The annual World Development Report which the World Bank produces has for the first time focused upon health issues. Central to its 1993 report Investing in Health was an analysis of the “global burden of disease”, addressing both mortality and morbidity. Previous attempts to prioritise health problems on a worldwide scale have focused on mortality, so common mental disorders have not appeared to be significant. The method of measuring the burden of disease described here has highlighted neuropsychiatric disorders, particularly depression, which accounts for around 30% of neuropsychiatric disorders. Neuropsychiatric diseases account for 5.7% of the total burden of disease for women in the developing world, and rank fifth in this respect. In the rest of the world, they account for 13.3% of the total burden of disease for women, and rank third. Prioritising health interventions is crucial given the scarce resources available. Sufficient evidence now exists to warrant greater emphasis on common mental disorders.

Kraepelin established manic–depressive disorder on the psychiatric map as a remitting but recurrent disorder. As the concept of affective disorder became broader, its potentially chronic nature was also recognised in long-term follow-up studies. However, the advent of antidepressants in the late 1950s gave rise to more therapeutic optimism, and a tendency to regard unremitting and chronic features as reflecting characterological rather than affective disorders. In the late 1970s, an era of reappraisal started, and it is now clear from long-term follow-up studies that recurrence is common and chronicity occurs, although probably in a smaller proportion than previously. The wheel has come full circle recently in Britain, as the Department of Health and the Medical Research Council have established relapse and chronicity in depression as major health service research priorities.

The Editor's initiative in seeking this Editorial was inspired no doubt by a number of recent cases and events in which the behaviour of those concerned seems to have defied rational explanation, and the power of ‘evil’ has been invoked in order to provide one. Perhaps the most compelling was that of the trial for murder of two ten-year-old boys for the murder of the infant James Bulger.

Many people with severe schizophrenia have increased cerebral ventricular size and diffuse reduction in cortical volume; recent attention has focused on subtle malformations of the cytoarchitecture in the hippocampus and parahippocampal cortex. Sufferers also show an excess of dermatoglyphic and minor physical abnormalities, and a significant proportion had psychomotor deficits, cognitive or behavioural problems as children. Such findings suggest that the form of schizophrenia most akin to Kraepelin's original description of dementia praecox results from neurodevelopmental impairment. This may have its origin in genetic defects in the control of early brain growth, or in early environmental hazards such as prenatal exposure to maternal influenza or perinatal complications. How foetal or neonatal lesions produce hallucinations and delusions two or three decades later remains a mystery, but maturational changes in the brain may be important.

A Western psychiatrist visiting a ward, out-patient department, or sheltered workshop in China would find much that was familiar, not only in terms of clinical syndromes and medication usage but also in the paucity of resources, problems with administrative hierarchies, and lack of status accorded by medical colleagues to psychiatry. Chinese psychiatric patients able to converse with their Western counterparts would discover that they shared much of the experience in common: stigma, problems with employment, and difficulties in finding a marital partner. Patients' relatives from East and West, likewise, would be able to recite a litany of similar concerns and complaints: the need for guidance and advice in handling disturbed behaviour at home, the gossip of neighbours, and the fear of another relapse.

A group of 114 long-stay patients in Friern and Claybury Hospitals was assessed while in hospital, and then again one year and five years after discharge to community placements. Neurotic symptoms, verbal and non-verbal behaviour and, most notably, negative symptoms all improved between the two community follow-up interviews. Patients were living under much less restrictive conditions in the community, and their appreciation of this freedom continued to grow over the years. Their social networks were enriched by an increase in the number of friends in the first year after discharge and in the number of confidants in the subsequent four years. There were no adverse outcomes, but these conclusions cannot yet be said to apply to all long-stay residents of mental hospitals.

Much has been written about the dangers of Cartesian dichotomy for psychiatry, with its equally perilous errors of ‘mindless’ or ‘brainless’ psychiatry (Eisenberg, 1986), as well as the nonsense of talking about disease as either ‘mental’ or ‘physical’, or with ‘somatic’ or ‘psychological’ symptoms. Kendell (1993) has made this point eloquently; this paper further extends the theme. We psychiatrists complain when our medical colleagues cannot get beyond the physical, even when evidence for psychosocial aetiology is quite blatant, but we may be guilty of an equivalent error in almost totally excluding spiritual considerations from the way we understand our patients. This was alluded to in the address to the Royal College of Psychiatrists by our patron (HRH the Prince of Wales, 1991). We ask patients to which religion they ascribe, but we neglect the much more important question of “what does your religion and your faith mean to you?”

The realisation that major depression is often both chronic and recurrent has slowly begun to change the way that depression is diagnosed and treated. In particular, the need for continuation and maintenance treatment is an issue that now deserves increased attention, especially with the availability of new classes of antidepressant treatments, which have excellent efficacy and more favourable side-effect profiles. Although the serious consequences of depressive disorders clearly indicate the need for effective and prompt intervention on the part of clinicians, the results of several studies indicate that patients with depression consistently receive no or low levels of antidepressant therapy. It is hoped that, through continued education of health care providers and patients about the consequences of depression, the issue of undertreatment of this serious illness will be resolved.

My Comment on Professor Prins' Editorial is based on my experience of observing evil in courts and tribunals.

The total direct cost of treating schizophrenia in the UK is £397 million, or 1.6% of the total health care budget. Hospital-based and community-based residential care accounts for nearly three-quarters of these costs, while drugs account for only 5%. A conservative estimate of the indirect annual costs of lost production is in the region of £1.7 billion. The heterogeneity of the disease and its outcome means that average treatment costs per person with schizophrenia should be treated with caution; 97% of direct costs are incurred by less than half the patients. Therefore, treatments which reduce the dependence and disability of those most severely affected by schizophrenia are likely to have a large effect on the total cost of the disease to society and may therefore be cost-effective, even though they appear expensive initially.

In pre-revolutionary China most disabled persons had no opportunity to receive education or obtain employment, and many of them experienced social discrimination. After the founding of the People's Republic, the government adopted a number of measures aimed at guaranteeing their livelihood. Efforts were made to give those who maintained the ability to work the opportunity to do so; those who were unable to work were provided with emergency relief or, if they had no family members who could support them, placed in orphanages, long-term psychiatric hospitals, and other types of welfare institution. Once the basic livelihood needs of the disabled were met, the next objective was to provide rehabilitative services. The evolution of these services has depended on three separate but related developments: the maturation of an organisational structure for the co-ordination of the services; the promulgation of laws that safeguard the rights and privileges of disabled persons; and the formation of academic societies of medical rehabilitation. This paper first considers these three developments and then examines how they have influenced the evolution of psychiatric rehabilitation in China.