An analysis has been made of patients aged 15 + referred to the community psychiatric service in a Danish rural population during 18 years. The mean referral rate per year was 17·9 per 1,000.

The majority of the patients (79 per cent) were referred to the clinic by the general practitioners, and it is stressed that a close and good co-operation between the psychiatrists and the local physicians is one of the most important factors in establishing a good community psychiatric service.

Only 11 per cent of all referrals were admitted to a psychiatric hospital. The admission frequency for psychoses was only 19 per cent, and it was estimated that it would have been approximately 44 per cent higher, if the service had been of the usual hospital-oriented type. Forty-three per cent of the patients were visited by the psychiatrist in their home at least once and 42 per cent of all 6,000 consultations were home visits.

When evaluating the treatment possibilities it was considered that approximately 50 per cent of all patients referred could be treated by the local physicians after examination by psychiatrists and discussion of the cases with them.

Plasma levels of amitriptyline and nortriptyline were similar in ten depressed patients after administration of amitriptyline hydrochloride in three divided doses or as a single daily dose. Maximum comparability of the plasma levels is achieved by sampling 12 to 16 hours after the single daily dose, or 3 to 7 hours after the morning dose on a thrice-daily schedule. Owing to the long biological half-life of these drugs, therapeutic plasma levels are maintained on a once a day dosage schedule, and the need for sustained release preparations appears questionable.

A year's cohort of 690 suicide ‘attempters' was followed for two years in order to monitor further attempts leading to referral to the general hospital. Eighteen per cent were involved in one or more repeat episodes, 16 per cent within the first year. More repeats occurred within the first three months than in the rest of the 21 months, and a large majority of repeats occurred within the first year.

Study of a smaller cohort of 141 persons gave information about the frequency and timing of previous attempts. Forty-five per cent had made previous recognized attempts and 10 per cent previous unrecognized attempts. Sixty persons reported 166 previous attempts. Of previous attempters 32 per cent made two or more attempts within a three-month period.

Three types of repeaters are suggested: (a) the chronic, habitual repeater; (b) the individual who repeats several times within a short period, and (c) the ‘one-off’ very occasional repeater.

In 26 depressed patients, a high correlation (0·89) was found between the Hamilton score and a psychiatrist's global rating and between the change (0 · 68) in these ratings during treatment. The Hamilton scale was able to differentiate at the 0·01 level four degrees of severity based on the global rating. Limiting the range of severity measured was found to lower significantly the correlation between the ratings. A prospective examination of a six-item sub-scale of the Hamilton scale developed by Beck and associates failed to confirm its claimed improvement in sensitivity or validity.

Imipramine and phenelzine were ineffective in the treatment of five primary unipolar depressives with delusions, even when plasma levels of imipramine and desmethylimipramine or activity of platelet monoamine oxidase suggested that an adequate dose of drug had been given. Four patients went on to receive ECT and all responded well. Five non-delusional patients responded satisfactorily to the antidepressant drug given. Nine out of ten subjects were women. Non-delusional patients showed some placebo response.

ECT is considered to be the treatment of choice in the acute phase of delusional depression in women.

Thirty-three married women, all agoraphobic but most with additional phobias, were exposed to a standard four-day intensive behavioural treatment programme as out-patients. The effects of this on the patients and their spouses throughout a one-year follow-up are reported and discussed.

Social anxiety was found to be the most common complaint in a sample of psychiatric patients reporting social interaction difficulties. High social anxiety was shown to be associated with impairments to social behaviour in socially anxious psychiatric patients and non-psychiatric volunteers. A comparison was made of systematic desensitization and a form of social skills training in the treatment of social interaction difficulties associated with high social anxiety. This indicated that while both therapies were effective in the reduction of social anxiety, the training programme was the more effective in reducing problem behaviour, but desensitization appeared to lead to a wider generalization of improvement as indicated by increases in social participation.

Nine patients diagnosed as having acute schizophrenic psychosis were treated with chlorpromazine. Their clinical response to drug treatment was measured by the use of a clinical rating scale developed from the Present State Examination, and a nurses rating scale. Plasma levels of chlorpromazine (CPZ), 7-hydroxychlorpromazine (7OHCPZ), monodesmethylchlorpromazine (NOR1CPZ) and chlorpromazine sulphoxide (SOCPZ), were monitored during the period of hospital treatment. Correlations were made between the increase in plasma levels of drug or metabolites and improvement in the different PSE scores. These showed that the most significant correlations occurred when symptoms with high diagnostic significance for schizophrenia (Group 1) and symptoms rating perceptual disorders (P) were correlated with plasma 7OHCPZ levels in plasma samples taken before the first morning dose of CPZ. The ratio of 7OHCPZ to CPZ in these samples increased significantly as clinical ratings improved, this correlation being most highly significant against the Group 1 and P scores. The ratio of 7OHPCZ to SOCPZ increased significantly only in the case of Group 1 and P scores. This indicates a preferential shift of CPZ metabolism towards the formation of the active 7OHCPZ during the period of clinical improvement.

A treatment for male genital exposure (exhibitionism) has been given successfully to 15 persons who have previously been resistant to change. The procedure involves the subject undressing before a mixed sex audience, followed by video-taping and subsequent replay to the patient. During the period of nakedness the subject describes in detail the events, his expectations and attitudes, and those attributed to his victim during exposure.

The success of the treatment appears to depend on the profound anxiety induced. During the phase of greatly increased anxiety, cognitive changes previously resisted seem to be made possible.

Schizophrenic patients in treatment with the Hawaii state system have been followed from 1962 to 1972. This cohort includes 1,689 persons: out-patients as well as in-patients; of Japanese, Caucasian, part-Hawaiian, Filipino, Chinese and other ancestries. After ten years, 60 per cent remain registered with the Hawaii Mental Health Division; 14 per cent are found living in the state; 12 per cent are lost to follow-up; and 14 per cent have died. Mortality is analysed for all causes by comparison with similar ethnic and sex sub-groups of the general population.

This paper presents a well-documented case of monozygotic male twins concordant for infantile autism, with a twelve-year follow-up. Assessments include birth records, laboratory studies, physical measurements, psychometrics and quantifiable behavioural ratings by independent raters using multiple scales. Possible aetiological factors of infantile autism, as well as outcome are discussed.

Seventy-eight depressives were assessed on the Delusions-Symptoms-States Inventory. The results supported Foulds' and Bedford's hierarchy model, in that nearly all patients fitted this model, and the relationship between delusions of Contrition and state of Depression was found to be an inclusive, non-reflexive one. Suggestions are made for extensions to this study.

The psychological function of the social network is considered in terms of attachment theory. Social bonds are proposed as essential for obtaining a commodity commonly but unsatisfactorily referred to as support. Requirements for this complex commodity can be discerned in a wide range of contexts. Examples considered are the evolutionary origin of the social network itself, the concept of psychosocial supplies, the distribution of neurosis in Western and non-Western populations, the use of medical consultations, psychotherapy and habitual responses to adversity or disaster. In these and other contexts, it is apparent that individuals have, quite simply, a requirement for affectively positive interaction with others. Under stressful conditions this interaction is called ‘support’. When support is lacking there is evidence that psychiatric and perhaps medical morbidity rates increase. For research, the objective must now be to determine whether depleted primary group interaction is causally related to morbidity, or whether it is only an associated or a secondary factor in aetiology, or indeed wholly unrelated. Elucidating more precisely why people need people constitutes an important new task for social psychiatry.

A survey of relatives' experience of coroners' inquests on suicides is reported. The survey was conducted shortly after the inquest and gave results similar to those of a survey which took place some years after the relevant inquests. Both surveys show that the inquest aggravates the distress resulting from bereavement by suicide. Implementing the Brodrick Report and preventing the publication of inquest reports in the press would relieve some of this additional distress.

The excess incidence of schizophrenia reported from Ireland may partly be due to the unusual distribution of the Irish population by maternal age at birth.

To test the Foulds and Bedford hierarchical model of personal illness, the Delusions-Symptoms-States Inventory (DSSI) was administered to 100 psychiatric in-patients. Ninety-six had symptom patterns compatible with the hierarchy. This is significantly more than expected on the basis merely of the number of DSSI items affirmed, and overall the results support the model.

A psychiatric investigation on 56 cases of male transsexuals in Singapore revealed a prevalence of 1 in 25,000. Eighty-two per cent were prostitutes and 83 per cent had completed secondary education. All were unmarried, and 35 per cent were co-habiting with men. Fifty-eight per cent had felt they were females before the age of 5, 65 per cent cross-dressed before the age of 10, and by the age of 20, 57 per cent were completely cross-dressed of whom 73 per cent were receiving female sex hormones. Their mean IQ was 105. Thirty-two (58 per cent) underwent sexual reassignment surgery. There was no report of psychiatric complications. It was concluded that transsexualism as described by different authors may not refer to the same condition. Aetiologically, these cases did not appear to be determined by early childhood experience.

Attitudes to the treatment of the pre-school child today stem very largely from the mainstream traditions in classical child psychiatry, the most powerful of which is still probably psychoanalysis. Recent articles (e.g. Freud, 1966; Frommer, 1967; Bentovim and Boston, 1973) describing treatment units for very young children exemplify very clearly the influence of these traditions and illustrate the difficulty of breaking new ground in conceptualizing treatment procedures. It will be the purpose of this paper to take issue with such traditions, and to argue that it is time for a new look at pre-school child psychiatry.

Junior schoolchildren were screened for high risk of emotional and educational disorder. The information was gathered from the school, using standard and objective tests. The multiple criterion screen employed, comprised: (a) classroom behaviour scale (Rutter B Scale), rated by teachers; (b) sociometric tests; choice of companions by classmates. From these, lack of positive choices was taken as a measure of isolation and a high rate of negative choices, as a measure of rejection; (c) Reading quotient of 75 or below on the Young Reading Test; (d) Absence from school for reasons considered by teachers to be trivial.

The number of cases identified by the screening was found to be 322 children per thousand. They may be seen as representing a high risk rate.

Using extreme scores as indicative of high risk, approximately 17 per cent of children were identified on the basis of the behaviour test; 12 per cent by the reading test; 9 per cent by the isolation test; 8 per cent by the rejection test and 3 per cent by the absenteeism test. Seventy per cent of the identified children were rated clinically as disturbed. Absenteeism identified the smallest percentage of cases and made the smallest independent contribution to identification. Isolation was not impressively related to neurotic or antisocial beha viour. The three important criteria, therefore, were behaviour, rejection and reading.

Corrected disturbance rates for our population of 7-8-year-old children, including those not identified by the screen, were 6-8 per cent markedly maladjusted and 33.7 per cent somewhat maladjusted.

An account is given of impressions and observations collected during three weeks in November 1975 which the writer spent with two of his chronic schizophrenic patients in a purpose-built isolation unit inside which it was impossible to have any idea of the real time.

This experience gave the observer an unusually close view of schizophrenic and institutional behaviour and some insight into the natural outcome of staff-patient interaction.