Many patients with depressive illness also show considerable anxiety and agitation and often require a tranquillizer in addition to an anti-depressant drug. A new combination—Ro 4-6270 or Limbitrol Forte (Roche)—consisting of amitriptyline 25 mg.+chlordiazepoxide 10 mg. has recently become available for clinical trial. Both amitriptyline and chlordiazepoxide are widely used as an anti-depressant and a tranquillizer respectively. Clinical trials by Harris (1960), Jenner et al. (1961) and Hordern et al. (1963) have confirmed the efficacy of these drugs. Karabanow (1962), Poldinger (1963), Tietzen (1964) and Haider (1967a) have reported the usefulness of the combination of amitriptyline and chlordiazepoxide in depressive states, but none of these studies was adequately controlled. In a previous study (Haider, 1967b) I reported the efficacy of a combination of an anti-depressant and a tranquillizer in improving anxiety and agitation in depressive illness, more than one would expect with an anti-depressant alone. As the combination was compared with a placebo, it was not possible to state with any certainty what was the role of the tranquillizer in improving these symptoms.

A raised incidence of neurotic personality traits and mental illness has been reported among the first-degree relatives of obsessional neurotics. It has been suggested that genetical factors are involved in determining a predisposition to this condition, but some authors have postulated that similarities in aspects of the environment such as early upbringing and family traditions may account for similarities shown by relatives.

The methods of treatment employed for most forms of psychiatric disorder are still largely empirical. Furthermore, they are subject to powerful socio-cultural influences. Hence, it is not surprising that examination of medical practice in different countries reveals wider variation in the treatment of psychiatric disorder than in that of most other forms of morbidity (Shepherd, 1962). To establish the patterns of variation, and to assess their importance, it is necessary to develop techniques which permit direct comparison between the therapeutic practices of representative national groups of psychiatrists. This cannot be an easy matter, since in addition to difficulties of language and protocol there are problems specific to the subject of enquiry. There is as yet no internationally accepted nomenclature for psychiatric disorders, and perusal of the available prevalence statistics suggests that there must be considerable variation in the diagnostic criteria recognized by clinical psychiatrists of different nationalities (Lin and Standley, 1962). Moreover, clinicians whose chief concern is with the treatment and management of individual patients, in part through the manipulation of inter-personal relations, may be reluctant to accept any simple, mutually exclusive classification of their therapeutic techniques.

It is known that peptic ulcer patients have an increased incidence of blood group O, (1) and that peptic ulcer patients have above average scores for Neuroticism on the Maudsley Personality Inventory (3). In view of this it seemed worthwhile to see if there is any relationship between blood group O and Neuroticism (2).

The classification and nature of psychoses with both schizophrenic and manic-depressive symptoms is still highly controversial. The original view based on the Kraepelinian dichotomy of endogenous psychoses was that the “mixed” or “schizo-affective” psychoses were mixed also in a genetic sense. This would mean that some individuals inherit both schizophrenic and manic-depressive Anlage. This view has not been confirmed. One alternative is that proposed by Kleist and Leonhard, namely, that atypical forms of endogenous psychoses exist, which are genetically independent of both schizophrenia and manic-depressive psychosis. It seems, however, that Leonhard's concept has attracted little attention. Slater (1953) stated that Leonhard's work was “most interesting”, but hardly mentions it in his text-book of psychiatry (Mayer-Gross, Slater and Roth, 1960). An account of Leonhard's views on schizophrenia has however, been given by Fish (1958).

In 1961 I decided to start a hostel for discharged male psychiatric patients. There was available a private house in the City of Gloucester near to the Day Hospital. This had been purchased in 1953 and was being used as an overspill annexe for long-stay male patients.

In the July 1964 issue of The Atlantic, William Sargant (6), made some controversial comments on American psychiatry. “Freudian converts”, he said, fear “allowing any other methods of psychiatric treatment to gain any real recognition and acceptance in … teaching centers” where physical and biochemical treatments are “dismissed” as “symptomatic” and “second-rate”. He argued, furthermore, that psychoanalysts' views are unrealistic because these practitioners are experienced merely with the “very mildest forms of mental illness”. “Only psychoanalysis holds out any real hope in treatment” is the credo which Dr. Sargant attributes to U.S. psychoanalysts. If these opinions were solely those of one author, they might be overlooked, but they are held by many European and American psychiatrists (1).

The confusion over the definition and nosological status of hypochondriasis has been stressed by many authors. Jelliffe (1931) refers to it as “a strange child in the psychopathological family”, and Macalpine (1953) uses the phrase “a stepchild in psychiatry proper”. It has been described in terms of the disturbed attitude to health and to doctors and also in terms of the symptoms presented. Factor analysis is a method well-suited to the examination of such a problem and has been used to investigate psychiatric syndromes in order to dissect out the symptom clusters which have been subsumed under a single blanket term. (Hamilton, 1960, Friedman, 1964; Overall, 1962).

Few with relevant experience would dispute the common observation that a striking change for the better has taken place in the behaviour of long-stay patients in British psychiatric hospitals over the past fifteen years.

This paper deals briefly with a few clinical observations made in the course of studies of changes in subjective experience reported by young patients in the early stages of schizophrenia. These studies aimed at delineating the early schizophrenic clinical picture in as specific a manner as possible with a view to later experimental validation, and the clinical findings concerning a group of forty young schizophrenics have been reported elsewhere (Chapman, 1966). The observations on which this paper is based were obtained by the same method of examination and interview technique as previously reported, the observer deliberately identifying with the patient, adopting his particular style of communication and encouraging him in the direct projection of his experiences. Thus these observations have been taken out of a matrix of abnormalities in cognitive function found in schizophrenic patients, and have to do chiefly with their visual imagery and motility. Before proceeding to present and discuss these observations it may be worth while to provide a background against which to view them, by referring first to what we know of normal imagery, and second to the breakdown in perception and cognition found in the patients from whom these observations were derived.

In the clinical evaluation of psychopharmacological agents there are many factors which operate simultaneously with the pharmacological effects. These other factors may independently have an effect on the patient's symptomatology. In uncontrolled studies, therefore, these “non-drug” factors may frequently lead to erroneous clinical conclusions in regard to drug efficacy as well as side reactions.

It is now just over a decade since chlorpromazine came into general use in psychiatry. Insulin coma treatment is no longer popular in the treatment of schizophrenia, yet no long-term comparative evaluation has been carried out.

A number of studies have shown with psychological testing that the form a particular response takes will depend on the personal relevance to the subject of the stimulus, and that the more personally relevant the stimulus the less the effects of other response determinants. For example, Dahlstrom (1962) has listed six “contextual” and five “mediating” variables which he feels account for responses to such test items as those composing the M.M.P.I. These variables include the experimental setting, the examiner and the specific test items (contextual variables), and the veridical facts, personality styles, test instructions (mediating variables). Similar arguments have been advanced with regard to projective testing by Hutt (1951, 1954) and Wertheimer (1957), among others. Caine (1967) has shown that response suppression operates in a sentence building test only when the test material is of limited personal significance to the subject, and that the consistency of response between different testing levels along the overt/covert dimension pertains only when the stimulus material is of psycho-pathological significance. With the T.A.T., Smail (1966) has argued that if meaningful results are to be obtained responses must be interpreted in the light of the patient's particular situation much more than is the general practice, and that responses which are clinically typical of a given diagnostic group may only appear where the stimulus card accurately reflects the situation in which the patient finds himself.

Maddison and Mackey, in their review article “Suicide, the Clinical Problem” (1966), emphasize “the interpersonal significance of suicide, a viewpoint which is complementary and not alternative to an intensive study of the patient's intrapsychic life.” They continue: “More than usual attention needs to be given to the specially significant individual to whom the suicidal patient is often ambivalently bound in a symbiotic relationship, for highly relevant psychopathology will very frequently be found in this person …”.

The title of this review would be regarded by some psychiatrists as provocative; they would relegate the biochemical concomitants of depression and mania to a secondary position and deny that biochemical changes have any place in the aetiology of these conditions. However, in my view, the weight of evidence, although it is by no means conclusive, suggests that biochemical changes are most important in the aetiology of affective disorders. A biochemical aetiology implies that there are certain biochemical changes in the brain which need to be restored to normal before the patient's clinical condition will improve. This does not deny that psychological and environmental events may precipitate and maintain the biochemical events which in turn lead to the affective disorder. The study of these biochemical events is clearly at too early a stage for speculations about the interrelationship between environmental and endogenous elements to be fruitful; this study must wait until the biochemical aetiology is clearer than at present.

The present study is concerned with what is inherited in mental disorder. Is it an unspecific tendency to mental disorder, is it specific symptoms or features such as age of onset, course or outcome, or is it psychiatric diagnosis?

The study of pairs of relatives with mental disorder is certainly the best approach to investigating the problem of what is inherited. Unfortunately there has been a paucity of studies primarily dealing with this particular problem.

The value of oxypertine in the treatment of chronic schizophrenia has been the subject of several clinical trials, the results of which have been reviewed recently (Skarbek and Jacobsen, 1965). In particular a comparison of the effects of oxypertine and trifluoperazine in thirty-five schizophrenic women revealed statistically significant differences between the drugs, oxypertine showing a tendency to activate the withdrawn cases (Calwell, Jacobsen and Skarbek, 1964). An opportunity arose to study five of these patients again under controlled conditions, and it was felt that this would be useful for two reasons. First, it would show whether the response to oxypertine was repeatable, as the patients had meanwhile resumed their previous treatment. Secondly, by a detailed examination over an extended period, using a battery of tests and flexible dosage, a more exact delineation of the optimal symptomatic response to oxypertine could be made.

Since the inception of the use of artificially induced convulsions as a therapeutic agent in 1935 by Meduna and the modification of this method of treatment by the use of electric currents by Cerletti and Bini in 1938, a vast literature has accumulated on this form of psychiatric treatment. Yet, despite this vast literature and the passage of over 30 years of experimental opportunity, no predominant or convincing rationale for the use of electroconvulsive therapy (E.C.T.) has emerged; Meduna's (53) original theory of the incompatibility of schizophrenia and epilepsy having been long discredited. E.C.T. remains, therefore, an empirical form of treatment.

In recent years a number of studies on attempted suicide in various cities in England and Scotland have been published (Batchelor, 1954a and b; Stengel and Cook, 1958; Harrington and Cross, 1959; Middleton et al., 1961; Kessel and Lee, 1962; Sclare and Hamilton, 1963). Direct comparison between these suicides is difficult, not only because they differ in presentation but also because regional and cultural differences contribute to varying clinical and epidemiological data. There is, however, general agreement that cases of attempted suicide have become depressingly common problems in the casualty departments and wards of most general hospitals in larger cities. The Ministry of Health Circular H.M. (61) 94 estimates that the annual incidence of attempted suicide in England and Wales is around 30,000 cases. The present writers agree with Stengel (1963) that this is likely to be an underestimate.

Nitrazepam (Mogadon), a benzodiazepine compound, chemically related to diazepam (Valium) and chlordiazepoxide (Librium) is a recently introduced sleep-inducing agent. Other studies (Baum et al., 1965; Fraser and Shepherd, 1966), found it to be both safe and effective. It is thought to induce sleep by “shielding the brain centre responsible for waking from emotioned stimuli”, and is therefore of particular interest for psychiatric illness. This study is a clinical comparison with sodium amylobarbitone, using a double-blind cross-over technique.