Fifty-one school phobic children, aged nine to fourteen years, were assessed for psychiatric diagnosis; this revealed the presence of two clinically meaningful sub-groups—depressed and residual school phobic. A wide range of symptoms were studied to identify those which might prove useful in diagnosing adult-type depression in childhood and early adolescence, both in terms of frequency of symptoms in the depressed group and the extent of the distinction between the two groups. Eleven such key symptoms were identified and based on these, a formula for diagnosing adult-type depression was evolved. The validity of several different ways of classifying the above cases were explored; these covered: kind of disorder; type of onset; adolescence versus pre-adolescence; and sex of the child. However, on only one dichotomy—depression versus absence of depression—were there many significant discriminants. Affective symptomatology of more recent onset was contrasted with pre-morbid personality traits, usually associated with school phobia. There was no evidence to support the concept of ‘masked depression’ in childhood.

Gestalt therapy was developed by Frederick (Fritz) Perls, (1893–1970), a German psychoanalyst originally trained in the Freudian tradition; he left Germany in the 1930's for South Africa and emigrated to the United States in the immediate post-war years. Despite the publication of his book “Gestalt Therapy—Excitement and Growth in the Human Personality” (Perls, Hefferline and Goodman, 1950) his work remained relatively little known until Gestalt Therapy was taken up enthusiastically by the growth movement in the early 1960's. Although it is widely regarded as an established therapy in the United States, Gestalt remains relatively little known in the United Kingdom and there are probably few psychiatrists who are familiar with its theory and techniques. This paper is intended to present an introduction to Gestalt Therapy together with some idea of its application in clinical psychiatric practice.

A category of suicide which only accounts for about 5% of the annual suicidal deaths in the country may at first seem unimportant. Suicide is seen around the world in different races and cultures, so it is a fact of human nature. However, the suicide of an in-patient is uncommon, and produces great guilt in doctors and nurses when it happens. The result is often a defensive fatalism. However, if we do not allow feeling to block thought and observation, it is possible to learn from each of these deaths something about human beings which we can use in the practice of psychiatry.

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.

Society's attitude to psychiatry has always been ambivalent. When, as a young doctor, I announced my intention to take up this discipline to my then chief, who was a distinguished clinical pathologist, his face turned a deeper shade of purple, and he muttered something about “mumbo-jumbo and guesswork” before stalking off into his den. Much more recently, I broke a lifelong tradition by actually entering into conversation with a stranger on a British railway train. Somehow or another, he extracted from me the information that I was a Professor of Psychological Medicine. “Well, well, he murmured, “and I always thought that was the stuff they put into those huge bottles of red and blue liquid you sometimes see in the windows of the older chemist shops”. That gentle twitting is small beer by comparison with the grave reservations expressed by many individuals and groups.

Multiple deficiencies of vitamins and trace metals have been demonstrated in Down's syndrome. The picture is complex, especially since not all individuals are affected equally. Deficiencies are not age-related, but appear to be lifelong. The brain in Downs's syndrome does not develop adequately; one area, the hippocampus, which is concerned with memory, is poorly developed and is also involved in the pathological changes of Alzheimer's disease. The role of nutrients is discussed in relation to damage to the mature brain, and to the ageing process.

The effect of depressed mood on the tachistoscopic recognition of neutral/unpleasant words was investigated in a group of 18 depressed inpatients and in 17 normal controls. A 50% recognition threshold for 30 neutral words was calculated for each subject, in order to exclude the effects of depressive slowness on the experimental task. Each subject was tachistoscopically presented with a series of experimental words (30 neutral/30 unpleasant) at his 50% level, and the ratio of neutral to unpleasant words recognised calculated. Depressed subjects tended to recognise a higher ratio of unpleasant to neutral words.

The overvalued idea, first described by Wernicke, refers to a solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer's life. Disorders conforming to his definition are well documented, though their recognition as such has been variable, and they may not be as rare as is often thought. As well as sharing a distinctive phenomenology, the conditions develop in similar settings and carry a uniformly poor prognosis. Their pathogenesis is obscure and difficult to account for in conventional terms.

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.

“Do we have a problem?” said the chief nursing officer. He had a list of 16 Exe Vale in-patients who had committed suicide in a period of 30 months. We looked at the list and then looked for something to compare it with in other hospitals; and that was where the trouble began. Such data as were available had been collected in diverse ways and often in the wake of special difficulties, e.g. the Warlingham Park Hospital enquiry (Croydon Area Health Authority, 1974/75). Comparisons were unrewarding, so we looked at our own 16 cases for indications of local problems. We also extended the study to the ten-year period 1972–81, during which there were 40 in-patient suicides. Since then more deaths have occurred—two in 1982 and four in 1983. These are referred to here only where special features warrant mention. Local monitoring of deaths continues; and certain deaths are notified to the Hospital Deaths Study of the Royal College of Psychiatrists.

Twenty-three patients who believed they suffered from food allergy were studied at the time of their presentation to an allergy clinic. The presence of organic food hypersensitivy could not be confirmed in 19 who attributed common neurotic symptoms to allergy; this group was almost identical, in terms of psychiatric symptomatology and general characteristics, with a group of new psychiatric out-patient referrals. There was no evidence of psychiatric disorder or food-related psychological symptoms in four patients with proven food-related atopic symptoms. The study failed to find evidence that psychological symptoms might be the result of organic reactions to foods.

Bipolar and unipolar patients respectively were separated into psychotic and non-psychotic sub-types. The bipolar psychotic patients were more likely to have certain severe symptoms, such as hallucinations and motor abnormalities, than were the unipolar patients, but the family histories of the four sub-groups were identical. The psychotic sub-groups had a different course of illness, in that they were less likely to have had a history of multiple episodes on admission and were more likely to show chronicity for a period of time on discharge. The data are interpreted as being opposed to the concept of a continuum of vulnerability in the affective disorders, and as not favouring either psychotic unipolar or psychotic bipolar illnesses or schizo-affective disorder being considered autonomous. One possible interpretation of the findings is that a trait or propensity to psychosis is transmitted totally independently of the major affective illness, and that this propensity is silent or not observed when the patient is in remission.

The extent to which concordance rates for schizophrenia in monozygotic twins (between 36 and 58%) fall short of 100% is often taken as an index of the role of an environmental factor in schizophrenia, but such an agent remains elusive. That schizophrenic symptoms are observed in some viral illnesses suggests that schizophrenia might be due to a gene-virus interaction, but analysis of age of onset in pairs of siblings with the disease rules out horizontal transmission. An alternative hypothesis is proposed that onset of disease is due to the expression of a ‘provirus', which is integrated in the genome, having been acquired either by prenatal infection or in the germ-line from an affected parent; this could explain why the season of birth effect is accentuated in, and perhaps confined to the group of patients without a family history of the disease.

Germ-line integration is known to occur following infection with agents of the retrovirus class.∗ Such agents can integrate at many sites in the host genome, but their interactions with proto-oncogenes (cellular genes which may act as growth factors) identify one type of integration site, and are. associated with some of their pathogenic effects. Some characteristics of schizophrenic illness, particularly their selectivity for the dominant hemisphere, can be understood on the assumption that the virus (perhaps a retrovirus) responsible for the disease interacts with a proto-oncogene, which induces the asymmetrical brain growth responsible, for laterality and cerebral dominance. The aetiologies of manic-depressive illness and schizophrenia may be related (the season of birth and onset effects are the same for the two conditions) and there is some evidence that the former transmutes into the latter in succeeding generations. The persistence of the functional psychoses may be due to the ability of the psychosis gene (or ‘provirus’) to induce change in the genetic mechanisms responsible for the development of laterality. (∗ See postscript pp 253).

Assessment of suicide risk is an important and complex issue. We know that a considerable proportion of those who kill themselves seek help before they do so (Robins et al, 1959; Barraclough et al, 1974), and it is therefore essential both to recognise indices of suicide risk and to react appropriately to them. This means being sensitive to many personal, social and environmental factors, rendered more problematic by the fact that each individual is uniquely responsive to life events. The traditional approach, based on clinical epidemiological considerations, has long identified such factors as depression, alcoholism, increasing age, social isolation, physical illness and significant loss as important correlates of suicide, but there is now increasing evidence of other important factors which are frequently associated with suicide. Patients who commit suicide exhibit a wide range of behavioural problems which may hamper recognition of underlying suicide risk (Seager & Flood, 1965); and young adults with a history of chronic social turmoil are highly represented amongst suicides (Ovenstone & Kreitman 1974).

Fifty schoolchildren, admitted as medical emergencies after poisoning themselves, were compared with 50 matched controls, resident in the same area of London, referred for psychiatric help for other reasons. The dependent measures were based upon systematically recorded clinical information in both groups. The self-poisoners showed more psychiatric symptoms and more disturbed family relationships than did the psychiatric group; they were more likely to meet criteria for depressive disorder and to come from families showing little warmth. This form of self-injury is not trivial or wholly culturally determined, and it warrants psychiatric intervention.

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.

Fifty-one patients with a primary major depressive disorder preceded by a stressful environmental event were compared for their response to pharmacological treatment with 75 depressives who experienced no stressful life event before illness episodes. There was no difference between the groups in treatment response rates after four and six weeks of treatment respectively.

A cohort of 120 patients, comprising all those who met the St Louis criteria for a diagnosis of schizophrenia, discharged from a mental hospital over a five-year period, were followed-up in the community after an interval of five to nine years; 105 were traced and 94 were alive. Of those, 66 were living in UK, out of hospital, and willing to be seen. Their mental states, and social functioning and circumstances were assessed by interview with the patients and those with whom they lived; 18% had recovered to the extent that they had no significant symptoms and appeared to function satisfactorily. More than 50% had definite psychotic features. No patients and few relatives sought a return to hospital care, but severe emotional, social, and financial difficulties were commonplace; 27% of the sample had no contact with medical or social services, a further 14% saw only community nurses, and 24% only their general practitioners. The findings emphasise the limitations of community services in dealing with the chronicity and severity of the impairments resulting from schizophrenic illness.

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.

The factors making for therapeutic engagement were examined in a series of 50 schoolchildren who had deliberately poisoned themselves. Of these 28 kept an appointment for psychiatric treatment: they were characterised by high levels of psychological symptoms, especially those of depression. The kind of treatment offered was not predictive, but parental attitudes and background contributed to the likelihood of returning for treatment. Psychiatric treatment, if effective, would be appropriate for many such children, and should be offered to them.