Duration of stay for unselected admissions to an acute psychiatric ward was reduced to an average of 11 days. The clinical methods by which this was achieved are described. Comparing patients randomly allocated to this experimental ward and other admission wards: (i) the readmission rate to the experimental ward was higher but readmissions were briefer so that total in-patient experience per patient over the course of one year remained substantially lower; (ii) symptom levels and burden on the family had improved equally at three weeks and at four months after discharge; (iii) experimental ward patients made fewer demands on their general practitioners and reported fewer parasuicides. Beds can be released for other purposes in this way.

It is well known that in some small European countries there exist especially favourable conditions for certain types of research which elsewhere meet enormous difficulties. This is exemplified in Denmark and other Scandinavian countries by the famous studies on the influence of genetic and environmental factors in schizophrenia, which were made possible by the exceptional availability of well organized national registers on twins, adoptees and psychotics.

Forty chronic obsessive-compulsive ritualizers were randomly assigned to treatment with oral clomipramine or placebo for 8 months. During weeks 4 to 7 these two groups were each randomly split into treatment by relaxation or by exposure in vivo, and during weeks 7 to 10 all patients had exposure in vivo. Double blind assessments were made at weeks 4, 7, 10, 18, 36, 62 and 114.

Results are reported to one year. Clomipramine produced significant improvement in rituals, mood and social adjustment, but only in those patients who initially had depressed mood. The clomipramine effect was maximum from weeks 10 to 18 and diminished thereafter. On stopping clomipramine patients often relapsed and improved again on restarting the drug. Relaxation produced little change. Exposure produced significant lasting improvement in rituals, but less change in mood; improvement generalized to social adjustment at follow-up. Clomipramine plus exposure had a slight additive but not interactional effect. Clomipramine enhanced compliance both with exposure and with relaxation.

Clomipramine is useful for compulsive ritualizers with depressed mood, but may need continuation for over a year and combination with exposure in vivo. Exposure in vivo remains the treatment of choice for rituals without depressed mood.

I am indeed sensible of the honour which you have conferred upon me, first, by including me among the honorary Fellows of the Royal College, and further by inviting me to deliver the 1979 Maudsley lecture. Equally am I conscious of my conspicuous lack of qualifications for these honours. My original university degree was in economics, a subject which hardly impinges upon psychiatry. My interest in your profession derives primarily from 44 years' experience as a magistrate (more often than not presiding) in London adult or juvenile courts, and, secondarily, from service as the former head of a University Department training social workers. Through these experiences I have not only had contacts with numerous psychiatrists about court cases and students, but have also got to know many of them personally, both at home and abroad. In this country my particular friends were the late Aubrey Lewis and our much beloved Peter Scott whose premature death has left a gap which many of us feel can never be filled. But I stand before you as a layman without any relevant professional qualification.

The paper examines the nature of causality and how the concept can be interpreted and used in epidemiological psychiatry. The relationship of causality to logical relations is reiterated, and it is emphasized that these relationships in their pure form cannot apply to any one cause of an effect which is the outcome of several causes. In such a case the relation of the cause to the effect is one of weak implication. The fact of weak implication opens the door to the construction of certain causal models, and the possibilities afforded by this situation are illustrated by reference to the work of Brown et al (1975). Weak implication may be an intransitive relationship, and this is shown to invalidate certain ways of testing such models and the conclusions which arise from them.

One hundred psychotic patients referred to a consultation service in a general hospital were compared with 50 psychotic patients without physical illness in a psychiatric unit. Background, mental and cognitive state were evaluated. In addition to providing a list of likely causes of cerebral dysfunction in such a sample, the study revealed an increased incidence of prior depression in those with cerebral dysfunction, and identified a group where psychosocial factors appeared more significant than cerebral dysfunction in determining the psychosis. The various ways in which a psychosis can be associated with a physical condition, and the various forms that it can take even when cerebral dysfunction is present, are discussed.

Among a consecutive unselected series of 29 patients with Cushing's syndrome 21 had bilateral adrenal hyperplasia and 8 had tumours. Twenty-five (86 per cent) were significantly depressed; three of the tumour patients, but only one of the hyperplasia group were free of symptoms so that if there are no psychiatric symptoms there is a three in four chance that the patient has a tumour. There was a family history of depression or suicide or a history of early bereavement or separation in half the cases. In six of the hyperplasia patients a major emotional disturbance had preceded the onset, and in five this was a loss. The severity of the depression was not related to the level of circulating Cortisol. The depression was rapidly relieved when the tumour or hyperplastic glands were removed. Depression in Cushing's syndrome might result from a substance other than Cortisol produced by the adrenal under excessive pituitary and/or hypothalamic stimulation, which could play a part in the aetiology of depressive illness in general.

In thirteen cases of senile dementia of the Alzheimer type severe loss of nerve cells from the locus caeruleus was frequently seen together with reductions in nucleolar volume and cytoplasmic RNA in surviving cells, averaging 14 and 21 per cent respectively. These histological findings were matched in two cases by biochemical measurements of loss of noradrenaline from all brain regions examined, ranging from 10 per cent in temporal cortex to 53 per cent in hypothalamus. By contrast, neither nucleolar volume nor cytoplasmic RNA was altered in cells of the substantia nigra, nor was dopamine content significantly altered in most regions. In vascular dementia neither noradrenaline nor dopamine metabolism was changed except in regions of local circulatory deficiency. These findings provide evidence of a primary degeneration of the noradrenergic system in Alzheimer type dementia.

This study of violent behaviour among psychiatric in-patients in three hospitals found that many incidents of petty violence occurred and serious violence was rare. Among the offending patients there were more females than males, more young than old and the most commonly represented diagnosis was schizophrenia. Nursing staff were by far the commonest victims. Most of the incidents occurred during the daytime and were perpetrated mainly by patients nursed on acute psychiatric wards. The vast majority of patients were nonviolent.

In a retrospective study of 67 elderly bipolar patients the first manic attack occurred at about age 60, often after a long period from the time of the first affective episode, after which further depressive episodes occurred. This calls into question Perris’ criteria for unipolar diagnosis. Among the men, a preponderance of cerebral-organic disorders was found. The evidence for sub-classification of bipolar disorders into secondary or symptomatic manias is discussed. The recurrent nature of the illness in old age stresses the need for further evaluation of lithium prophylaxis.

The concept of mental illness which Henry Maudsley developed and espoused has a special significance at this time. Psychiatry appears to have entered a new phase in its evolution as a mental science, in which its dependence on both the biological and the psychosocial disciplines is recognized, in which clinical observations are made under carefully controlled conditions, and where hypotheses lead to research rather than conclusions. This maturation was encouraged and predicted by Henry Maudsley who, more than a century earlier, had synthesized from the knowledge of his time a prospectus of psychiatric progress which anticipates much of our present thinking, often in considerable detail and striking exactitude.

The relationship between life events and the onset of organic physical illness has been studied in a group of women in the general population. The link between severe events and the onset of organic illness, which held only for women of 50 years or younger, was not a direct causal association but mediated by an intervening psychiatric disturbance of an affective kind, all occurring within a six month period. The findings are discussed in the light of the high psychiatric morbidity found in physically ill patients.

A 20 per cent prevalence of mild clinical depression was found in 120 women assessed at about six weeks postpartum. The strongest associated factor was occurrence of recent stressful life events. Previous history of psychiatric disorder, younger age, early postpartum blues, and a group of variables reflecting poor marital relationship and absence of social support were also notable. Poor marital support acted as a vulnerability factor, only producing an effect in presence of stressful life events. Previous psychiatric history produced a strong independent effect, both with and without life events. Postpartum blues were only associated with depression in the absence of life events, suggesting a small hormonal sub-group. Overall the findings indicate the importance of social stress in puerperal depression.

This paper describes 35 patients whose artefactual illness gained them admittance to hospital. The 15 wanderers were more likely than the 20 non-wanderers to have been in more than 10 hospitals, possessed histories exceeding 10 years, presented with abdominal or psychiatric complaints, volunteered poor work records and displayed psychopathic traits. The non-wanderers were more likely than the wanderers to possess socially conformist personalities. Twenty-six patients had severe sexual/marital problems. Neither group attended well for psychiatric follow up appointments.

In 1976, 163 patients were approved by the Department of Health and Social Security for transfer from the Special Hospitals to the open wards of the National Health Service. By autumn 1978, a quarter were still waiting for admission. Patients meeting most difficulty were the severely handicapped non-offenders, who were usually refused unseen on the ground that local subnormality hospitals were full. The role of the DHSS and of the Regional and Area Authorities was in general restricted to bewailing problems they could not help to solve.

Some two years after their transfer, enquiries were made in the NHS about the 105 transferred patients. Removal back to the Special Hospital had been requested for seven, and another three had been removed by the police and prosecuted.

In research into the origin of schizophrenia discrepancies repeatedly arise through the habit of treating schizophrenia as an entity. If independent subforms are differentiated, many ambiguities can be cleared up. A special form of catatonia (periodic catatonia) seems to be transmitted by dominant inheritance, a special paraphrenia (affective paraphrenia) recessively. In a large group of schizophrenias (systematic schizophrenias) with a poor outcome family histories of psychosis were rarely found, but examination of twins suggested a psychosocial origin for the disorder. In cycloid psychoses with a benign outcome family histories of psychosis were also seldom found. Only by diagnostic separations can the discrepancies in the field of schizophrenia be solved.

Fifty-seven cognitively impaired elderly had significantly elevated serum IgG (P $0.005) and IgA (P $0.01) levels and similar IgM levels, compared to a population of 65 elderly matched for age and sex, who did not manifest cognitive impairment. These findings are compatible with a current hypothesis that immunological factors may be important in the cognitive disorders observed with increasing frequency among the aged.

Fifteen patients with active Cushing's syndrome have been compared with 15 other patients who had been treated successfully for Cushing's syndrome and with 13 patients with other pituitary tumours. Depression was the main psychiatric diagnosis made by the CATEGO programme after Present State Examinations. Patients with active Cushing's syndrome were significantly more depressed (Hamilton Rating Scores), than were the other patients. Compared with the control patients, those with active Cushing's syndrome had slightly lower plasma concentrations of total tryptophan, though the concentrations of freely diffusible tryptophan were not significantly changed.

Information about perceptions of labour and delivery and about immediate emotional reactions to their newborn babies was obtained from two groups of primiparous women (n = 112 and n = 41) and from 40 multiparae. About 40 per cent of primiparae and 25 per cent of multiparae recalled that their predominant emotional reaction when holding their babies for the very first time had been one of indifference. Maternal affection was more likely to be lacking after delivery if the mother had had a forewater amniotomy and had, in addition, either experienced a painful and unpleasant labour or been given more than 125 mg of pethidine.

Most mothers developed affection for their babies within a week of delivery and, in all groups of subjects, no longer term adverse effects were seen, such as post-natal depression or aggressive impulses directed at the baby. Three months post-natally it was, however, found that a mother was more likely to express feelings of dislike or indifference towards her baby if she was clinically depressed at the time.

In 42 patients with cognitive dysfunction (senile dementia) significant correlations between immunoglobulins and various tests of intelligence were observed. Serum IgG emerged as the single best predictor of behavioural status. There is need for further research in this field.