Patients who do not comply with therapeutic procedures have been of longstanding concern to the clinician and have presented knotty methodological problems to those involved in evaluating the effectiveness of different treatments and treatment modalities (1, 2, 4, 6, 10, 11, 12, 13).

The year 1957 heralded a significant advance in the treatment of depressive states. It was then that Loomer et al. (1957), and Crane (1957), published their findings on the use of iproniazid, and Kuhn (1957), published his findings on the use of imipramine. Iproniazid was the first of a series of monoamine oxidase inhibitors which were rapidly developed and used in the treatment of depressive states. In the last few years, their use, especially in “endogenous” depression, has been eclipsed by the iminodibenzyl derivatives; first imipramine, then amitriptyline and later the demethylated derivatives, desipramine and nortriptyline. However, the later monoamine oxidase inhibitors are still widely used, especially in “reactive” depression and some neurotic states.

This paper is one of two considering certain aspects of the Mental Health Act, 1959, in relation to subnormal patients; it is based on a report of a Working Party submitted to the Council of the British Psychological Society and is published with the Society's approval. (The second paper (Mittler and Castell, 1964) considers plans for hospital and community care.)

Conditioning therapy has been widely applied in the treatment of certain kinds of neurotic illness.

During the course of a morbidity study in two communities in the town of Croydon, carried out between 1960 and 1962, it proved possible to incorporate an investigation of the shortened version of the Maudsley Personality Inventory (M.P.I.). This twelve-item questionnaire, constructed by Eysenck (1958) for studies of this type, gives measures of neuroticism and extraversion as defined within his personality theory (Eysenck, 1959). Initially the inventory used was identical with that described by Eysenck. After a time (during which test-retest was carried out on 130 adults), however, it was felt that three of the questions relating to extraversion were rather cumbersome, and the following changes were made. Question D, “Are you happiest when you get involved in some project that calls for rapid action?”, was amended to “Are you happiest when you get involved in something that calls for rapid action?”. Question G, “Do you usually take the initiative in making new friends?”, was amended to “Do you usually take the first step in making new friends?”. Question L, “Would you be very unhappy if you were prevented from making numerous social contacts?”, was amended to “Would you be very unhappy if you were prevented from meeting lots of people ?”. It was assumed that these minor alterations would not significantly affect the extraversion scores, and this assumption is borne out by the fact that neither the means of scores nor the test-retest correlations were significantly different on comparison of the two versions. This present study reports the frequency distribution of M.P.I. scores in the population studied and the test-retest reliability of the inventory.

In the preceding paper the effect of experimental distraction was examined and the findings discussed. The present report is concerned with a similar study of the effect of distraction on tests which involve another aspect of schizophrenic performance, that of psychomotor ability. Earlier studies (Chapman and McGhie, 1961, 1962) produced both clinical and experimental evidence that auditory distraction disrupted the motor responses of some schizophrenic patients. As the previous experimental findings were based on two tests involving only very limited areas of psychomotor performance, it was necessary to examine patients on a wide range of psychomotor tests. A second aim of the present investigation was to assess any differential effects due to variation in the sensory modality of the distracting stimuli.

It is common practice to divide depression into two illnesses: reactive (or neurotic) and endogenous (or manic-depressive psychosis). This dichotomy is a source of extensive argument, and its value is controversial.

The present study is a sequel to the investigation concerned with the genesis of male homosexuality (1965). In both investigations the same methods were used and their description can be found in the previous study.

It is well recognized that the depressed person occasionally commits murder as a consequence of the mood disorder (Mayer-Gross, Slater and Roth, 1960). Despite the popular view to the contrary, there is much evidence that murders are rarely committed in or after epileptic seizures. Alström (1950), in a study of the frequency of criminality in 345 adult male epileptics, did not find any cases of homicide. In a 10-year period, crimes of violence were recorded for 17 per cent of the patient series and 11 per cent. of a control group. All these crimes, however, were minor, usually a complication of the abuse of alcohol. Neither severe bodily injury to others, nor a crime committed during a psychomotor seizure were encountered. He also made the important observation that, while mentally normal patients with idiopathic epilepsy had an incidence of criminality similar to that of the general population, those epileptics displaying mental disorder in addition to fits had twice this frequency of criminal records. Hill and Pond (1952) state that, from their experience in an epilepsy ward and clinic, violent or dangerous behaviour during epileptic or post-epileptic automatisms is rarely seen in any patient. Levin (1952), who studied 52 cases of epileptic clouded state admitted to the Boston Psychopathic Hospital, concurs with this view. He comments that these patients are often potentially aggressive, but their intellectual faculties are so disorganized that they are unable to carry out well-planned integrated behaviour of any kind, including aggressive acts. However, in a clinical and EEG study of 100 prisoners awaiting trial for murder, Hill and Pond, in 1952, found 18 cases of epilepsy, an incidence of epilepsy thirty-two times that of the general population. In all these cases, careful examination of the circumstances of each crime excluded the occurrence of a seizure beforehand with a high degree of probability. They concluded that a relationship exists between epilepsy and murder, although it is not directly a result of the seizure or of its immediate sequelae. In some cases, at least, the common factor may be a mental illness in the epileptic, in which the epilepsy plays an important causative role. Pathogenic factors in such cases include the disturbance of cerebral function by the seizure discharges and also the difficulties in psychosocial adjustment caused by the fits themselves or the underlying organic brain disease causing them.

Obsessions are abnormal mental compulsions. They are experiences with a compelling quality which persistently intrude into consciousness. Though recognized by the patient as an irrational product of his own mind and resisted by him, they are incapable of being expelled. They may be thoughts, images, fears, urges, or acts. An obsessional disorder is one where such symptoms dominate the clinical picture and are not associated with any underlying psychosis.

Out-patient services in Britain for psychiatric patients have expanded enormously under the National Health Service. Well over half a million patients are seen at clinics annually. Concomitant with this increase the out-patient department has changed in function. No longer is it principally concerned with providing follow up and support for discharged mental hospital in-patients; instead, because of the greatly increased demand for psychiatric care for less severe disorders and under the influence of the movement for community care it now should play a part not at all subservient to the in-patient department. The clinic, properly run, should be an arena of treatment in its own right.

A new drug, trimipramine (Surmontil, 7162 R.P.), has been found to have a specific antidepressant effect (Lambert et al., 1961), and has been used in France for two years; hitherto no controlled trial of trimipramine has been published. This paper reports a three weeks' comparative trial between this drug and imipramine (Tofranil), in the treatment of psychotic depression, using the statistical method of sequential analysis, the actual design used was that at the 5 per cent. chance level (Armitage, 1960).

The development of student health services in colleges and universities has led, during the past decade, to a growing awareness of the importance of mental health problems in student populations (see Davy, 1960; Malleson, 1963).

This case is considered to merit a brief report, mainly for the following reasons which will be further considered in the Discussion: (1) the extent of the sexual deviation and its true nature were not immediately apparent; (2) there has recently been a suggestion that the success of aversion therapy in similar cases may have been in a large measure dependent on a “transference situation”. We think that this case may contribute some evidence to the contrary.

Following the introduction of imipramine hydrochloride as the first specific thymoleptic drug, further compounds related to the iminodibenzyl family were developed. One of these was an iminostilbene derivative with a piperazine sidechain: opipramol (Insidon, Geigy), which has the formula 4-[3-(5H-dibenzo[b,f] azepine-5-yl)-propyl]-1-(2-hydroxyethyl)-piperazine-dihydrochloride (Schindler and Blattner, 1961). The nucleus is almost identical to that of imipramine and the sidechain is identical to that of perphenazine. This compound has since been used by a number of Continental and American investigators. They have claimed thymoleptic, neuroleptic and tranquillizing properties for the drug. Some authors found an antidepressive effect inferior to that of imipramine (Schneider and Villa, 1961; Racamier, 1962); others considered it superior to imipramine in that it causes fewer side-effects and helps patients unresponsive to imipramine (Schmitt et al., 1962). Most workers mention a mild sedative effect. Donzallaz (1961) achieved most favourable results treating “psycho-autonomic disturbances”, and Hoff (1962) reported good effects on neurasthenic patients with depressive traits. All these studies were uncontrolled and, on the whole, rather impressionistic. The only blind trial known to us was done by S. R. Splitter (1963), who gave opipramol and placebo on a double-blind basis to 100 medical out-patients suffering from various disorders, with or without psychosomatic symptoms, and also exhibiting some degree of anxiety and depression. Using concomitant drug therapy as required in about half his cases, he observed excellent or good responses of target symptoms including depression, anxiety and psychosomatic complaints, as well as amelioration of any physiologic disorder in 94 per cent. of the opipramol group as against 4 per cent. in the placebo group. However Splitter's material covered a large number of divergent conditions such as adolescent behaviour problems, diabetes and cancer; they were insufficiently matched for diagnosis and apparently not at all for age.

An earlier paper (Kay, Beamish and Roth, 1964b) described 26 features that differentiated significantly between mentally normal and functionally ill subjects over the age of 65, or between normals and those with organic mental illness. These features were found to fall into four main groups concerned with (i) physical disability, (ii) social isolation, (iii) personality deviation, (iv) social and income status. Many of the features appeared clearly to be inter related, but to an unknown degree, and this complicated the interpretation of the results. In the hope of shedding some light on this problem, a factorial analysis of 34 features, including most of the 26 previously described, was carried out. Because of missing items, the number of patients was reduced by 27 to 267, consisting of 152 mentally normal subjects, 88 subjects with functional illness, and 27 with organic mental illness. This report is complementary to the two previous articles (Kay, Beamish and Roth, 1964a, 1964b), in which the method of selecting the subjects and the definitions of organic and functional disorder are fully described.

The Maudsley Personality Inventory (M.P.I.) is now established as one of the most widely used personality tests in the investigation of a variety of clinical, psychosomatic and genetical problems. When the M.P.I. is employed for such purposes it is most important to know how constant are the scores and how much they are altered by the changes in mental state which often occur in psychiatric patients over a period of days or weeks.

In their review of the schizophrenia-like psychoses of epilepsy, Slater et al. (1963) document the belief that although epilepsy (especially that of the temporal lobe) often precedes schizophrenia-like reactions, schizophrenia rarely precedes epilepsy. In their review of literature on the co-existence of schizophrenia and epilepsy, Slater et al. found but one reported case where temporal lobe epilepsy developed in a patient already psychotic. Their own series of 69 cases contained no instance of psychosis occurring prior to definite onset of epilepsy.

Much of the current research on personality questionnaires has concerned itself with response style or bias related to “social desirability”, in which the first factor dimension of the M.M.P.I. is implicated (Edwards and Heathers, 1962). Stable personality differences have been detected between those who are placed high and low on this dimension as measured by a number of M.M.P.I. scales (e.g. Pt (Psychasthenia), K (Defensiveness), Taylor's MAS (Manifest Anxiety), Welsh's A (Anxiety) Scale—see Christie and Lindauer, 1963). However, a lack of integration has resulted from a failure to recognize that the same personality variable is being measured by scales of “social desirability”, “repression-sensitization”, or the tendency to deny or admit symptoms, and as well as “social desirability”, this factor has been identified as “general maladjustment or ego weakness” (Kassebaum, Couch and Slater, 1959), and “neuroticism” (Eysenck, 1962).

In 1937 an excellent investigation, by Pentreath and Dax, of the work of a London observation ward appeared in the Journal of Mental Science. In the course of their conclusions, they pointed out that: “observation wards are still in their infancy so far as their developmental possibilities are concerned—in fact, we are still in the process of deciding what their purpose should be.” In the ferment of ideas that culminated in the Mental Health Act of 1959, and the fresh insights into administrative psychiatry which have followed, the future function of such units seems to have received little attention. Freeman and Farndale's book Trends in the Mental Health Services (1963) does not introduce the concept of the psychiatric emergency, nor does it consider any special provision for these patients.