One of the central paradoxes of the Victorian reforms in the treatment of the mentally ill was the curious fact that the “scientific” discovery of mental illness and the adoption of a more rational approach based on this discovery—an approach which aimed at treating and curing the lunatic, rather than neglecting him or incarcerating him in a gaol or workhouse—were associated with an explosive growth in the number of insane people. Edward Hare's recent Maudsley Lecture raises again the interesting question of whether or not this reflects a true increase in the incidence of mental illness in nineteenth century England. As he correctly notes, the aggregate data collected at the time do not allow a “decisive answer”, but I am pleased that his reassessment of the probabilities led him to endorse my prior conclusion that its incidence was indeed increasing. (Scull, 1979).

In this new era of structural and functional neuroimaging technologies, it is the unsurpassed anatomical resolution of magnetic resonance imaging (MRI) (Andreasen, 1989; and Besson, this supplement) that has resulted in a new generation of studies on cerebral morphology in schizophrenia. With the recent development of whole-body magnets of very high (⩾ 1.5T) and uniform field strength, it has become possible to extend the scope of this approach to include measurement of certain fundamental neurochemical processes, via magnetic resonance spectroscopy (MRS: Hubesch et al, 1989; Lock et al, this supplement). The purpose of this article is to introduce and review critically the existing literature on the application of MRI and MRS to schizophrenia, and to give a preliminary account of some of our own recent studies in these areas.

Psychiatric morbidity among 74 non-affected first-degree relatives and 93 non-affected second-degree relatives of patients with Huntington's disease (HD) was compared with that of 37 patients with HD and with matched control groups. Due to specific age criteria, the first-degree relatives were at decreased risk and the second-degree relatives at negligible risk of being carriers of the gene for HD. Information on admissions to departments of psychiatry and diagnoses at discharge were obtained for all subjects from a nationwide central register. Psychiatric morbidity was no greater among relatives than among controls, whereas HD patients had significantly more admissions and psychiatric diagnoses than relatives. Growing up with a risk of developing HD does not itself increase the risk of developing psychiatric illness resulting in hospital admission. Severe psychiatric disorders in HD patients were thus most likely to be aetiologically related to the disease process, possibly through a genetic mechanism.

The breathing rate and PCO2 in end-tidal air have been studied in controls and in patients with endogenous depression (retarded and non-retarded), with neurotic depression, and with schizophrenia. It has been shown that breathing rate goes up and PCO2 down in non-retarded and neurotic depression. Schizophrenia gives more anomalous results. The fact is emphasized that such changes must lead to alterations in pH and other variables. Studies showing some small chemical differences between these clinical entities and control subjects might therefore be explained by these findings.

One hundred and ninety three raters drawn from six countries and representing different professional groups considered 16 case histories. Raters were asked to indicate what degree of ‘dangerousness' they attributed to each individual and what they considered to be the optimal management.

The level of agreement between raters concerning the assessment of dangerousness was generally low, the level of 60 per cent being reached for only 4 cases out of 16. Psychiatrists did not reach a higher level of agreement on the ratings of dangerousness than non-psychiatrists. Psychiatrists had a tendency to rate individuals as more dangerous than did non-psychiatrists.

The results of this exercise do not support the use of ‘dangerousness' as a scientifically or operationally valid concept.

The reduction of mental hospital populations in Britain and the United States has generated a considerable amount of literature on policy, but detailed studies of the effects on patients and the conditions under which they live after discharge are rare. In the United States, a National Institute of Mental Health review of the literature commented that “the question of what actually happens to patients who leave mental hospitals and re-enter the community is largely unanswered” (Bachrach, 1976).

Four healthy people on lithium for manic depressive liability relapsed within 14 days of the drug being secretly replaced by placebo. Their new manic attacks were at least as severe as any of their previous episodes.

In an earlier study this research group reported iprindole, a relatively new tricyclic derivative, to be an effective drug for use in depressed neurotic out-patients (ii). We found it to produce significantly greater improvement than placebo on a variety of outcome measures. Good response to iprindole as compared to placebo has also been reported by Hicks (5) and Daneman (3). Sterlin et al., comparing iprindole with amitriptyline in a relatively small patient sample, reported that iprindole, while faster acting, produced less overall improvement (15); differences in improvement did not, however, reach statistical significance.

Incubation is the process by which life events influence the onset of psychiatric disorder after an appreciable delay. It has long been recognised clinically. In this paper we use data from the Camberwell Collaborative Depression Study to see whether incubation effects can be demonstrated in depressive illness. We used a novel adaptation of survival analysis for this purpose. The results suggest that incubation does occur in depressive disorder, that it is much less important than the effect of life events close to onset, that it is apparent in women but not in men, and that it is no more evident preceding endogenous than neurotic symptom patterns.

Primary affective disorder is defined as an illness which is characterized by depressions or manias or both. This illness is seen in an individual who has no history of any preexisting psychiatric illness except for uncomplicated episodes of depression or mania. Clinically there are two types of primary affective disorder. The first is manic depressive disease (bipolar psychosis) which may be considered as a primary affective disorder in which mania is seen; usually, but not always, depression is also seen in this kind of patient. The other type may be called depressive disease; a synonym that might be used is unipolar psychosis; here only depressive episodes are seen (one or more episodes). In addition to the difference in the clinical picture, considerable genetic data exist which indicate that the two illnesses are quite distinct from each other.

In a previous paper (Leff, 1973) data from the International Pilot Study of Schizophrenia (IPSS) (WHO, 1974) were analysed, and it was found that patients from developed countries showed a greater ability to differentiate between unpleasant emotional states than those from developing countries. The data on which this finding was based were scores derived from the sections on Depression, Anxiety and Irritability in the Present State Examination (PSE), a semi-structured psychiatric interview (Wing, Cooper and Sartorius, 1974). The scores were the sums of ratings made by psychiatrists interviewing patients from their own countries. The psychiatrists judged whether or not a symptom was present on the basis of the patient's verbal response to a series of questions, most of which are stipulated in the PSE. The patient's nonverbal behaviour is not taken into account in making these ratings.

It is often said that the Disorders of Affect are the most commonly encountered psychoses and it is, of course, depressive illness which accounts for the large majority of such disorders; nevertheless Mania and Hypomania present as great a problem. As great because from the medical point of view treatment is less certain and less satisfactory, and socially because the manic, and even more the hypomanic, patient seems capable of doing more harm to his family and home by his ill-judged actions and schemes than almost any other person. He seems, too, to have a singular affinity and attraction for wasters, ne'er-do-wells and psychopaths who assist all too readily in the disposal of goods and money and encourage him in his grandiose and extravagant schemes.

For depressive illness we have, in Electro-Convulsant Therapy, a ready, useful and comparatively reliable, safe and effective therapeutic measure. The majority of patients accept such treatment quite readily and respond well to it. Where there is a history of chronic or recurrent illness, leucotomy (often in one of its modified forms) seems to offer a good hope with an excellent prognosis. Depressed patients, moreover, from the very nature of their illness, tend to accept treatment, even if they dislike it, often maybe from poorly concealed masochistic urges and as punishment for what they believe to be their guilt and unworthiness.

Manic and hypomanic patients, on the other hand, present a totally different problem. Firstly they rarely, if ever, complain themselves and consequently they resent being referred to the doctor. When they do come it is often unwillingly or merely to demonstrate their well-being; or maybe to show some invention, gadget or discovery they believe they have made. Secondly, such patients, even when they have been seen, are notoriously unreliable over treatment and will rarely accept it. In the majority of patients it is only when under some form of control (which for all practical purposes means certification) that treatment can be carried out satisfactorily.

In Mania (and Hypomania) as in depression, convulsion therapy—usually E.C.T.—proves satisfactory in many instances, but the problem of long-term prognosis is not affected and in the case of recurrent manic attacks leucotomy seems to have no benefits to offer and is in fact often liable to make things worse. Any effective method of treatment is therefore to be welcomed, and more especially so if there is any suggestion that it can be continued after the patient leaves hospital, on a maintenance or prophylactic basis.

In connection with a demonstration programme of comprehensive psychiatric care for hospitalized schizophrenic patients, it was necessary to develop a rapid and effective method for rating patients' ward adjustment and social behaviour. The scale, entitled the Albany Behavioural Rating Scale (ABRS), and its validation, are described in this report. The nature of the problem required that the scale be readable, easily completed and scored, and suitable for use by nursing and rehabilitation personnel (OT, CT, Music Therapist, etc.). Further requirements included adequate scoring reliability and validity, as well as amenability to quantification.

Various rating scales have been described in the psychiatric literature, but these did not meet our needs. Some were too cumbersome and time-consuming. Others required individual psychiatric interview. Frequently they demanded high literacy of the rater. Certain scales are indeed useful for special purposes, as for example the MSRPP (Lorr, 1953) which can be employed with confidence as an aid to psychiatric classification. Lucero and Meyer (1951) have discussed the requirements of an adequate rating scale.

In an earlier paper (Ackner, 1954) various aetiological approaches to the problem of depersonalization were examined and no common agreement was found. The salient phenomena of depersonalization were examined and found to be so lacking in precision that no clear-cut boundaries could be considered to exist. This explained the lack of any truly adequate definition of depersonalization and suggested that some of the past disagreements had been the result of failure to make explicit the phenomena under discussion.