1. Depression is not an illness, but a psychobiological reaction which can be provoked in anyone.

2. It is much more easily provoked in some people than in others.

3. Vulnerability to depression is partly dependent upon social factors, as George Brown has demon strated. It is also determined by internal factors in the personality.

4. There is increasing evidence to show that the child's attachment to his mother is an important determinant of future mental health.

5. It will be argued that children who make ‘anxious attachments’ to the mother, as described by Bowlby, are less likely to incorporate her as a ‘good object’ within the psyche, and that this renders them more vulnerable to later depression than children who form ‘secuartetachments.’

6. Many features of depression in adults resemble or are related to ‘anxiouatstachments.’

7. The way in which psychotherapy can alleviate vulnerability to depression is described in terms of this hypothesis.

8. Reference is also made to the fact that effective action can be a source of self-esteem as well as love. Many of the great creators were partially effective in dealing with vulnerability to depression by work.

9. Freud affirmed that mental health depended upon the capacity to love and the capacity to work. It will be argued that the former capacity has been over-emphasized at the expense of the latter.

The principles underlying the development of the Present State Examination and the instruments and computer programmes associated with it are discussed in the light of comments made in three recent papers by psychiatrists trained in the German tradition of clinical phenomenology. Many of their comments are cogent and highly relevant to the future development of the system. Some common misunderstandings are also considered; in particular, those that lead to results being interpreted outside the limits of the specifications laid down. The potential for improvement in the system is emphasized and the next stage of development briefly described.

There is a difference of opinion among psychiatrists in this country about the place of psychodynamics in their subject. They appear to be divided roughly into two groups, the “cons” and the “pros”. This paper considers what the attitude of psychiatrists ought to be to psychodynamics, and it does this by selecting and examining the epistemological standing of one example of psychodynamic work. The example is contained in a book by Dr David Malan, entitled Individual Psychotherapy and the Science of Psychodynamics. The examination of this example brings out in what ways the two groups, the cons and the pros, are both wrong and right; and the way in which, therefore, the current difference of attitude is inappropriate, but understandably connected with the uneasy situation in which psychiatrists find themselves.

Opinions vary on the relative importance of biological and learning processes in the aetiology of sexual expression and deviance. The structure of personality, consistency of fantasy patterns, and the familial nature of homosexuality hint at a biological an/age. Research with the HY-antigen complex and X chromosome, and the elucidation of the interactions of intrauterine testosterone and its products with the foetal brain and neurotransmitters, have given us new models to understand the programming of sexuality. However, gonadotrophin feedback is not relevant as an indicator of brain feminization in primates and man. Finally, the interaction of masculinization and defeminization provides us with a model for understanding homosexual behaviour.

1848, as every student of history knows, was a revolutionary year in Europe. During that year, a minor, long forgotten revolution occurred in London medical circles when a physician, John Elliotson, published a paper entitled ‘Cure of a true cancer of the female breast with mesmerism’ (Elliotson, 1848). It is, as far as I can ascertain, the first recorded case of its kind. The author hypnotized his patient, a 42-year-old single woman, for “5 years and upwards … and for the greater part of the period three times a day”; during that time, Elliotson observed a ‘cancerous tumour’ in her right breast shrink away completely. No less than seven physicians and surgeons independently attested to the diagnosis of breast cancer, but no pathological examination was carried out. Elliotson was roundly abused, not for using hypnosis to treat cancer, but for using hypnosis at all—a practice condemned by certain physicians of fervid imagination as “indecent, disgraceful … liable to excite lascivious passions … an infernal system … the workings of Satan” (Elliotson, 1848).

A research neuroscientist in his fifties, who has recovered from endogenous depression after several years, describes the experience and makes some comments on treatment and management. He found electroconvulsive therapy, mianserin, lithium carbonate and diazepam acceptable. He considers that occupational therapy and conventional psychotherapy were counter-therapeutic. He stresses how physically ill he felt when depressed, and compares this with prolonged influenza. He hypothesises that the underlying psychological disorder in endogenous depression is the learned extinction of optimistic thoughts, and suggests that any psychotherapy used should be aimed at restoring these.

Psychotherapy, like any other effective treatment in medicine, may lead to negative effects either in the patient or those around him. The source of these unwanted effects may be in the patient's or the therapist's personality, in the patient-therapist interaction, in faulty therapy technique or in the patient's unresolvable social situation. The possibility of negative effects should be anticipated during the descriptive and psychodynamic assessment of the patient and before establishing the therapeutic contract. The technique of a trial of psychotherapy should be more frequently used than it is in cases where the therapist is in doubt. If negative effects do develop, these should be minimized by decreasing the frequency of psychotherapy sessions and depth of exploration. This may be done by allowing greater therapist “transparency”, by making fewer psychodynamic interpretations and by altering the focus of therapy from problems of early development to problems of current living.

The literature on the simulation of psychosis is reviewed and six patients who were thought to be feigning a schizophrenic psychosis were studied. On follow-up, all but one of the patients became overtly schizophrenic. It is argued that the simulation of schizophrenia is a prodromal phase of the psychosis occuring in extremely deviant premorbid personalities.

A 46-year-old mother with a history of chronic headaches and other symptoms, and a clinical diagnosis (in Western terms) of depression, ascribed her condition to non-observance of Chinese postpartum ritual. The characteristic features of ‘wind illness' are described. Western medicine proved useless but acupuncture was beneficial. The case underlines the importance of understanding the patient's own view of his/her illness and its causes in arriving at a correct diagnosis and intervening effectively: this is particularly true when the gap between the doctor's and the patient's cultures is wide. The value of the distinction between the disease (the pathological process, which may be universal) and an episode of illness (the personal and cultural construction of disease) is emphasized.

The aim of the study was to explore the way psychiatric symptoms might influence independent psychiatric assessment of outcome one year after stereotactic subcaudate tractotomy. In a sample of 34 patients consecutively accepted for psychosurgery the results showed that both ‘good’ and ‘poor’ outcome groups improved overall. No patients were significantly worse and the symptoms which improved most were nervous tension, depressed mood and somatic anxiety. It was not possible to identify symptomatic predictors of outcome because the preoperative symptom profiles of both groups were so similar. The reason why symptomatic outcome is so variable despite a basically identical psychosurgical technique is discussed.

One hundred and sixteen patients with major depressive disorder were asked for details of headaches during a depressive episode and during a nondepressed period. They experienced a headache rate similar to controls during the nondepressed period, but had an increased headache rate during depression (P <.02). Patients with an increase in depressive headaches were younger, had more somatic complaints, and experienced more hypersomnia than other depressives.

A study on the Standardized Assessment of Depressive Disorders (SADD) in collaboration with WHO Headquarters, Geneva, is reported in this paper. The instruments used for the study were screening forms and the SADD schedule, both of which were supplied by WHO. Fifty depressed patients were selected from the outpatients and inpatients of the Accra psychiatric hospital by experienced specialist psychiatrists using the screening forms. The two investigators then carried out a clinical assessment on each selected patient using the SADD schedule. The data collected were subjected to computer analysis. Findings were similar to those from previous WHO/SADD studies in different cultures. Specifically, the investigators found a “core” of depressive symptomatology among African patients in Ghana. An interesting finding was the change in the presentation of depression in African patients over the past 30 years. Broad diagnostic groupings like endogenous depression and psychogenic depression could easily be applied to the study patients. There is a great need for more SADD studies in Africa.

Particular instances of sexual deviation can not be discussed sensibly without first considering certain general issues.

The first of these is the question of definition. The notion of what constitutes abnormal sexual behaviour has changed in the course of history and indeed its boundaries have expanded and contracted at different times. What emerges from the history of the concept is that it has been defined by the social and moral climate of the time and indeed sexual deviance can be seen, for the most part, as a social rather than a medical concept (Bancroft, 1974).

An index of brain tissue density was obtained from the CT scans of 37 elderly depressed patients by measuring Hounsfield Units (HU) in 12 predefined brain areas. Comparisons were made with 23 patients suffering from senile dementia and 36 healthy controls. As a group the depressed patients resembled the dements more than the controls, although analysis of variance indicated differences between all three groups, controls showing the highest HU values and dements the lowest. In the depressed patients ventricular dilatation, which had already been shown to predict increased mortality, was also associated with lower HU levels. The significance of these and other findings is discussed.

The aetiological model proposed by Brown and Harris was examined in a sample of 110 working class women with children in Oxford. Using the same methodology as Brown and Harris, the role of provoking agents in the onset of affective disorder was found to be very similar to that which they originally described. Lack of an intimate relationship with a husband or boyfriend was found to act as a vulnerability factor, increasing the risk of psychiatric disorder in the face of a provoking agent. There was a trend for women with three or more children aged 14 or under to have an increased vulnerability. However, unemployment was not found to be a vulnerability factor. These results provide general support for Brown and Harris's causal model.

The prophylactic effects of carbamazepine (CBZP) were studied in 32 patients with affective disorder who were receiving long-term therapy with CBZP. Complete inhibition of both manic and depressive episodes was observed in four cases, reduced incidence of episodes or decreased intensity of symptoms in twenty, and no change in eight. CBZP was significantly more effective in cases with an onset before the age of 20, and subjects showing a continuous pattern of alternating episodes responded better than those with a more intermittent history of mania and depression. Where CBZP had an effect it was generally apparent soon after therapy started. These results suggest that in some cases CBZP is an agent suitable for long-term continuous prophylactic therapy in manic-depressive disorder.

In a prospective (controlled) trial, the result in 18 patients receiving eight, weekly half-hour sessions of brief problem-oriented dynamic psychotherapy was compared with the result in an equal number receiving eight weekly half-hour sessions of family practitioner therapy and in another 20 receiving no additional therapy. The subjects were drawn from patients at ten suburban family practices in Sydney. They had had psychological complaints for at least six months. No differences between the three treatment groups were found in the final outcome, either in a symptom severity and social dysfunction factor or in a physical disability and medication factor.

A follow-up enquiry was carried out after two years on 54 patients who had earlier participated in a controlled experiment on home-care through a community nurse in Bangalore. Thirty seven of these patients could be contacted, of whom 21 had undergone the experimental care (home care) and 16 were from the control group, which had been treated by hospital admission. It was found that the experimental subjects had maintained a significantly better clinical status than the controls, and had been readmitted less often.

Intracavernosal injection of phenoxybenzamine, in a dose too small to have significant general effects, caused full erection lasting between half an hour and 30 hours in 3 of 4 potent men (2 normal, 2 anorgasmic) and in 6 of 11 impotent men. In the remaining potent man and 3 of the remaining impotent it caused the penis to be stiff enough for intromission. Six of the eleven impotent men have had sexual intercourse, for the first time for months or years, while under the drug.

The practical implications of this new discovery are discussed.