Psychiatry has an advantage over other medical disciplines in that its skills are ones that can be practised in almost any setting. Although this is a truism it is worth repeating as psychiatry is still strongly associated with hospital treatment in the public mind. This view is endorsed by the activities of most psychiatrists, who spend their working lives in psychiatric hospitals or in extensions of them such as out-patient clinics or day hospitals. The reasons for this are at least partly historical. The great mental hospital building programme of the 19th century was planned deliberately to set up hospitals in isolated areas away from the centre of the community they served (Scull, 1979). Many countries are still left with this legacy of mental quarantine and find it difficult to overcome its geographical handicaps. Although it is appreciated that more patients can be treated successfully outside hospital it is often easier to follow the maxim, “if in doubt don't keep them out” and admit patients who seem to need further assessment. This is understandable whilst most personnel are based within the hospital and is certainly easier than setting up alternative systems of care away from the hospital base.

Man and animals are sporadically exposed to mycotoxins (the secondary metabolites of moulds), which include those produced in damp and cool environment by the almost ubiquitous soil-microfungi, the Fusaria. Perinatal exposure to the mycotoxins may cause damage to many organs, including the CNS and those which are targets for oestrogenic agents. Depending on the levels of the mycotoxins and the time of their action, the effects may manifest themselves as neonatal abnormalities, or as neurological and behavioural anomalies and chronic disorders later in life. The relationship between the anatomical and behavioural development of individuals and their perinatal exposure to fusarial mycotoxins requires further investigation.

Suicide is intentional self-killing, and parasuicide an act of deliberate self-harm—either by injury, ingestion or inhalation—not resulting in death (Black et al, 1982). Both are rare under the age of 12 and the rate of suicide in those under 16 remains consistently low. Referrals to psychiatric services reported by Shaffer (1974) indicated that 7–10% were for threatened or attempted suicide, while Hawton (1982) quoted studies giving the incidence as 10–33% for children aged six to 12; in England and Wales (1962–1968), suicide accounted for 0.6% of deaths in the 10–14 age-range. McClure (1984) found that between 1975 and 1980, only ten such deaths were recorded in the 13-and-under range, and 26 deaths in the 14 year-olds, after which the number of suicides rose sharply with each successive year. That study also showed that parasuicide was most common in the 15–24 age-group, but at younger ages there was a higher proportion of undetermined deaths, as against officially recorded suicides. The social taboos associated with suicide may lead to its systematic under-reporting, but even allowing for that, the phenomenon is still a rare one under the age of 16.

Battles have always been a feature of psychiatry, and the traditional hegemony of the hospital has been contested particularly often. Mosher (1983) has made one of the most recent major incursions into enemy territory on behalf of the community care guerillas, in a paper in the New England Journal of Medicine.

The “Italian Experience” in closing down mental hospitals has been highly praised by some British observers, who have seen lessons for Britain in the development of community care. However, it has been the subject of heated debate in Italy—and the policy is now to be reversed by law. Two questions arise: why have the claims been exaggerated? And why have they found such ready and uncritical acceptance in Britain?

Seventy-seven patients with diagnosis of schizophrenia (62) or schizoaffective disorder (15) were studied 2–20 years since onset of illness, when in a stable condition. The investigation included clinical assessment, measurement of plasma concentrations of neuroleptics and prolactin, computed tomography brain scan, neuropsychological and neurological examination. Outcome of illness was classified according to the presence of chronic psychiatric symptoms and social impairment, and response to neuroleptics according to the effect of treatment in the most recent psychotic episode. Neither outcome nor response to neuroleptics was related to duration of illness. The groups with good and poor outcome differed in premorbid adjustment, age at onset and symptoms of the initial episode, but not in drug bio-availability or prolactin response. Large cerebral ventricles and cognitive impairment, but not neurological ‘soft’ signs, were associated with unfavourable outcome. The three measures of organicity were not inter-related. No clinical differences were found between chronic patients with and without signs of organic dysfunction. The findings suggest that schizophrenia with good and unfavourable outcome may be separate sub-types. However, the role of organic factors in the latter group remains unclear.

Fifty-six patients with RDC schizophrenia (42) or schizoaffective disorder (14), of two to 20 years' duration, were assessed for neurological ‘soft’ signs and cognitive impairment when in a stable condition—the ‘outcome’. Neurological dysfunction (46% of 50 examined patients) was associated with a history of developmental abnormalities, but was unrelated to outcome, psychiatric symptoms, or treatment. Deficits in particular cognitive fields were related to two independent factors: overall severity of residual psychiatric disorder (outcome) and neurological dysfunction. There was no relationship between the size of the lateral brain ventricles on CT scan and either ‘soft’ signs or cognitive impairment.

The findings do not provide evidence for an association between the presence of organic brain disorder (as indicated by the joint occurrence of neurological dysfunction and cognitive impairment) and either poor outcome or particular symptoms of schizophrenia.

The present status of monoamine oxidase inhibitors in the treatment of depression is reviewed. With adequate doses they are effective antidepressants, but dosages have in the past been too low. Provided proper dietary precautions are taken, the incidence of fatality from dietary interactions is very small and should not deter doctors from using these drugs, especially in those depressed patients who do not respond to tricyclic-type antidepressants. The present status of combining monoamine oxidase inhibitors with tricyclics is discussed, as are the newer specific inhibitors particularly clorgyline and deprenyl.

Computed tomography brain scans were carried out on 40 patients with schizophrenia or schizo-affective disorder of 2–20 years duration. Ventricular-brain ratio (VBR) was significantly greater than that of the control group. In six patients the VBR exceeded the control mean + 2 s.d. Among the 13 whose VBR was more than 1 s.d. above the control mean, none had schizo-affective disorder, all but one had chronic illness, and patients with negative symptoms and those with premorbid schizoid traits were over-represented. VBR was unrelated to medical history, age, duration of illness, or neuroleptic treatment. It was not associated with neurological ‘soft’ signs or cognitive deficit. Among chronic patients, clinical features showed no association with ventricular size. The findings suggest that large ventricles may be related to a sub-type of chronic schizophrenia rather than to its particular clinical features.

A follow-up study of all patients entering the MRC double-blind trial of fluphenazine decanoate in chronic schizophrenic out-patients achieved a trace rate of 94%. In general, these patients were severely disabled, continued under the care of the maintenance clinic, and their diagnoses remained remarkably consistent; more than one-fifth were found to be in acute schizophrenic relapse and in over a half of these cases, the relapse was not known to the treatment agency. The maintenance clinic attenders were little different from those who no longer used such a facility.

There cannot be many hospitals and medical schools owing their origins to the visual hallucinations and grim forebodings of a depressed monk. Yet that is precisely the story of how the venerable institution of St. Bartholomew's Hospital was founded. The monk Rahere, on a journey to Rome to obtain forgiveness for his sins, “fell ill and thought his last hour was drawing nigh. He burst into tears and vowed a vow that if he should be allowed to return to his own country he would there build a hospital for the recovering of the poor” (Moore, 1918). On his way home, he had a vision of St. Bartholomew who instructed him, among other things, to build a church in Smithfield. Was it, asks Moore, a fantastic illusion, such as men have in their sleep, or was it a heavenly oracle? Was the illness, he might have added, a depressive illness given the melancholic mood, tearfulness, feelings of impending doom, and gradual recovery? And why a vision of St. Bartholomew? The saint is associated with medicine, or more accurately with surgery. The fact that he was flayed alive and thereafter has tended to be protrayed pictorially with his skin draped in folds about his bones has suggested to some a distinctly ‘barber-surgeon’ flavour, and he is indeed the patron saint of butchers. Less well-known is the fact that he exorcised a devil from King Polimius's daughter—a therapeutic action which entitles him to be regarded as the patron saint of nervous diseases, (Dawson, 1957).

It is now generally agreed that the words ‘handicapped individual’ need to be considered as having a social rather than a medical or educational meaning. To arrive at such a conclusion, however, it is necessary briefly to consider the words ‘impairment’, ‘disability’ and ‘handicap’ (Figure 1).

The behaviour and self-help skills of mobile, severely or profoundly retarded adults with behaviour disorders, living in hospitals, were compared with those of a matched group in small homes outside hospital. The residents in the homes more often engaged in simple constructive activities. Although stereotypies were as common in the homes as the hospitals, in the former they were more likely to be combined with constructive pursuits. There were no differences between the groups in self-help skills. In the homes, the staff: resident ratios were higher and the staff had more autonomy in management and responsibility for organising their own services. The care practices in the homes were more resident-centred, and social contacts between staff and residents were more frequent. However, there was no evidence that, for this type of resident, placing a small home in a residential street had advantages over other geographical locations.

During the investigation of somatosensory evoked cortical potentials arising from a complex vibro-tactile stimulus to the forefingers, an abnormal lack of lateralisation of response was found in 10 out of 21 schizophrenic patients. Eight patients with severe affective illness all had the expected degree of lateralisation of cortical potentials, as did 12 out of 15 normals. Three normals and 3 schizophrenic patients had a loss of lateralisation of the evoked response on stimulation of one hand but a normal lateralisation on stimulation of the other. The considerable technical problems of this and related techniques are discussed, but it is suggested that further exploration of this technique is justified. At this stage, no conclusion can be drawn about the cause of the abnormalities.

Compulsive water drinking is associated with a broad spectrum of psychopathology, from mild neurosis to psychosis. Since the normal kidney is capable of excreting large volumes of fluid rapidly, water intoxication requires both a pathological basis and a psychiatric explanation of why so much water is being taken. Excessive water consumption can be dangerous, so that the fluid intake of patients with a history of polyuria together with a low urinary specific gravity should be closely observed. Four cases of water intoxication resulting from psychogenic polydipsia are described, three of them in chronic schizophrenics, where inappropriate ADH secretion might represent part of the psychosis.

Seven years after the completion of the original trial, over 73% of patients were maintained on depot neuroleptics, and 70% had received such medication for over seven years. About 40% had presented with a problem of compliance at some time, and there was a significant correlation between poor compliance and in-patient admissions and schizophrenic relapses. The prevalence of parkinsonian side-effects, akathisia, and tardive dyskinesia was low. Non-psychotic symptoms were common, even in the absence of acute psychosis. Depression was found in a subgroup of patients; it was frequently reported as an indication for admission during follow-up period, and seemed to be part of the schizophrenic illness rather than a result of antipsychotic drug treatment.

The writings of Franco Basaglia are critically reviewed, both from a technical psychiatric point of view and from a general political and social one. Basaglia maintained that the causes of psychiatric disorder are essentially social in nature, and that the only valid treatments are political struggle and the revival of the patient's aggressiveness. Therefore, no institution can be therapeutic for the patient, since its aim must be his custody and violent destruction. These statements are considered in the light of the need for institutions which are a therapeutic alternative to the mental hospital. Basaglia's ‘liberal’ defence of the individual against society is analysed, in relation to the negative consequences that the Italian Law 180 of 1978 is having on the care of long-term psychiatric patients. This law ‘forgot’ such patients, as well as adversely affecting the treatment of acute patients, for whom an insufficient number of psychiatric beds was permitted in general hospitals. A revision is proposed of Law 180 that would make possible the setting up of alternative institutions to outdated mental hospitals, but at the same time allow a transformation of their old structures.

An investigation of eating disorders in a population of chronic schizophrenic patients confirmed that there is a distinction between eating disorders of psychotics and eating disorders of the young. All the DSM-III criteria of eating disorders, except one, were observed among the psychotics although no patient fulfilled the necessary criteria for an eating disorder diagnosis except for one anorexic woman. All varieties of schizophrenic eating disorder were reported: in two-fifths of the patients eating disorders were associated with delusions and in one sixth with hallucinations; more than half of the patients had deviant eating behaviour which was not associated with any thought or perceptual disorders. Schizophrenic eating disorders were common, yet not disturbing to the social life of the open mental hospital or to that of the community surrounding it.

Forty-three patients with non-endogenous depressive disorders were assessed shortly after psychiatric referral, and reassessed at six and at 20 weeks. The pattern of improvement appeared to be set shortly after the initial consultation, but could be most clearly predicted by the degree of improvement at the end of the third week. Key baseline factors predicting a more marked improvement at each follow-up were a more severe depression, the break-up of an intimate relationship, and the presence of weight loss. Positive life events occuring after the initial assessment predicted improvement at six and at 20 weeks, while the presence of a neutralising event (which negated an earlier threatening life event) predicted improvement at 20 weeks.