The following findings apply to 50 cases who were operated upon in the last six months of 1942. The very short time which has elapsed since the operations were performed makes it necessary to treat the results with the greatest reserve. It is therefore hoped that this account will be regarded as a progress report.

In an institution, 57 people with mental retardation who had shown assaultive behaviour during the last year were compared with a control group of 57 people in the same institution, matched by sex, level of retardation and age. The study group were younger and had more people with a moderate level of mental retardation than the total population of the institution. Compared with the controls, the assaultive group had more resources available, had more psychopathology, consumed more psychotropic drugs, and had a higher frequency of other problem behaviour. We found no group differences in personal skills, including communication. Generally, the observed covariates of assaultive behaviour resembled that seen in other populations with assaultive behaviour.

The ionic theory of cell excitability shows how impulses are generated, conducted and propagated by movements of ions between the cells and the extracellular fluid. It is known that changes in the concentration of sodium and potassium in either the extracellular water (E.C.W.) or the intracellular water (I.C.W.) may have a marked effect on the resting and action potentials of excitable cells. If affective disorders are manifestations of complex but reversible changes in brain excitability, hen these in turn might be caused by alterations in the concentration of electrolytes within the cells of the central nervous system (C.N.S.). Although it is not possible to measure the distribution of electrolytes specifically in the C.N.S. in man, it is possible to measure their distribution in the body as a whole. In previous papers we have shown that residual sodium (intracellular plus a small quantity of bone sodium) is increased by 50 per cent. in depression (Coppen and Shaw, 1963) and by nearly 200 per cent. in mania (Coppen, Shaw, Malleson and Costain, 1965). The present paper shows that there are also abnormalities in the distribution of potassium, the other main cation determining cell excitability, in patients suffering from severe depression.

In 1929 Berger (1) discovered that changes of electrical potential in the human brain could be detected through the unopened skull. Since that time the study of electro-encephalography has occupied the attention of many workers, and the literature is already too extensive for adequate review in this place. A brief description of the technique for obtaining an electro-encephalogram, or “EEG”, and a summary of its normal and pathological characters may be found in a communication by one of us (2) on the relation between the EEG and the presence of intracranial neoplasms. The cortex in the region of a tumour was found to produce abnormally slow potential waves, which were provisionally called “delta” (δ) waves to distinguish them from the normal “alpha” (α) waves which are the original “Berger rhythm”. In the same paper a case was reported in which a focus of δ waves was found in the left parieto-occipital region associated with an area of degenerating cortex. The history in this case was of occasional minor attacks and one major fit and an indefinite severe illness in infancy, the only sign being a right homonymous hemianopia in accordance with the left-sided focus. Ether and nitrous oxide anæsthesia are also accompanied by the production of slow waves, but in this condition there is no fixed focus, the whole cortex being engaged in abnormal electrical activity. Since the publication of the above-mentioned results, a case of cerebral abscess has been examined, and the EEG was found to indicate a δ focus similar in character to those which have been found in cases of new growth.

We have previously reported the use of repertory grid testing to extend the understanding of psychopathology in neurotic patients and to test predictions about the effects of therapy (Ryle, 1967; Ryle and Lunghi, 1969). In these tests the elements were people known to the subject, and the constructs were elicited from him. Repertory grid testing can supplement the data obtained from clinical interviews, notably in the following ways:

The issue of whether the incidence rate of schizophrenia may have declined over recent decades has generated considerable controversy. This study sought to ascertain and interview all patients who satisfied contemporary diagnostic criteria for schizophrenia within a defined and unusually homogeneous region of rural Ireland having a total population of 25 178 people; morbid risk for schizophrenia was then examined by quinquennia of birth from 1920–24 to 1965–69. Morbid risk appeared essentially constant for persons born between 1920 and 1939 but fell by 37% for those born between 1940 and 1969, the fall being considerably more prominent in females (–56%) than in males (–19%). Attention is focused on sexual dimorphism in cerebral development and on temporal changes in endogenous or exogenous factors that influence the rate of occurrence of schizophrenia in females.

Fifty-three hospitalized chronic schizophrenic patients were treated with either propranolol, chlorpromazine or placebo in a double-blind randomized trial for up to three months. Propranolol in a usual dose of 640 mg/day, produced marked cardiovascular effects but no improvement in schizophrenic symptomatology relative to placebo. The effects of chlorpromazine were small and inconsistent.

The psychiatric out-patient department fulfils a comprehensive role in the diagnosis and treatment of a wide range of psychiatric disorders; it is no longer an annexe of the mental hospital principally concerned with providing follow-up and support for discharged patients. But despite the enormous growth of out-patient facilities and treatments, there have been few studies analysing the out-patient services. The Bethlem Royal and Maudsley Hospitals present detailed accounts of their out-patients, but although they serve a defined area their special functions possibly make their clientele unrepresentative. Diagnoses of out-patients in Buckinghamshire were analysed by Kessel and Shepherd (1962), but this survey gives no information about the treatment or disposal of patients. Innes and Sharp (1962) presented detailed statistics for combined inpatient and out-patients in the North East of Scotland, but did not separate the two classes of patients. The most comprehensive information concerning patients attending a hospital psychiatric out-patient department—their diagnosis, treatment and disposal—comes from Kessel and Hassall (1965 and 1971) in their evaluation of the functioning of the new Plymouth Nuffield Clinic, and from Kaeser and Cooper (1971) who investigated a group of general practitioner referrals to the Maudsley Hospital to assess the satisfaction gained by the patients and family doctors from such consultations.

Eighty parasuicide patients were studied. The importance of life stress, age, and General Health Questionnaire score as predictors of the suicidal intent and medical lethality which they exhibited was examined. Medical lethality and suicidal intent were closely related: those whose parasuicide resulted in high lethality differed from those showing low lethality in their degree of suicidal intent, but did not differ in life stress, age, or GHQ score. Although both life stress and GHQ score were significantly correlated with suicidal intent, the GHQ score accounted for a greater proportion of the variance. These results suggest a more complex relationship between life stress, GHQ score, and suicidal intent than is often assumed.

Of patients with ‘conspicuous psychiatric morbidity’ in British general practice, 5 per cent annually are seen by psychiatrists, roughly equal numbers are referred to non-psychiatric specialists (Shepherd, Cooper, Brown and Kalton, 1966), and cross-referral rates are low (Mezey and Kellett, 1971). The clinical, as opposed to the social, reasons why so few patients are referred to psychiatrists must be inferred from the indirect evidence of epidemiological surveys (Shepherd et al., 1966), studies of patients already referred to an out-patients clinic (Kreitman, Sainsbury, Pearce and Costain, 1965), doctors' referral letters (Mowbray, Blair, Jubb and Clarke, 1961), and surveys of doctors' attitudes (Shepherd et al., 1966; Mezey and Kellett, 1971). Few studies of referral have been prospective (Kaeser and Cooper, 1971) and none has been by interview of patients before referral has taken place. Meanwhile, detailed clinical studies of psychiatric illness continue to focus almost exclusively on patients already in care of psychiatrists. It follows that more knowledge is needed of the clinical factors which lead to specialist referral; otherwise the significance of hospital-based studies for the wider context of psychiatry in general medical practice cannot be properly appreciated. This need is particularly acute with respect to the so-called minor affective disorders which are common in general practice but of which only a minority come to the notice of psychiatrists (Watts, 1966; Taylor and Chave, 1964).

In a prospective study, 153 consecutive new referrals to a psychogeriatrician in Oxfordshire in 1973 were followed up for 15 years. The percentage of the over-65 population at risk was 0.27 and, of those aged over 80, 0.6. Alzheimer's dementia and depressive illness comprised over two-thirds of referrals. A quarter became permanent admissions, half of them with Alzheimer's dementia, 19% of whom were alive five years later. Depressive illness, at ten years, had a mortality 1.2–1.6 times that of the population at risk. The distinction between Alzheimer's dementia and depressive illness, based on their natural history and causes of death, was reinforced.

Depressive states have long been classified by various dichotomies into reactive versus endogenous, agitated versus retarded and neurotic versus psychotic. The reactive-endogenous dichotomy is an aetiological classification, whereas the agitated-retarded and neurotic-psychotic divisions are symptomatological ones. It is generally considered that there is much correlation between these different classifications, although it is agreed that there may be some overlapping and various points of difference.