In view of the structural similarity of imipramine and promazine, an attempt has been made to obtain a stronger anti-depressive effect by means of chlorination of imipramine at the same place in the molecule. Brandner (1964) has described the results of mono-chlorimipi-amine (MCI) administration in a series of 25 cases of various kinds of depression.

There is a growing body of evidence that oxypertine (Win. 18,501), a recently developed indolylalkyl-phenyl-piperazine (1, 9), is of value in the treatment of schizophrenia (6). Oxypertine has been described as superior to trifluoperazine in its effect on certain aspects of schizophrenic behaviour (2, 5).

In a leading article on mental symptoms in vitamin B12 deficiency (Lancet, 1965), it was pointed out that “though mental illness due to vitamin B12 deficiency is uncommon, it is readily treated, and, as in general paralysis of the insane, its protean manifestations and uncertain physical signs call for an easily applied screening test comparable to the Wassermann reaction”. In the correspondence which followed it was suggested that in psychiatric practice today mental symptoms were likely to be found more frequently in association with vitamin B12 deficiency than with a positive serological test for syphilis (owing in part to the increasing number of patients with deficiency syndromes following gastro-intestinal surgery); and that estimation of serum B12 concentration should be performed much more readily without waiting for clear-cut haematological evidence or neurological complications of megaloblastic anaemia (Hunter and Matthews, 1965). This was emphasized by the evidence of Strachan and Henderson (1965) who described three patients with psychiatric syndromes attributed to vitamin B12 deficiency in whom not only peripheral blood but also bone marrow was normal; and the report from a mental hospital in Norway by Edwin et al. (1965) that of 396 patients over the age of thirty years admitted over a twelve months period, 23 (5·8 per cent.) had serum B12 concentrations below the critical level of 100 μμg. per ml. as estimated by Euglena gracilis assay. This finding was challenged by Herbert et al. (1965), who suggested that drugs of the phenothiazine group administered to the patients might have suppressed the growth of the organism, but this was disputed by Edwin et al. (1966).

The object of this paper is to assess, in retrospect, the relative effectiveness of amitriptyline (‘Triptizol’) and amitriptyline with perphenazine (‘Triptafen’) in the treatment of depressed patients.

Tropical neuropathies have been causally related to disturbances of pyruvate metabolism (Monekosso, 1963); like the neuropathy described by Wernicke, they are thought to be due to vitamin B deficiency. The clinical picture includes mental disturbances of the organic type, such as disturbance of memory, confabulation, apathy, disorientation, etc. Reports do not mention symptoms suggestive of functional psychosis.

Since the introduction of chlorpromazine in the early 1950's, various phenothiazine tranquillizers have become established as standard treatment in schizophrenia. However, it is recognized that these drugs have their limitations; every mental hospital contains a large group of schizophrenics whose illness is unaffected or only partially modified by phenothiazines, and some patients develop side-effects sufficiently severe to preclude these drugs being given in fully effective doses.

In previous papers (2, 3) we have set forth our neurophysiopathogenic theory of alcoholism, which is an amplification of Jellinek's hypothesis (1) that the gamma and delta types of alcoholism form an addictive disease. The physical dependence characterized by a state of distress and an overpowering desire to consume more ethanol, assumes three forms: (a) “inability to stop” the ingestion (Jellinek's “loss of control”) noted moments after ingesting a small quantity of ethanol following a period of abstinence, which characterizes the gamma or intermittent clinical form of alcoholism; (b) “inability to abstain” from ethanol hours after the last ingestion and after continuous drinking (each 4 to 8 hours during months or years), which characterizes the delta or inveterate clinical form of alcoholism, and (c) primary physical dependence without ethanol having necessarily been ingested previously, which characterizes remittent, or epsilon alcoholism or dipsomania.

During the treatment of mental illness, a phase is reached when the patient is encouraged to resume his life in the community by spending increasing periods of leave at home.

Wolpe (1958) has described the technique of treating phobias by reciprocal inhibition. The patient is encouraged to relax by appropriate procedures, and is then asked to fantasy a series of situations which he has previously arranged in order of their ability to evoke anxiety. This personal hierarchy of situations is put to him for short periods in ascending order.

There can be no more urgent or conspicuous problem in psychiatry, as a scientific discipline, than that it lacks a generally agreed theoretical framework on which to base practice and teaching.

Shapiro and Nelson (1955) suggested that an important factor in the cognitive impairment of psychiatric patients was a diminution of present learning ability. They devised a new test in which the subject had to learn and retain the meanings of five previously unknown words. Walton and Black (1957) developed this technique in their Modified Word Learning Test (MWLT). In this test, the patient is given the Terman-Merrill Vocabulary until he is unable to recall the meanings of ten consecutive words. He is then told the meanings of these ten words. If, immediately afterwards, he fails to give the definitions of at least six of them, the meanings of all ten words are given again, changing the wording to avoid rote learning.

It is usual to encounter, in any large mental hospital, a group of patients who are considered by the staff to be difficult. This opinion is slowly formed, but, once established and repeatedly expressed in nursing reports and medical records, it rarely alters and may have a powerful influence on the patient's career in hospital. A difficult patient may find himself deprived of privileges and moved to a “lower level” ward (9, 10, 11) and his demotion in this way can affect his relatives' attitudes towards him (17). On the other hand, patients informally classified by the staff as “good patients” may be granted certain advantages and, as Cohen put it, “if they behave okay, they move to a better billet” (5).