People with schizophrenia lack the ability to develop – to differentiate and integrate – their self- and object-representations, and suffer from primitive ‘object-relations’ conflicts, which occur when they try to develop (to differentiate and integrate) their self- and object-world. When a therapist interacts beneficially with a schizophrenic patient and enables him/her to identify with the ego functions involved in this interaction, the patient's frail psychic structure receives nourishment that will strengthen it: this process is similar to human development, where a child attains psychic organisation by interacting with the one who nurtures him/her. The recommended approach in the psychoanalytic psychotherapy of schizophrenia is to ‘allow’ the natural evolution of the fusion–defusion and introjection–projection processes to appear in the experiences of transference and counter-transference.

The conduct of this survey has brought home to us the great diversity which exists in the amount, content and methods of teaching psychiatry in U.K. medical schools today. No two schools are quite alike in the type of staff facilities, in the allocation of teaching time in the several years of the course, or in the persons available to act as teachers. After two trial runs, we evolved a schedule of inquiry which has enabled us to compare schools in a number of respects in which reasonably reliable and quantifiable data were available. This report necessarily concentrates upon those aspects in which the various schools can be compared with each other: it does not do justice to the full detail of all the teaching given in any one school. In particular, we have deliberately confined our attention to teaching which is given to all students, whether they take advantage of it or not. Except for some observations on organized periods of elective study, we have not dealt with the extra opportunities which arc available in a number of schools for students who go out of their way to seek additional experience in psychiatry. Our schedule of inquiry was discussed by one of us personally with the psychiatrist responsible for teaching in every school except one—a London part-time teacher who remained obdurately “too busy” to comply with this request. It was found necessary, in the majority of cases, to supplement our interview and the schedule return by further inquiries; in a few particulars, and in respect of certain schools, we are still left in some uncertainty as to the accuracy of the information given to us. This report is submitted, however, as the best approximation possible within the limitations of our survey.

A 34-year-old heterosexual intravenous drug abuser presented with a paranoid psychosis and was subsequently found to have the Acquired Immune Deficiency Syndrome (AIDS). The patient died 14 days later of generalised septicaemia. The case is reported and the aetiology and pathogenesis of the organic psychosis are discussed. It is anticipated that similar psychiatric manifestations will occur as the AIDS epidemic increases.

Although recent research in social psychiatry has produced an encouraging congruence of findings and conclusions, puzzling inconsistencies continue to be reported. One explanation which is often overlooked is that subtle differences in the way seemingly identical variables are grouped can produce sizeable, and sometimes dramatic, differences in the patterning of the same data. Re-examination of existing results can therefore often better clarify confusing inconsistencies than collection of new data. This is illustrated by examples from recent studies of affective disorder where the grouping of variables is discussed in three broad areas: parental loss in childhood, precipitating stress, and social support. Until the aetiology of affective disorder is more fully understood, it will often be clearer if data are analysed more than once, so that several combinations of variables are systematically examined.

The introduction of anaesthesia and muscle relaxation has made ECT relatively safe. In a retrospective study of the case notes of 367 consecutive patients receiving ECT over a two year period, chest X-ray and full blood count added no significant information and were ineffective in predicting morbidity, in contrast to physical examination alone.

Erythrocyte membrane adenosine triphosphatase activities were examined in twelve unipolar depressed patients receiving ECT. Eleven patients undergoing diagnostic cystoscopy served as controls for the acute effects of anaesthesia, and sixteen healthy subjects served as non-depressed controls. The unipolar depressed patients had a slight reduction in their (Na++K+)-ATPase activity but effective ECT treatment was not associated with any increase in this activity. This approach is unlikely to cast further light on the membrane phenomenology of depressive illness.

The demonstration that an endocrine disorder can precipitate a specific mental illness would be an important step towards the development of much needed animal models of affective disorder. To this end we have sought and found evidence for a causal connection between Cushings syndrome and the apprearance of a depressive illness (Kelly et al, 1980 and 1983). Whether or not hyperthyroidism can cause a manic depressive illness is at present uncertain. Reported values for the incidence of depression in hyperthyroidism vary from 1–20 per cent (Bursten, 1961; Clower et al, 1969; Dunlap and Moersch, 1935; Johnson, 1928; Katzenelbogen and Luton, 1935; Kleinschmidt et al, 1956; Lidz and Whitehorn, 1949) and these are similar to estimates of the incidence of depression in a general population (Watts et al, 1964; Shepherd et al, 1966; Crombie, 1974; Brown and Harris, 1978). Similarly estimates of the incidence of hyperthyroidism in depressed patients are around 1 per cent (Bursten, 1961; Bluestone, 1957; Martin, 1963) which is also similar to the incidence of hyperthyroidism in the general population (Tunbridge et al, 1975). Finally in a population of patients with recurrent manic depressive illness, the eight observed episodes of hyperthyroidism striking during normal health were not apparently followed by any mental disturbance (Checkley, 1978). We now report upon a patient in whom two episodes of mania coincided with two episodes of hyperthyroidism and discuss the possibility that the two illnesses were related to each other.

SUMMARY The paper describes a two-month period of study in four bipolar manic-depressive patients in a metabolic ward. Plasma renin activity, packed cell volume, plasma sodium and potassium were determined at intervals. Twenty-four-hour urinary sodium, potassium and creatinine were also estimated daily. Aldosterone production rate was measured on two occasions for each patient. Three of the patients showed at least one episode each of mania and depression during the study, while the fourth patient, who was receiving prophylactic lithium throughout, had one ten-day depressive episode but was otherwise normal.

No obvious relationship between mood and plasma renin activity was observed, but the group showed a high resting renin activity, a blunted renin response to posture, and inappropriate aldosterone production rates for the renin activity found.

It is postulated that a primary defect in the aldosterone-renin system may be present in bipolar manic-depressive psychosis.

The decade following the end of World War II saw a progressive rise in the admission rate to mental hospitals in this country. The population of mental hospitals rose to a peak of 152,000 in England and Wales in 1954, since when there has been a steady decline. These fluctuations have been analysed by such authors as Norton (1961) and Tooth and Brooke (1961). The latter attributed the more recent decline to increased efficiency of treatment and rehabilitation, and predicted a continued fall so reducing the mental hospital patients by about 1970 that they would be covered by an allocation of 1 · 8 beds per thousand population. Maclay (1963) believed this prediction to err if anything on the conservative side and the Ministry of Health (1962) based its plans for psychiatric beds upon this ratio. In these plans the Ministry accepted the thesis that short-stay psychiatric patients should preferably be treated in general hospital units near to their homes whilst patients needing a longer hospital stay should be catered for in specialized hospitals for that purpose. The prediction in the Ministry of Health's Hospital Plan (1962) that there would be a steadily declining mental hospital population has been severely criticized by Gore and Jones (1961) but supported by Orwin and Sim (1965) in their analysis of the effects of the provision of acute general hospital psychiatric units in the Birmingham area. The importance of accurately assessing the psychiatric hospital bed needs over the next twenty years, given a full range medical and ancillary services, is vital to future planning and has been much in the author's mind when writing this paper.

In a study of children adopted at an early age, discrimination between hereditary and family dynamic factors is possible. The biological parents have given the child their genetic characteristics and sometimes the very early environment, while the adoptive parents have provided the more permanent family environment and rearing. The major goal of the Finnish adoptive family study was to re-assess the genetic contributions to schizophrenia and to provide further measures of the adoptive family rearing environment. In other words, we were interested in the joint effects of genetic and family environmental variables and in their possible contribution to both the psychopathology and the healthy functioning of adoptees during their development. This approach paid attention to the possibility that a healthy, possibly protective, rearing family environment may reduce the genetic risk. During the course of the study, we also considered whether the direction of the effects between genetic and family environmental factors can be clarified through a prospective, longitudinal study of the adoptees at risk.

The response to the dexamethasone suppression test (DST) was examined in 543 patients suffering from major depressive illness and 246 healthy controls, from 13 research centres, representing 12 different countries, in a World Health Organization Collaborative Study. In almost all the centres, the post-dexamethasone plasma Cortisol concentration was significantly higher in the patients than in the controls. Although there is variation between centres, this abnormal response to the DST was shown to be frequent in patients from widely different geographical areas.

The nature and extent of psychological and social disability following head injury remain issues of considerable practical and theoretical interest. Practical because of the size of the problem and the resulting burden of care; theoretical because head injury should provide a powerful model for an improved understanding of the relationships between cerebral disorder and psychological impairment. (Lishman, 1973)

The Department of Health in England has long encouraged the routine measurement of clinical outcomes in mental health services but has now decided to use outcome measures as part of a new payments system – Payment by Results. We examine how these two policies should or might interact.

We assessed prevalence rates of mental disorders in 206 mothers who had experienced the Kosovo war 10 years previously: 100 lone mothers widowed by the war, 71 non-bereaved married mothers, and 35 married mothers bereaved since the war (loss of family other than husband). A total of 96% of widowed lone mothers reported a major depressive episode, an anxiety disorder or a substance use disorder as compared with 54.9% and 60% in the married groups. Furthermore, 45% of widowed lone mothers reported current suicide risk as compared with 16.9% and 22.9% in the married samples. War-related widowhood combined with lone motherhood constitutes a significant factor for elevated psychopathology.