The differential diagnosis of schizophrenia and depression is clinically important in so far as these diagnoses carry therapeutic and prognostic implications. The Kraepelinian dichotomy was foreshadowed in Griesinger's recognition that “a state of vague, objectless emotion, be it sad or cheerful, and vague general delirium, is always more favourable than the appearance and continuance of fixed ideas … In melancholia, too, the appearance of hallucinations is decidedly unfavourable; those especially which refer the malady to external agencies (to other persons, to witchcraft, etc.) are remarkably persistent, and introduce at a later period a condition of dementia” (Griesinger, 1861). Kraepelin's descriptions of maniacal-depressive conditions and of dementia praecox remain the basis of contemporary systems of classification of the functional psychoses.

Lysergic acid diethylamide (LSD) has been used at Powick Hospital since 1952. During the early years of the treatment it became apparent that many of the dramatic psychic manifestations of the drug, including the vivid hallucinatory experiences, sensory hyperacuity, etc., were of no therapeutic value and that the chief use of the drug lay in its ability to bring into consciousness repressed traumatic experiences and relationships suffered by the patient during childhood. In particular, feelings such as those of parental rejection and hostility, sexual assaults, the sense of loneliness and impending doom engendered by inhalant anaesthetics in a strange hospital environment were repeatedly recovered and abreacted with great release of emotion. LSD appeared to be unique in the ease with which under its influence these deeply repressed memories could be recovered, and analysts using the drug in relatively small doses found that it would produce in one or two sessions unconscious material which would normally only be recovered after some months of analysis.

In recent years the introduction of neuroleptic drugs into large overcrowded mental hospitals has been accompanied by a striking improvement in their atmospheres which have become more therapeutic and less custodial (W.H.O., 42). Accordingly it has become possible, often for the first time, to organize effective programmes of rehabilitation for the chronic schizophrenics who still constitute a high proportion of mental hospital populations (Brill and Patton, 7). The new programmes have usually included group nursing, planned activities, and graded incentives for patients to strive to regain their positions in society. This approach has placed emphasis on the patient as an individual, having rights and responsibilities, safe, trustworthy, and, with assistance, often able to help himself and others (W.H.O., 41). Because of these changes in the State Hospital, it is not surprising that the literature has been flooded with enthusiastic reports and wholehearted endorsement of the merits of a variety of neuroleptic agents.

All who have used lysergic acid diethylamide (LSD-25) acclaim it as a valuable aid to psychotherapy, regarding it as a “deep” abreactive agent, in that in certain cases it erupts early traumatic experiences as far back as infancy, with appropriate emotional catharsis which is believed to be of considerable therapeutic benefit to the patient. It is also claimed that it facilitates and enhances the transference situation.

Clements (1962) has shown that atropine given intravenously has a vagal blockage effect superior to that achieved by subcutaneous injection. Electroconvulsive therapy is such a frequent reason for inducing general anaesthesia that a knowledge of the best premedication technique to use seemed to us important. Clearly the cardiovascular protective effect of the atropine is more important than the suppression of salivation. Maclay (1953) reported that in 62 deaths after E.C.T., 19 (30.6 per cent.) were attributable to the respiratory system. Clement's findings (1962) suggest that vagal blockade is adequate in protecting against cardiovascular disturbance 75 seconds after the injection of 1 mg. of atropine intravenously, but he mentions that the antisialogogic action is reputed to take longer to develop, and his paper did not include an assessment of this action.

This paper is a continuation of a previous study (Monro, 1962), on the Self-Referent Attitudes of Neurotic and Inadequate Personalities. It deals with the social attitudes of the same population of 150 patients. The techniques used derive from Professor Drever (1949) of the Department of Psychology, University of Edinburgh, from Cattell (1946) and from Eysenck (1944, 1947). The orientation towards social factors is in accord with one of the main traditions of psychology, exemplified by Adler (1927), H. S. Sullivan (1953), and Murphy (1947), to mention only a few outstanding exponents.

In 98 depressives of various diagnostic categories, Anderson and Dawson (1962) found that a raised fasting blood acetyl methyl carbinol (AMC) level was associated with marked verbal retardation and depressive preoccupation. They also found that raised fasting blood AMC levels fluctuated more than normal ones. It was suggested that the increases in amount and in fluctuation were best regarded as signs of impaired metabolic homeostasis because there was no reason to attribute any signs or symptoms to the effect of AMC itself.

After reviewing the literature pertaining to intellectual deterioration, Yates (1956) concluded that the major determinant of declining vocabulary in hospitalized persons, especially schizophrenic patients, was the length of stay in hospital. The studies on which Yates based his hypothesis were cross-sectional; that is, groups of patients admitted for relatively short periods of time were compared with patients admitted for longer periods. Two studies of schizophrenics showed that long-term patients did not perform as well as short-term patients on vocabulary subscales (Nelson, 1953; Rabin, King and Ehrmann, 1955). Similar decline was noted both in long-term epileptic patients (Capps, 1939) and in non-psychotic residents of old-age homes (Fox and Birren, 1949).

Amitriptyline hydrochloride (“Tryptizol”) is a new antidepressant with a predominant action on the central nervous system. It is 5-(3-di-methylaminopropylidene) - dibenzo (a,d) (1,4) cycloheptadiene hydrochloride, and is related chemically to imipramine.

Frohman et al. (1960a, 1960b, 1961, 1962) have investigated the effect of plasma of schizophrenic patients on carbohydrate metabolism. They measured the production of lactate and pyruvate by the nucleated red cells of the chicken after incubation with patients' plasma. After incubation with plasma from schizophrenic patients, the lactate/pyruvate ratio was raised significantly above the ratio found after incubation with plasma from normal subjects. This observation was interpreted as evidence of an inhibition of aerobic metabolism induced by the plasma of schizophrenic patients. We report here an attempt to confirm these findings.

This survey is the concluding part of an investigation of the distribution of abnormalities of the sex chromatin body in the whole of the patient population of Harperbury Hospital. The results of the survey of the male patients of the hospital have already been reported (Shapiro and Ridler, 1960).

Definition of Medical Rehabilitation

A full definition of medical rehabilitation should contain three parts. The first is a statement of aim: ideally, to settle or resettle an individual in his normal domestic setting, and in work appropriate to his talents. Most patients and doctors can measure their success against these two practical indices, although what is regarded as socially desirable varies widely and some individuals prefer a highly idiosyncratic way of life.

The importance of non-drug factors in the response of patients treated with psychotropic agents has been widely commented upon in recent years, though very few investigations have been undertaken specifically to identify and study these factors and to determine their role in pharmacotherapy (Hamilton and Hordern, 1963).

This abstract reports a factual study of 48 neurotics aged 20 to 59 years. All were mental hospital patients, whose attitude to admission and life difficulties were explored by means of a questionnaire. Assuming that illness and personality are independent variables (Foulds, G. A., 1955, 1958, 1959) and that they can be related meaningfully to the attitudes studied the relationships of these attitudes to personality, illness, sex and social class were investigated.

Since the first studies of the use of lithium in manic illnesses by Cade (1949), and Noack and Trautner (1951), other investigations have followed in Denmark, France, Italy and Germany. Reference is made to these by Schou (1959) in a recent review of 10 years' use of lithium as psychiatric therapy.

Studies using objective tests have found that two relatively independent types of thought disorder occur in patients diagnosed as “schizophrenic”. In several studies (Payne, 1961) approximately half the acute schizophrenic patients showed an extreme degree of intellectual and motor retardation, more severe than that found even among retarded depressed patients, while half suffered from overinclusive thinking, as measured by the tests used. There was a significant tendency in one study (Payne and Hewlett, 1960) for these two types of thought disorder not to occur in the same acute schizophrenic patients.

Delayed Auditory Feedback (D.A.F.), sometimes known as delayed side-tone, is the name given to the technical process in which a subject's speech is recorded, delayed, amplified and returned to his ears through a headphone at such power as to prevent him hearing it through the normal channels of direct air and bone conduction. This process has been found to produce marked disturbance of speech, the main changes found being the production of an artificial stutter, marked slowing of speech, increase in loudness of speech and development of a flatness of intonation or decrease in vocal intensity variation (Lee, 1950/1951). The slowing and increase in intensity have been found by Black (1951) to be related to the variation in delay and amplification, but even when these factors are held constant there is considerable individual variation in the response to D.A.F.

The question of the long-stay mental hospital population has recently received a great deal of attention. Proposals, based on the statistics of mental hospital admissions and discharges over the last few years, the increasing development of day hospitals, out-patient clinics, psychiatric units attached to general hospitals, and community services for the mentally ill within the general framework of new and improved methods of treatment, have led to considerable thought as to how best to reintegrate former mental hospital patients into the community. The process of discharging long-stay patients has, of course, been continuous, but the numbers involved have been comparatively small in the past. A policy of reducing considerably the number of mental hospital beds depends partly on aiming at the highest possible maintenance capacity of discharged patients. For long-stay female patients this would involve, among other aims, the re-training in domestic skills to adequate levels, while in male patients the aim would have to be some form of industrial resettlement. The general aim of increasing the activity and skill level of long-stay mental patients has found its expression in the establishment of industrial workshops. From its early beginnings (Baker, 1956) this form of therapy has developed into the establishment of production workshops or factories both inside and outside the walls of mental hospitals. (Wadsworth, Scott and Tonge, 1958; Early, 1960; Cooper and Early, 1961; Wadsworth et al 1961, 1962.)

Interest has been directed lately to the changes in sodium metabolism in depressive disorders, revealing a complex picture. Gibbons' finding (1960) that recovery with electroconvulsive therapy (E.C.T.) was associated with an apparent drop in total exchangeable sodium, was attributed by Coppen et al. (1962) to failure of his technique to allow for redistribution of sodium between body compartments. Their own work, allowing for different equilibration rates with isotopic sodium, showed no change in total exchangeable sodium during successful treatment with E.C.T., but did not exclude intercompartmental shifts. Coppen had in fact previously shown (1960) that the transfer of sodium from blood to cerebrospinal fluid is abnormally slow in depression, and is corrected during effective electroconvulsive therapy. Demonstration of significant shifts of electrolytes and fluid between, e.g., extracellular and intracellular spaces might thus cast light on important physiological factors in depressive illnesses.

Since Faris and Dunham (1939) found that the mental hospital admission rate for schizophrenia was higher in the central slum districts of Chicago than in the rest of the city, many studies have been carried out on the association between low social status and hospital admission with a diagnosis of schizophrenia. With few exceptions (for example, Clausen and Kohn, 1959; Jaco, 1954) these studies have confirmed that those in the lowest social group (in this country class V in the Registrar-General's scheme) have the highest admission rates. Some of these investigations have been “ecological” or “indirect”; i.e., admission rates have been calculated for areas of a city defined, for example, as slum, working, or middle class areas, and the rates for these areas compared; other studies have been “individual” or “direct”, where admission rates have been calculated for aggregates of individuals, defined as belonging to particular social classes, and the rates for the classes compared. An ecological study, like that of Faris and Dunham, may show that rates are higher in poor districts, but it does not necessarily follow that the patients admitted are themselves poor. Individual studies, however, do show that men in unskilled jobs have the highest admission rates.