I regard it as a singular honour and privilege to have been invited to deliver this lecture named in honour of Dr Henry Maudsley. His name is revered in medicine, not least because of his generosity in founding the Maudsley Hospital, famous throughout the world, but also because, as a former President of the Royal Medico-Psychological Association, he was active in that body out of which your distinguished college eventually evolved. The topic I have chosen is one which seems to me to be of great topical interest in an era both of increasing public scrutiny of medical practice and of the delivery of health care in a changing society. This scrutiny has brought advantages, but also substantial disadvantages to clinical medicine.

The patients seen at five psychiatric clinics in general practice (GP) serving an urban population of 78, 200 are described, and their attitudes to the clinic compared with those for conventional out-patient clinics. The GP psychiatric clinics were strongly preferred, mainly because of their ease of access and absence of stigma; 19 per cent of the patients seen would not have attended a hospital clinic. The patients seen encompassed the entire range of psychiatric disorder, but most were treated in the clinic or by other members of the primary care team. It is concluded that GP psychiatric clinics offer a way of achieving better community psychiatry without any need for increased resources.

The impact of devolving out-patient care to general practice (GP) psychiatric clinics over a two-year period is examined by comparing the frequency of contact with different psychiatric services in practices with and without psychiatric clinics. The clinics led to an increase in the number of outpatients seen, but to a fall in the number of new referrals. There was also a relative increase in the number of domiciliary visits and increase in acute day hospital referrals. The most important result was a 20 per cent fall in the number of admissions to the psychiatric hospital, which took place at a time when the national trend of falling admission rates was reversed. The findings suggest that psychiatric resources for in-patients can be deployed successfully in primary care without any increase in staffing.

The contribution of genetic differences to variation in ageing and the relationship of ageing to certain types of dementia are discussed. Neuropathological changes commonly found in the ageing brain are present in more severe form in Alzheimer-type dementia, Down's syndrome, multi-infarct dementia, and a substantial number of patients with Parkinson's disease. An increased frequency of ageing-associated changes outside the brain have been reported in Alzheimer-type dementia, Down's syndrome, and multi-infarct dementia, although the evidence is generally meagre and in many cases requires further corroboration. Genetic studies of Alzheimer-type dementia support the existence of heterogeneity on the basis of family history and age of onset; early onset is associated with greater genetic risk and severity of abnormality. The increasing evidence of an association between DNA damage, premature ageing, and neuronal cell loss may provide insights into the aetiology of these and other forms of dementia.

Twelve patients with obsessive compulsive disorder were studied with psychophysiological measures during a randomised, double-blind placebo-controlled drug trial. Significant clinical improvement followed six weeks of treatment with the tricyclic antidepressant clomipramine, but was not evident after an equal period of treatment with the monoamine oxidase inhibitor (MAOI) clorgyline. Compared to placebo, both drugs reduced skin conductance indices of baseline arousal, but only clomipramine reduced skin conductance and heart rate responses to loud tones and tonic and phasic skin conductance responses in a two-flash discrimination task. This suggests that reductions in autonomic responses to important and/or aversive stimuli may be critical to clinical improvement in obsessive compulsive disorder.

One hundred and six adult neurotic patients attending a behavioural psychotherapy unit were asked about their use of alcohol and other drugs and the perceived anxiolytic effect of these substances. Their drinking behaviour was not significantly different from that of the general population. Alcohol and other drugs were not perceived as reliable anxiolytics and not regularly used as such. Where alcohol or drug abuse coexist with anxiety-related problems, it is helpful to ask the patient to withdraw from these substances prior to starting behavioural therapy of the latter. We ask patients having behavioural therapy to refrain from alcohol or drug use prior to therapy or homework tasks.

Professional raters who were blind to proband diagnosis used the schedule for affective disorders and schizophrenia (SADS-L) and the Research Diagnostic Criteria (RDC) to evaluate 1, 210 first-degree relatives of 327 probands with primary major depression, participating in the family sub-study of the NIMH Collaborative Study of the Affective Disorders – Clinical Branch. Bipolar II probands were significantly more likely to have bipolar II relatives than were non-bipolar or bipolar I probands. Bipolar II probands were slightly more likely than non-bipolar probands and slightly less likely than bipolar I probands to have relatives with bipolar I illness. Similar patterns have emerged in two other recently reported family studies of bipolar II illness. Taken together, these data suggest heterogeneity among patients with bipolar II depression. Some appear to be genotypes for bipolar I illness, while a small proportion may be genotypes for non-bipolar illness. A third group, of undetermined size, may breed true.

The concept of ‘projective identification’, introduced by Melanie Klein and extensively used by her followers, is still held by many to be highly controversial and difficult to understand. Great importance is also attached by Kleinian workers to what they describe as the infant's early use of ‘idealisation’ as a defence against anxiety. A hypothesis is presented according to which both mechanisms could be seen as the continuation or persistence, in mental form and in early post-natal life, of some of the ways in which the unborn child could be said to relate to the mother physically during the last few months of intrauterine life.

Serum cholesterol levels were estimated in 313 mentally handicapped patients who subsequently died from various causes. Although cholesterol levels in the mentally handicapped are lower than those in the general population, it was found that there was still an association between relatively low serum cholesterol values and mortality due to cancer of the colon. Similarly, patients who died from myocardial infarction had relatively high serum cholesterol levels. The mechanism of the relationship between hypocholesterolaemia and cancer of the colon is unclear, but the increasing longevity of the mentally handicapped is an important factor which has contributed to a rising incidence of cancers, particularly gastrointestinal forms, in this group.

Measurements of skin conductance response frequencies (SCRf) were obtained from 30 acutely ill schizophrenic patients during a standardised videotaped interview, conducted with the patient's key relative present. Significant differences in SCRf's were demonstrated between patients whose relatives had high and low Expressed Emotion (EE) respectively. Patients at high risk of relapse were allocated either to a control or an experimental group, the latter being offered a number of social interventions in order to reduce the relative's EE and/or contact with the patient. Follow-up measurements were obtained on 19 patients nine months after discharge. Although social intervention was highly successful in reducing relapse rates, its effects did not appear to be directly mediated via SCRf, which was found to be independently related to relapse.

A review of reported cases of attempted suicide in Benin City indicates that the incidence has not increased over the four-year period 1978 to 1981, during which the average crude suicide attempt rate was 7 per 100, 000. Eighty seven per cent of the attempters were under the age of 30, but the commonest age-group was 15–19 years (39.4 per cent). The female/male ratio was 1:1.2. The majority of the attempters (64 per cent) were students, housewives, and the unemployed. Ingestion of drugs (68 per cent) or of chemicals (20 per cent) was the predominant method. The major predisposing factors were mental illness (32 per cent) and conflicts with parents (24 per cent).

In a retrospective study, 20 psychotic children and adolescents with hallucinations were compared with 15 psychotic controls without hallucinations. In the former, auditory hallucinations predominated, which tended to be localised in the internal space of the child. Subjects with hallucinations had significantly more symptoms of depression and anxiety, more precipitants of illness and problems in reading ability. There was a trend for increased laconic speech in them. The findings suggest a link between hallucinations and mood and cognitive changes in children and adolescents with psychoses of late onset.

The paper compares the prevalence of psychiatric morbidity amongst sentenced prisoners and in the general population. Major psychosis was no more common in the majority of studies of criminal populations. Although prisoners have a higher level of neurotic symptomatology, this was mainly found to be secondary to imprisonment itself. Long term imprisonment was not found to be a precipitant of severe psychiatric morbidity or intellectual deterioration, and prisoners adopt elaborate coping mechanisms which may themselves be protective. However, there is a higher prevalence of mentally handicapped and epileptic prisoners, and doctors in the Prison Medical Service have to cope with frequent, serious behavioural problems. Prisons appear to be a particularly important area for future psychiatric research.

Generalized and partial seizures induced by antipsychotic agents are well documented in the medical literature, but these patients generally do not present a management problem. The incidence of this phenomenon is less than 1% in both psychiatric and general medical population (Malcolm, 1972); we came upon only one report of a psychomotor status-like episode due to iatrogenic drug effect in the relevant literature (Kuschke, 1972). According to Gastaut's (1970) classification of epileptic seizures, the general term for psychomotor status is partial seizures with complex symptoms.

The dexamethasone suppression test (DST) was carried out on 143 patients with a major depressive disorder, who were classified into those with a history of weight loss (n = 89) and those without (n = 54). Seventy-three per cent of patients with weight loss and 61% of patients without had an abnormal DST; this difference was not statistically significant. Of the patients receiving prophylactic lithium therapy, 13 were found to have changed their DST status on retesting after a period of 14 months, but there was no significant difference in their weight. It is concluded that weight loss is not a necessary condition for an abnormal DST in depressive illness.