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.

Anxiety may be present to a greater or lesser degree in almost every psychiatric syndrome. The ability to quantify the degree of anxiety present in an individual patient has important implications for diagnosis, treatment and prognosis. Accurate clinical assessment of anxiety is by no means an easy task, although many psychiatrists believe it to be. If no other methods are used, there is no way of knowing how often an individual clinician is right or wrong. However, if several independent methods of assessing anxiety are used, more data are available, and a better overall judgment on an individual patient can be made.

In this journal, Hardwick, Pearse and Petrow (1957) advanced the view that slightly lowered steroidal production may predispose individuals to abnormal mental states, thus suggesting the possibility of treating such disorders with some form of replacement therapy. They screened a number of steroidal compounds for such use and concluded that the most promising was 6β hydroxy:3: 5 cyclopregnan 20-one (“neurosterone”). In their small-scale preliminary study this agent appeared to be of value in the treatment of a variety of psychiatric patients, including those with symptoms of anxiety, depression, and obsessive behaviour.

Few psychiatric controversies have been as persistent as the disagreement surrounding the nosology of depression. The conflict centres on the question of whether depression is a single illness, with its many faces manifestations of individual idiosyncrasy and severity, or whether it constitutes two or more separate conditions. The 1926 debate at the British Medical Association Meetings, with Edward Mapother (11) propounding the case for a single illness and Buzzard and Ross advancing claims for a dichotomy, has in one form or the other continued until today. The issue is complicated by the fact that few terms in psychiatry are used with as many different meanings as depression. Unfortunately the use of the term is seldom clearly defined. As Humpty Dumpty said in Through the Looking-Glass, “it means just what I choose it to mean—neither more nor less”.

Electroconvulsive therapy, modified by intravenous anaesthesia and muscle relaxants, has long been accepted as a satisfactory form of treatment. Relatively simple and safe, and effective in selected cases, the technique has undergone little change in recent years and seems almost in danger of becoming fixed indefinitely in its present form.

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.

It is now widely accepted that tricyclic compounds are of value in a proportion of depressed patients and that drugs of the imipramine group can take four or more weeks to exert their effect (Moody et al., 1967). There is a temptation to assume that one must wait this period before assessing response and that this is necessarily the best time for predicting the ultimate outcome of treatment. In experience with amitriptyline and nortriptyline both authors gained the impression that patients who were going to respond well were already a clinically distinct group after two weeks' exhibition of the drug, and indeed that waiting till four weeks blurred the distinction because by then poor responders might also have improved. It was decided to test this impression further.

In depressive illness disturbance of the sleep pattern is regarded as one of the most important and characteristic of the clinical features. It is commonly believed that the pattern of insomnia is typical or even diagnostic of certain affective disorders. Reactive depressions are said to cause a delayed onset of sleep and endogenous depressions to cause early waking.

The relationship between ordinal position of birth and mental illness, and particularly schizophrenia, is a familiar issue to regular readers of this journal. Its significance rests mainly in the fact that on genetic grounds each ordinal position of birth in a sibship is equally vulnerable. Therefore conclusive evidence of a positive relationship between birth order and mental illness, while not excluding the importance of hereditary factors, offers a good indication of the operation of some, possibly early, familial environmental influences.

There have been many reports which suggest that there may be abnormal glucose metabolism in severe depression. Glycosuria was first reported nearly 60 years ago (Allers, 1914). In 1919, using an oral glucose tolerance test, Kooy observed decreased tolerance in a heterogeneous group of mentally ill patients which included melancholics. Since then many investigators have reported decreased glucose tolerance in depressive illness, and the extensive literature is reviewed by McFarland and Goldstein (1939) and Altschule (1953). Oral glucose tolerance tests have usually shown high or delayed peaks and a slow return to fasting levels, although the latter are usually reported normal. Intravenous glucose tolerance tests have also shown results nearer those obtained in diabetic patients than in normal subjects. Pryce (1958) reported decreased glucose tolerance with intravenous tests in a sample of 20 depressed patients, and he also found that glucose tolerance did not alter significantly after clinical recovery. Glucose supplements were added to the diet of six patients prior to testing, but he concluded that these supplements did not appear to alter glucose tolerance.

Foulds (1965) proposed that the classes of psychiatric illness can be described in terms of a continuum of increasing degrees of failure to maintain or establish mutual personal relationships. This concept of all psychiatric illness as an “illness of the person” centres on processes which occur in the mentally ill that interfere with the satisfactory establishment and relative endurance of adequate personal relationships. Foulds conceptualizes these interfering processes as barriers to achieving “personhood”: they may present as signs or symptoms of psychiatric illness or as abnormal degrees of personality traits. Thus, for example, cognitive disorder would make the schizophrenic unable to cope with the demands of interpersonal situations. Similarly, egocentricity would render the psychopath incapable of empathy and with a tendency to treat “others as objects or as organisms than as persons”. In both examples social alienation is inferred, manifested in the first case as withdrawal and in the second case as rejection. It is Foulds' thesis that this incapacity for mutual relations increases along a continuum from normality, through the personality disorders, neurosis, integrated psychosis (melancholics, manics and paranoids) to non-integrated psychosis (the schizophrenics).

Since Janssen's (1959) introduction of haloperidol, numerous clinical trials have been published showing its usefulness in the treatment of mania and hypomanic states. Davies (1962) found it an effective drug in the treatment of adult patients showing aggressive behaviour resulting from various causes, and in the management of mania. Gerle (1963), in his review, showed the effectiveness of this drug in the control of disturbed behaviour in mentally sub-normal patients. He also showed (1962) that patients taking this drug are remarkably free from toxic reactions such as jaundice, agranulocytosis and allergic dermatitis. Haloperidol has been used in our unit (Rogers, 1955, 1965a) over the past three years. The impression has been gained that it controls aggressive, overactive and destructive behaviour in severely disturbed children, without impairing their ability to participate normally in the therapeutic activities of the unit (Rogers, 1965b).

At the Massachusetts Mental Health Center (M.M.H.C.), a well-staffed university psychiatric hospital, an outbreak of alleged chlorpromazine-induced skin rashes recently occurred involving five dramatic young female patients. Investigation of the complaints led us to doubt whether medication was the cause. Why then did these women blame chlorpromazine? Thus, the central concern of this investigation: which patients are likely to complain of drug-induced side-effects and under what conditions? A second issue arising from our study and described in the literature is the need for care when differentiating the true from the alleged medication side-effect.

The measurement of muscle blood flow using occlusive plethysmography has recently been proposed as an objective index of anxiety (Harper et al., 1965; Kelly, 1966, 1967). Although the method has been used by physiologists for many years, and its sensitivity to psychological stress has often been mentioned as an incidental finding in physiological studies, its application in psychiatric or psychological research has been slow to develop, perhaps because rather cumbersome apparatus is required. However, promising results were reported by Kelly (1966), who differentiated patients suffering from anxiety states from mixed neurotic patients and normal controls, and who showed changes after leucotomy in anxious patients.

Two common forms of alcoholism are described (World Health Organization, 1952; Kessel and Walton, 1965). The first is well recognized clinically, and has often been portrayed accurately by novelists and dramatists. So successfully has this more conspicuous form of alcohol addiction been publicized by Alcoholics Anonymous that Jellinek (1960) cautioned medical readers against overemphasis on it to the exclusion of the other clinical variety of the illness.

The results of a comparative trial of desensitization and psychotherapy for phobias have been reported (Gelder, Marks and Wolff, 1967). Desensitization was found to have a rapid and rather specific effect on phobic symptoms, which was followed by improvement in social adjustment. During group and individual psychotherapy, phobias and other symptoms changed more slowly and social adjustment often improved without any corresponding improvement in phobias. At the end of the investigation the phobias of 14 of the original 26 psychotherapy patients had shown no worthwhile improvement. Six months later, another follow-up showed that 5 had improved further, leaving 9 still unimproved. It was decided to try the effects of desensitization with these patients, particularly in view of a finding by Lazarus (1961) that desensitization helped patients who had not responded to a very brief form of group psychotherapy. As Lazarus worked with volunteer subjects rather than psychiatric patients, and as his “group therapy” averaged only eight weeks, his finding required confirmation before it could be applied to psychiatric patients.

In view of the increasing demand for paediatric psychiatric services a separate department of Child and Family Psychiatry was set up at Stratheden Hospital, Cupar, in 1958 to provide a comprehensive service in the County of Fifeshire, Scotland. The establishment consists of one consultant, one senior registrar, two registrars, three social workers and one psychologist. The department also has 12 beds to which children are admitted for psychiatric assessment and treatment. Out-patient clinics are held in general hospitals throughout the county and emergencies are seen both in the department and at out-patient clinics.

Toxaemia of pregnancy remains the “disease of theories” both in respect of its causation and treatment. Among the many treatments suggested, although not generally accepted, is the administration of progesterone from the middle trimester for the relief of toxaemic symptoms (1, 2 and 3). An unexpected finding has been the clinical observation that children of progesterone-treated mothers appear to reach their milestones earlier and to make excellent progress at school.

Drugs that increase the concentration of catechol and indolic amines in brain may relieve depression, while those that lower their concentration may cause it.

The work described in this paper began as just another drug trial. The authors' interest was aroused by the possibility of a new, fast-acting anti-depressant, unrelated to the monoamine oxidase inhibitors or tricyclic compounds.