Empirical evidence for the effectiveness of community treatment orders (CTOs) is at best mixed. We examine CTOs through the prism of human rights and discrimination, bearing the evidence in mind, and argue that a necessary condition for their use is that a person lacks decision-making capacity.

Since it was first reported by Kuhn in 1957, the value of imipramine in the treatment of depressive illness has become generally recognized and confirmed by clinical trials (Blair, 1960; Daneman, 1961; Rees et al., 1961). It continues to hold an important place in therapy despite the introduction of many other antidepressant drugs and the occasional adverse report (Ashby & Collins 1961). Nevertheless the indications for its use are by no means established. It has been claimed that certain types of depression respond better than others: “psychotic” better than “neurotic” (Azima, 1959), “endogenous” better than “reactive” (Ball and Kiloh, 1959). Yet the difficulty of making these categorical distinctions, and of making reliable comparisons between the findings based upon them by different workers remains notorious. It is clear, however, that only a proportion of depressed patients respond well to imipramine. It is also certain that within the group which does respond well are to be found representatives of every type and degree of depressive state. There is evident need, therefore, for information that will help to indicate which characteristics of an individual will render him more or less susceptible to imipramine, and there does not appear to have been any study particularly devoted to this. In this paper we give the results of correlating certain clinical features of depression with the response to treatment by this drug.

In the communication which I have the honour to submit to the members of the South-Western Division to-day, I intend to bring forward some facts and some figures, not hitherto recorded, relating to the female patients now and formerly resident at this asylum.

Four elderly schizophrenic patients who had never been treated with neuroleptics, and a fifth patient who had received only the briefest exposure to such drugs, had retained their distinct clinical characteristics. Involuntary orofacial movements and cognitive dysfunction were found more uniformly than any particular pattern of symptoms.

In 1963–4 the Oxford University Penal Research Unit managed to collect information about 90 per cent of the offender-patients who were admitted to N.H.S. and Special Hospitals under hospital orders made by criminal courts: this cohort has been described in Crime and Insanity, Vol. II, by Walker and McCabe (1973). One of the by-products of the follow-up of these offender-patients was a rough and ready scoring system for predicting reconvictions (within a two-year follow-up) of 456 offender-patients who were allowed to leave hospital within a year of admission. A prediction system can be used to assist human decision-making (though it should not be a substitute for it)∗ and can also be used to assess the efficacy of measures—such as after-care—by seeing whether individuals with equal predicted reconviction-rates do better with than without the measure (Mannheim and Wilkins, 1955).

This case is reported in the absence of any documented evidence of the systematic and successful treatment of blepharospasm. A flexible behaviour therapy approach, guided by behavioural analysis and experimental psychology was used (Sharpe and Meyer, 1973).

In an attempt to evaluate the clinical significance of alcohol withdrawal, the rate of symptoms and incidence of treatment were determined in 84 female alcoholics following abrupt withdrawal. Results indicated that abstinence symptoms of an emergency type (delirium tremens, convulsions) only rarely occur and require active treatment, whereas those physical and emotional disturbances frequently seen in alcohol withdrawal need very little medical help. This finding is in contradistinction to current clinical opinion.

The advent of new imaging techniques is broadening our understanding of the major psychiatric illnesses. The increased knowledge of brain function will have consequences for the expert medical witness who has to give evidence in court. Both the insanity defence and the defence of automatism depend on disorders of the mind. Psychiatry is now able in many cases to produce evidence that these are consequent upon disorders of the brain. In presenting evidence in court there is an apparent conflict between ‘brain words' and ‘mind words'.

Significant sibling-sibling and within-family correlations of human red blood cell catechol-o-methyl transferase activity have suggested a high degree of genetic control over levels of activity of this catecholamine-related enzyme. However, family studies do not disentangle genetic from environmental similarities as causative of within-family correlations. We therefore undertook a human twin study using the monozygotic-dizygotic comparison method. Twelve pairs of monozygotic twins had an intraclass correlation of .90 in red blood cell catechol-o-methyl transferase activity, and seven pairs of dizygotic twins had an intraclass correlation of .37. Heritability of the enzyme activity was estimated by different methods as between 68–100 per cent.

Specific inhibitors of 5-HT reuptake are reported to have lower preconvulsive activity than other antidepressants. A patient with post-traumatic epilepsy who had remained fit-free for many years until she was given the 5-HT reuptake inhibitor fluvoxamine is reported. Changes in serotonergic function may play a more widespread role in the pathophysiology of seizure disorders than hitherto thought.

Four sets of commonly used ‘operational definitions' of psychiatric disorders were applied to clinical information, obtained on the basis of semi-structured interviews with samples of hospital in-patients, out-patients, and general population. The agreement among them in defining ‘cases' and in assigning specific diagnostic categories was examined. There was considerable variation among the diagnostic systems in distinguishing between ‘cases' and ‘non-cases' and in identifying sub-groups of cases as having specific diagnoses. Comparison of operationally defined syndrome categories with diagnoses assigned by clinicians also showed much disagreement.

Fifty-six psychiatric patients were interviewed to obtain a record of life events preceding admission to hospital, using a modified version of the Schedule of Recent Experiences. Two control groups were studied for comparison: medical and surgical in-patients and a ‘normal’ population studied independently by Myers. Psychiatric patients reported a significantly larger number of events than the medical-surgical patients, who, in turn, reported significantly more events than the ‘normal’ population. There were no significant differences in the specific life event histories between groups.

The use of unilateral ECT as a method of exploring differences between the functions of the cerebral hemispheres has been suggested by Pratt et al. (1971). These authors found a greater impairment on a test of naming and a tendency to slower return to consciousness after left-sided than after right-sided treatments. Assuming that these effects depend on left hemisphere language specialization, they went on to use them as possible indicators of cerebral dominance for speech in left handers. The present enquiry was designed to explore these differences further by comparing patients immediately after right-sided and left-sided ECT for their ability to name objects and to make visual discriminations and for their time of recovery. Handedness was assessed through a measure of relative manual speed as well as by the usual questions of preference and family handedness. The speed differences give a continuous measure of degrees of right and left handedness which can be correlated with measures of differences between the effects of right-sided and left-sided ECT.

An important topic in the neurobiology of the affective disorders relates to changes in the metabolism of neurotransmitters. Since the early 1960s, the ‘serotonergic’ hypothesis (Coppen et al, 1972) has been supported by findings such as a low concentration of 5-hydroxy-indoleacetic acid (5-HIAA) in the cerebro-spinal fluid (CSF) of patients with melancholic depression and/or suicidal behaviour (Banki & Arato, 1983; Åsberg et al, 1984; Banki et al, 1984; López-Ibor, Jr et al, 1985; Korpi et al, 1986) as well as the efficacy of serotonin precursors, when combined with MAOIs, in the treatment of depressed patients (Coppen et al, 1963; Glassman & Platman, 1969; Ayuso et al, 1971; López-Ibor, Jr et al, 1976).

The responsiveness of eccrine sweat glands to local intradermal injections of carbachol and phenylephrine was studied in six male and six female healthy volunteers and six female patients suffering from anxiety neurosis, using a plastic paint impression method. Carbachol evoked consistently greater responses than phenylephrine. The response to carbachol attained a peak approximately two minutes after injection, whereas the response to phenylephrine attained a peak within fifteen seconds of the injection. Males showed greater responsiveness to both drugs than females, this being reflected in significantly higher maxima of the dose-response curves for the males. The anxious females showed a higher level of spontaneous sweat gland activity and greater responsiveness to both drugs (reflected in higher maxima of the dose-response curves) than the normal females.

The finding of chromosomal mosaicism in mongolism (Clarke et al., 1961) has added a new dimension to the problem of mongolism which has helped to answer some questions, but which has also created some new ones. It has been suggested that mosaicism may explain some of the microsymptoms of mongolism found in the siblings, parents and relatives of mongols. This has particular application to the increased atd angles on the palms of some mothers of mongols (Penrose, 1963).