the earlier reform movements, but depended upon local magistrates for the execution of their ideas. The early development of a single county asylum is described from its beginnings, as are some of the personalities involved.

Progress in science depends upon the fertility of inspiration, the acuteness of observation, and the accuracy of instruments to measure those observations. It is with respect to the last of these that progress in psychiatry has lagged. Instruments in plenty have been devised, many have been acclaimed and some accepted as a standard against which the other measures are judged; some have even come to be used as a definition of the disorder to be measured, the achievement of a certain score indicating that the disorder is present.

Drinking is an activity determined partly by oropharyngeal stimulation and gastrointestinal sensations as well as biochemical changes, and thirst need not be involved. It is sometimes disturbed in mania or depression. Overdrinking (polydipsia) is common in long-stay in-patients, but only gives rise to water intoxication when there is a variable functional renal abnormality such as SIADH causing water retention. In contrast, in affective disorders, disturbance of sodium retention may be seen, possibly representing failure of nervous vascular control as part of the mental illness.

Of 250 patients newly referred to the mental illness services of South Manchester, almost two-thirds were referred directly by their GPs; a further third were referred by hospital doctors. Non-medical sources of referral accounted for only 2% of new cases. Patients with somatic problems had the longest interval between seeking care and referral to the psychiatric services. Being employed was associated with a longer delay before seeking care; among women, those living with their husbands or children had longer total intervals between the onset of the problem and arrival at the psychiatric services.

A new psychosocial/biological model of the psyche is proposed, in which the affects play a central role in organising and integrating cognition. The psyche is understood here as a complex hierarchical structure of affective/cognitive systems of reference (or ‘programmes for feeling, thinking, and behaviour’), generated by repetitive concrete action. These systems store past experience in their structure, and provide the functional basis for further cognition and communication. Affects endow these programmes with a specific qualitative value (such as motivation), connect cognitive elements synchronically and diachronically, and contribute to their storage and mobilisation according to context. They also participate in differentiating cognitive systems at higher levels of abstraction. These assumptions are supported by recent findings on the role of the limbic and hypothalamic system for the regulation of emotion, on neuronal plasticity, and on the phenomenon of state-dependent learning and memory. Refutable hypotheses are formulated for further research on the interaction of emotion and cognition.

One hundred and forty non-depressed primiparous women in a stable relationship completed two personality measures (the EPI and the IPSM) antenatally, and were then assessed for depression at several times post-natally. The risk of depression at six months was increased up to tenfold by high interpersonal sensitivity and threefold by high neurotic ism. When previously depressed women were excluded from analyses, high interpersonal sensitivity and, to a lesser extent, high neuroticism were still associated with an increased risk of being depressed. Interpersonal sensitivity, as measured, is suggested as a refined personality risk factor to both the onset and recurrence of depression.

Sexual abuse in childhood and adolescence was studied in 286 working-class mothers living in Islington, who were contacted on three occasions over a two-year period. The sample was collected primarily to study current vulnerability factors in the onset of depression, but childhood measures were also included to look at longer-term risk factors. Twenty-five women – 9% of the sample – reported sexual abuse involving physical contact before age 17 and, of these, 64% had case depression in a three-year period (which included the year before first interview). While such abuse was related to other earlier stressful experiences such as parental indifference, violence to the child and institutional stay, it was associated with an increased risk of depression over and above these factors. Sexual abuse before age 17 also related to having been divorced/separated or never having married/cohabited.

The long-term treatment outcome of 248 bipolar patients in an out-patient lithium programme was assessed. Over half of the patients (138 or 56%) had no affective episodes in the year observed. Patients were divided into outcome groups according to GAS scores: the outcome for 40% of patients was good, for 41% fair, and for 19% poor. More frequent psychiatric admissions before starting lithium treatment was the best predictor of poor outcome, followed by a negative affective style in the family and lower social class. Current alcohol and drug abuse was associated with poor outcome. Although familial and psychosocial factors were significantly associated with outcome, the findings suggest there may be inherent differences in the pathophysiology of bipolar disorder reflected in an increased frequency of episodes which account for a large variance in lithium treatment outcome.

Among 24 chronic schizophrenic patients, the 10 with high ratings for negative symptoms had significantly higher left-frontal: temporal–cortical T2 ratios. This finding was unrelated to age, dose of medication, length of illness or handedness. No T1 or T2 changes were found to be associated with positive symptoms or tardive dyskinesia in the regions examined.

A group of 64 Falklands war veterans who were still serving in the British Army were studied and compared with a group of matched controls. Half the veterans reported some symptoms of post-traumatic stress disorder, and 22% were rated as having the complete PTSD syndrome. Presence of the symptoms was associated with intensity of combat experience and the retrospective report of emotional difficulties in the initial period on return from the war.

“This paper discusses the advantages and disadvantages of case management systems for the co-ordination of care of people with long-term mental illness living in the community. Many of the principles are equally applicable to other client groups with long-term needs, e.g. elderly people or people with learning difficulties. Some of the historical background to the emergence of case management concepts is discussed, culminating in the recent White Paper on Community Care. The underlying concept of case management is examined, together with a number of fundamental questions concerning who should act as case managers, what kinds of training they will require, problems of inter- and intra-agency co-operation, and the empirical evidence regarding its effectiveness. It is concluded that case management could be an important element in a comprehensive range of mental health services, but it is not a substitute for basic community provisions.”

The purpose of this paper is prediction. It is bound to be proved wrong. Like long range weather forecasters and economists, psychotherapists are in an “impossible profession” (Freud, 1937), dealing with non-linear and therefore inherently unstable systems, unable to make accurate predictions about the future. But psychotherapists are familiar with uncertainty, and indeed perhaps actively cultivate it in order to work more creatively. Also, the development of chaos theory (Gleick, 1988) has now made vagueness a respectable topic for scientific inquiry.