I am grateful to those who have included me in the honourable company of Maudsley Lecturers. When you invite a speaker from outside psychiatry, I think you hope to find one who will speak from his own central interest and experience in a way which will illuminate your own. After some inner debate, I decided that I would try to justify that expectation, even though my experience may seem remote from yours. I hope none the less that what I have to say may have some relevance to some of the sciences on which you rely, perhaps even to your profession.

“The great majority of physicians, including our own specialty, have written off frontal lobe surgery as a therapeutic weapon for any illness short of chronic major psychosis.”

Community surveys abroad have shown that there is a high prevalence of serious mental illness in old age, much of which is not treated in hospital (Gruenberg, 1961; Nielsen, 1963). Most community surveys of the aged in this country have, however, been concerned chiefly with general medical and social problems (Sheldon, 1948; Simonds and Stewart, 1954), or have formed part of whole-population studies and recorded only the most severe kinds of mental disturbance in old age (Mayer-Gross, 1948). An exception is the study of a Scottish rural practice by Primrose (1962).

This paper describes the social and clinical progress of a group of male schizophrenic patients who left London mental hospitals during 1959 and were followed up for one year. The study was designed to test specific hypotheses concerning the association between family relationships and the course of the patient's illness (Brown et al., 1962).

The literature of the psychological effects of brain injury is extensive and disconnected. It abounds in inadequate definitions, incompatible theories and disagreements as to appropriate methods of investigation. This situation results partly from the variety of disciplines which guide different investigators; but it results too from the great logical difficulties encountered by anybody who seeks to throw light on normal intelligent behaviour by studying the effects of cerebral lesions. Some have even argued that such attempts are always unprofitable (47, 77).

The proven effectiveness of electroconvulsive therapy (E.C.T.) and antidepressant drugs has lately led to a resurgence of interest in the treatment of depressive states. Amongst the principal problems currently confronting the clinician, the following would seem to be particularly pertinent: should E.C.T. be used in preference to drugs or vice versa? Which drug is to be preferred? Can drug response be predicted? How long should drugs be given? When are drugs contra-indicated? Given in maintenance dosage after a depressive episode, do antidepressants lower the rate of relapse? This paper, the third report on an investigation of the effectiveness of amitriptyline (‘Tryptizol’, ‘Elavil’, ‘Tryptanol’) and imipramine (‘Tofranil’) in depressive states, sets out to answer the above questions in the light of the results that were obtained.

Introduction

The concept of hypochondriasis, and particularly its nosological position, is far from clear, and there is still a great deal of controversy as to whether or not there exists a condition of primary or essential hypochondriasis. Many of the historical and theoretical ramifications are reviewed in another paper (Kenyon, 1964). The object of the present paper is to give an account of the clinical findings in a large series of patients in order to evaluate some of the hypotheses put forward in the literature, and especially to determine if there is sufficient evidence to delineate a separate group suffering from primary hypochondriasis only. There is a dearth of well-documented case series published, although studies based on the investigation of a group of patients have been made by Gillespie (1928, 1929), Brown (1936), Katzenelbogen (1942), Alarcon (1956), Shirvaikar (1957), Greer (1961) and Ladee (1961). However, none of these attempt any sort of comparison with a “control” series, as is done in the present investigation, nor in most cases are numbers sufficiently large for drawing valid conclusions.