Although in common use, treatment-resistant depression is unhelpful both conceptually and practically. In this issue a new term, multiple-therapy-resistant major depressive disorder, is proposed; although it may be useful in guiding treatment options for patients with persisting depression, it should not be an automatic trigger for further, more invasive treatments.

The Chief Medical Officer's report for 2013 was the first of its kind to highlight the public's mental rather than physical health and thus represents a very important landmark for public health in the UK. Written primarily from the perspective of psychiatrists, the report has created confusion in public health circles by failing to adequately address the public health perspective. David Foreman's editorial in this issue, calling as it does for more training in public health for psychiatrists, is therefore very welcome and timely.

Acute alcohol intoxication is commonly followed by partial or total amnesia† for events occurring during the drinking period (Goodwin et al., 1969a). Individuals observed during the ‘blackout’ period have been noted to have a specific short term memory deficit, with remote and immediate memory largely intact (Ryback, 1970; Goodwin et al., 1970; Tamerin et al., 1971). The amnesia appears to be anterograde rather than retrograde, resembling the characteristic memory deficit in Korsakov's syndrome. Speculation has ensued that blackouts and Korsakov's syndrome may share common pathophysiological elements, though there is no direct evidence for this (Goodwin et al., 1969b).

In research into the origin of schizophrenia discrepancies repeatedly arise through the habit of treating schizophrenia as an entity. If independent subforms are differentiated, many ambiguities can be cleared up. A special form of catatonia (periodic catatonia) seems to be transmitted by dominant inheritance, a special paraphrenia (affective paraphrenia) recessively. In a large group of schizophrenias (systematic schizophrenias) with a poor outcome family histories of psychosis were rarely found, but examination of twins suggested a psychosocial origin for the disorder. In cycloid psychoses with a benign outcome family histories of psychosis were also seldom found. Only by diagnostic separations can the discrepancies in the field of schizophrenia be solved.

“Standard” leucotomy in the plane of the coronal suture is undoubtedly an effective treatment for many cases of otherwise hopeless prognosis. The main objection to its use, resulting in many “modified” operations being devised, has been the occurrence of serious personality deficits afterwards. Ström-Olsen and Tow (1949) found that these handicapped nearly three-quarters of patients with “severe neurotic depression, obsessive-compulsive neurosis and chronic tense hypochondriasis”, and though 76 per cent. were relieved of illness only 8 per cent. were in full employment. Tow (1952) has repeated his concern at the serious damage inflicted on well-preserved personalities. Partridge (1950), who has given a full account of the personality changes after McKissock's (1943) “standard” leucotomy, detected some personality deficit in nearly every case of the 300 he investigated and suspected that intellectual impairment was present in all, though he could only be sure of it in a proportion. I have elsewhere (Pippard, 1955) reported the clinical results in 240 cases followed up 1½ to 5 years after rostral leucotomy by Mr. McKissock and this paper should be consulted for details of the operative techniques and scales used for rating the results.

Cattell's basic strategy in personality research has been first to establish personality factors for each of three major types of measurement, rating (Life-Record), questionnaire (Self-Rating), and objective tests, then to compare factors from one realm with factors from another (7). A factor in any one realm is established in the first place by being replicated. As Cattell says (4, p. 291): “… a functionally unitary trait or process should nevertheless not be considered established by a pattern in a single factor analytic research, but must reappear consistently and persistently in independently rotated studies.”

Foulds (1965) proposed that the classes of psychiatric illness can be described in terms of a continuum of increasing degrees of failure to maintain or establish mutual personal relationships. This concept of all psychiatric illness as an “illness of the person” centres on processes which occur in the mentally ill that interfere with the satisfactory establishment and relative endurance of adequate personal relationships. Foulds conceptualizes these interfering processes as barriers to achieving “personhood”: they may present as signs or symptoms of psychiatric illness or as abnormal degrees of personality traits. Thus, for example, cognitive disorder would make the schizophrenic unable to cope with the demands of interpersonal situations. Similarly, egocentricity would render the psychopath incapable of empathy and with a tendency to treat “others as objects or as organisms than as persons”. In both examples social alienation is inferred, manifested in the first case as withdrawal and in the second case as rejection. It is Foulds' thesis that this incapacity for mutual relations increases along a continuum from normality, through the personality disorders, neurosis, integrated psychosis (melancholics, manics and paranoids) to non-integrated psychosis (the schizophrenics).

Kuwait, the country with the world's highest per capita income,∗ has a population of roughly 325,000, of whom only half are ethnically Kuwaiti. The original settlers left the Nejd in Central Arabia about 1710 because of a severe drought, and after wandering about for several years with their herds and flocks eventually settled at the head of the Persian Gulf. The country they founded, about the size of Northern Ireland or of the State of New Jersey, is wedged in between Iraq and Saudi Arabia. Next to the Kuwaiti, the second largest group of inhabitants is the Bedouins who “are recognizable by their particular Arabic accent, their characteristic smell, and their long hair and beard”, according to a resident of Kuwait City. The Bedouin women can also be recognized easily because the black “thaub” which covers them completely from head to foot is made of solid cloth with narrow slits for the eyes, whereas the “thaub” of the Kuwaiti women has a black veil built into it.

The psychiatric aspects of the investigation of these patients having been covered in the first of the papers of this series, it is the purpose of the present paper to provide details of physical factors, especially those relating to the epilepsy.

In a previous paper (1) the iron, copper and manganese content of the human brain were recorded, with special reference to the G.P.I. cortex, which in certain cases contained an excess of both total and “available” (i.e., non-hæmatin) iron.

This investigation was designed to determine whether significant alterations in the metabolism of nitrogen, calcium, and phosphorus occur in psychiatric patients during the therapeutic administration of electric convulsive treatments. Gour and Chaudhry (1) observed transient changes in serum calcium following grand mal convulsions in a series of patients. Jarvie and Mulligan (2), repeating this experiment in patients receiving muscular relaxants during the administration of E.C.T., failed to demonstrate similar calcium changes. More intimate knowledge of electrolyte metabolism can be obtained by means of balance techniques (3), whereby the degree of retention or loss of a particular substance can be ascertained by maintaining each patient on a constant daily intake and regularly determining the urinary and stool excretion of that substance.

Samples of ventricular CSF were taken from 52 consecutive patients admitted for psychosurgery for intractable depression. Concentrations of asparagine, aspartate, glutamine, glutamic acid, and serine were determined. Glutamate and aspartate concentrations, implicated in excitotoxic brain damage, were not affected by various types of psychotropic drug treatment. Serine, a modulator of glutamate responses, was significantly elevated in samples from subjects receiving antidepressants. These subjects responded poorly to the operation. Psychotropic drugs are unlikely to be neurotoxic. Nevertheless, antidepressants may influence excitatory neurotransmission.

There have been many reports which suggest that there may be abnormal glucose metabolism in severe depression. Glycosuria was first reported nearly 60 years ago (Allers, 1914). In 1919, using an oral glucose tolerance test, Kooy observed decreased tolerance in a heterogeneous group of mentally ill patients which included melancholics. Since then many investigators have reported decreased glucose tolerance in depressive illness, and the extensive literature is reviewed by McFarland and Goldstein (1939) and Altschule (1953). Oral glucose tolerance tests have usually shown high or delayed peaks and a slow return to fasting levels, although the latter are usually reported normal. Intravenous glucose tolerance tests have also shown results nearer those obtained in diabetic patients than in normal subjects. Pryce (1958) reported decreased glucose tolerance with intravenous tests in a sample of 20 depressed patients, and he also found that glucose tolerance did not alter significantly after clinical recovery. Glucose supplements were added to the diet of six patients prior to testing, but he concluded that these supplements did not appear to alter glucose tolerance.