The 50th anniversary of the inauguration of the NHS provided the occasion to review the evolution of mental health services and of psychiatry itself in Britain during that period.

The principal themes to be followed were the decline of a mental hospital system that had existed for over a century, the development of an alternative policy of ‘community care’, the emergence of a numerous and well-trained psychiatric profession, and the interaction between political and legal processes and mental health care.

An examination of Ministry of Health and Department of Health and Social Security files in the Public Record Office, interviews with influential figures, examination of the secondary literature, and personal experience of events described.

The material has been analysed, in the light of the expressed aims, and important trends have been described. The current situation is assessed.

The replacement of one system of care and treatment in Britain by another has been a process fraught with overwhelming difficulties. While adhering to the aim of ‘community care’, governments have been reluctant to provide the means for achieving this. The psychiatric profession is now faced with very large but ill-defined responsibilities.

Opposition to homosexuality in Europe reached a crescendo in the 19th century. What had earlier been regarded as a vice evolved as a perversion or psychological illness. Official reviews of homosexuality as both an illness and (for men) a crime led to discrimination, inhumane treatments and shame, guilt and fear for gay men and lesbians. Only recently has homosexuality been removed from all international diagnostic glossaries.

To review how British psychiatry has regarded homosexuality over the past century.

Review of key publications on homosexuality in British psychiatry.

The literature on homosexuality reflects evolving theories on sexuality over the past century. The assumptions in psychoanalysis and the behavioural sciences that sexuality could be altered led to unscientific theory and practice.

Mental health professionals in Britain should be aware of the mistakes of the past. Only in that way can we prevent future excesses and heal the gulf between gay and lesbian patients and their psychiatrists.

This paper takes as its starting point the paper by Aubrey Lewis entitled “The psychopathology of insight” published in 1934, unreferenced.

To attempt to explore the historical antecedents and consequences of this work.

Speculative review.

Lewis's approach to phenomenology, contemporaneous movements in psychology and Lewis's own life and times – notably the eugenics legislation in Nazi Germany – probably shaped his conclusions. Modern concepts of insight, which emphasise neuropsychology as well as social psychology, were anticipated in Lewis's writings.

The concept of insight has stimulated research into difficult theoretical and practical areas such as self-awareness and treatment compliance, respectively. Concern over a patients capacity for insight has the potential to humanise psychiatry.

A previous study demonstrated a higher rate of first hospitalisation for schizophrenia in twins than in singletons.

To compare the schizophrenia rates in monozygotic twins, dizygotic twins and the general population.

Through record linkage between the Young Cohort of the Danish Twin Register and the Danish Psychiatric Case Register, the rate of schizophrenia in’ monozygotic and dizygotic twins and the rate in the general population were compared.

The rate of first admission to hospital for schizophrenia in dizygotic twins was 40% greater than that in the general population. The rate in monozygotic twins was not increased. The difference between the rates in mono- and dizygotic twins was statistically significant (P < 0.001)

This result is surprising and is in the direction opposite to that expected, suggesting new possibilities in the study of risk factors.

About one-third of patients fail to respond to initial antidepressant therapy, which suggests a need for more effective drugs.

To compare the efficacy and safety of venlafaxine and paroxetine in 122 patients with non-chronic treatment-resistant depression.

In-patients or out-patients satisfying DSM – III – R criteria for major depression in evolution for less than eight months, having a baseline HAM–D score 18 and a HAM – D Item 3 score < 3 were eligible. Patients were required to have a history of resistance to two previous antidepressant treatments and a CGI improvement score of 3 at the beginning of treatment. Doses were adjusted to 200–300 mg/day for venlafaxine and 30–40 mg/day for paroxetine.

For the observed-case analysis, the response rate was 51.9% for venlafaxine and 32.7% for paroxetine (P=0.044), and a remission was achieved in 42.3% of venlafaxine-treated and 20.0% of paroxetine-treated patients (P=0.01). The incidence of adverse effects was comparable between treatment groups.

Venlafaxine showed some evidence of superiority to paroxetine in this difficult-to-treat patient population.

Alcohol misuse, as well as being a major form of psychiatric morbidity, is also commonly associated with other psychiatric disorders. A greater understanding of the brain mechanisms underlying the adverse effects of alcohol is now possible, thanks to significant research advances made over the past decade.

To elucidate for psychiatrists the growing knowledge of the importance of specific neurotransmitter interactions in the effects of alcohol.

A survey of the literature, extracting current knowledge of interest to psychiatrists.

There is good evidence that the acute effects of alcohol are mediated through interactions with amino acid neurotransmitters plus parallel changes in amines such as noradrenaline, dopamine and serotonin. Neuroadaptive responses at amino acid receptors probably underlie significant components of the withdrawal syndrome and probably also contribute to neuronal death found in chronic alcoholism.

An understanding of the pharmacology of alcohol use may lead to greater ability to treat psychiatric consequences of alcoholism, and may also prevent some of the secondary psychiatric comorbidity and later brain damage.

Most pharmacotherapy trials in post-traumatic stress disorder (PTSD) have been conducted upon male combat veterans. Outcome studies relating to civilians are therefore needed.

To demonstrate that fluoxetine is more effective than placebo in treating PTSD.

Civilians with PTSD (n=53) were treated for 12 weeks with fluoxetine (up to 60 mg/day) or placebo. Assessments of PTSD severity, disability, stress vulnerability, and high end-state function were obtained.

Fluoxetine was more effective than placebo on most measures at week 12, including global improvement (much or very much improved: fluoxetine 85%, placebo 62%, difference 0.24, 95% CI 0.01–0.47; very much improved: fluoxetine 59%, placebo 19%, difference 0.40, 95% CI 0.16–0.64), and high end-state function (fluoxetine 41%, placebo 4%, difference 0.37, 95% CI 0.17–0.57)

Fluoxetine was superior for measures of PTSD severity, disability, stress vulnerability, and high end-state function. The placebo-group response was low when viewed as a broad outcome based on a portfolio of ratings, but was higher with a traditional global rating criterion.

Schizophrenia occurring for the first time in late life may be a distinct entity or part of a continuum.

Can late-onset schizophrenia (LOS) and early-onset schizophrenia (EOS) be differentiated by their phenomenology and risk factors to their development?

Convenience samples of 27 DSM–III–R defined LOS subjects, 30 EOS subjects and 34 control subjects were systematically assessed.

Premorbidly, both groups of subjects with schizophrenia had personality traits that were different from controls but not from each other. The EOS subjects had more family members with a history of psychiatric illness or schizophrenia and less hearing impairment than the other two groups, which did not differ from each other. Clinically, LOS and EOS subjects were similar, except that EOS subjects had more negative symptom scores, tended to have more delusions of guilt/sin and of being controlled and more formal thought disorder, and had significantly poorer instrumental activities of daily living.

Phenomenology and risk factors do not distinguish discrete LOS.