In the report On the State of the Public Health 1970, the Department of Health and Society Security have commented on some of the effects of setting up the special clinics for the treatment of drug dependence. They consider that there is room for guarded optimism about the containment of heroin addiction, and state that in 1970 14 treatment units were issuing only about two-fifths of the amount of heroin used 2½ years earlier (respectively over 3,000 grams each month in 1968 and 1,358 grams in December 1970). The number of new patients in 1969 was 652, but only 353 in 1970. The numbers of first notifications of heroin addiction under the age of 21 were 291 in 1969 and 140 in 1970; there were 1,173 first notifications to all DDA drugs in 1969, but only 762 in 1970; and second and subsequent notifications were 1,977 in 1969 and 1,489 in 1970.

The constructs (Kelly, 1955) which individuals use when describing other people may be classified as ‘psychological’, i.e. those referring to the personality and emotional state of the people, or as ‘objective’, i.e. those referring to their physical characteristics, social class, clothing etc.

The renewed use of modified forms of narcosis, generally given together with ECT and antidepressant drugs, arose from a series of observations made during attempts to treat a group of chronically tense patients. These patients, the majority of whom had been diagnosed as ‘chronic tension states', had been referred to the Department of Psychological Medicine at St. Thomas' Hospital for assessment regarding their suitability for modified leucotomy. Birley (1964), in a follow-up study of previous patients with ‘tension states' treated by leucotomy at St. Thomas' Hospital, had found that many developed clear-cut attacks of depression following the operation. This suggested to one of us (W.S.) that such ‘tension states' might have been masked depressive illnesses, in whom the underlying diagnosis had been missed. Consequently it was decided that in the future such patients should be treated with suitably long courses of ECT, together with one or both groups of antidepressant drugs, before any question of recommending leucotomy arose. As a result, a considerable number of these patients were greatly improved and no longer required a leucotomy. Others, however, became more tense and distressed during treatment with ECT and drugs; modified narcosis, therefore, was given in addition, to allow the full course of ECT to be completed. It was then that another of us (C.W.) observed that patients who were treated with combined narcosis, ECT and antidepressants appeared to respond more favourably, and were much less upset by the treatment, than those receiving ECT and antidepressants alone. In a preliminary report published in 1966, Sargant, Walter and Wright described a group of 73 patients with ‘chronic tension states', of whom 67 per cent had improved markedly with further treatment of their underlying depression. It was noted that 15 of the 37 patients treated with ECT and antidepressants alone still required a leucotomy, while in the group treated with modified narcosis in addition to ECT and antidepressants the operation was needed in only 3 of the 36 patients. It appeared, therefore, that the addition of narcosis to drugs and ECT greatly improved the recovery rate.

Our Study of Denmark commenced on Wednesday, 28 April 1971, when the party travelled via Harwich and Esbjerg to Aarhus, Denmark's second largest town. Here we encountered an inflationary problem worse even than our own; and, with traffic moving at an even more frighteningly fast rate than ours, we realized that Denmark had its quota of pushful and aggressive drivers. Overall, however, we were impressed with the natural courtesy of the Danish people, their placid stability and their tolerance. And so to the purpose of our visit.

Early studies (21, 22, 25, 12) have pointed to a genetic component in the aetiology of manic-depressive disorders. More recently, careful clinical observation has suggested the division of the affective disorders into two distinct groups: the so-called bipolar or manic-depressive group and the unipolar type with recurrent depressions only (14, 27, 1). Although genetic differences in terms of family risk have been demonstrated between the so-called bipolar and unipolar psychoses, it is not yet evident whether each group constitutes a homogeneous entity. Moreover, the diagnosis of unipolar depressive disease for the authors cited above includes such syndromes as involutional psychotic reactions, psychotic depressive reactions, and probably also psychoneurotic depressions.

In 1968, the Veterans Administration and the National Institute of Mental Health organized a multi-hospital collaborative study on the effectiveness of lithium carbonate in acute mania. Two hundred and fifty five newly-admitted patients with this disorder were randomly assigned to lithium or chlorpromazine treatment for a three-week period. Patients were classified as highly active or mildly active on the basis of hyperactivity shown at admission. Results have been reported in a previous paper (7). Briefly, it was found that chlorpromazine was significantly superior to lithium in treating the highly active patient: chlorpromazine acted more quickly than lithium, produced significantly fewer treatment failures, and had a lower incidence of severe side effects. The difference between treatments was less clear-cut with mildly active patients, although lithium appeared to be the better treatment. Both drugs effectively reduced manic symptomatology, but lithium produced fewer severe side effects and left the patient less sluggish and fatigued. The poor results with lithium among highly active patients were attributed to the drug's relatively slow onset of action. As a group, highly active patients on lithium showed relatively little change in manic behaviour during the first week; it was ten days before some patients showed any improvement. Almost 40 per cent of the highly active patients had to be taken off lithium before the end of three weeks because of unmanageable behaviour or toxicity. In contrast, chlorpromazine, with its quick onset of action, generally controlled manic symptoms

This study compares the mental symptoms of two groups of aged mental hospital patients. One group had senile brain disease but no brain infarcts. The other group had brain infarcts but no positive evidence of senile brain disease.

Although depression is well known as a sequel to influenza, mania is not. We describe a patient with a severe psychotic illness who first showed features of a confusional state but then developed a manic psychosis. The occurrence of functional affective psychoses during or following systemic physical illness has been well described (Bonhoeffer, 1909; Kraepelin, 1921; Kiloh, 1961; Post, 1965), but the nature of the relationship has never been clear. In some instances, the physical illness may simply act as a form of non-specific stress precipitating the mental disorder; evidence for a more direct patho-physiological relationship has been lacking. When, in addition to a background of physical illness, a patient shows disorientation and clouding of consciousness together with signs of a manic psychosis, the diagnostic problem is especially difficult, particularly so since a confusional state can occur as part of a severe manic illness (Maudsley, 1895; Kraepelin, 1921). Conversely, hypomanic symptoms can occur in an organic psychosis (Bonhoeffer, 1909).

‘The Samaritans' were founded in 1953 to help ‘the suicidal and despairing’. As with similar lay agencies abroad, their growth in the past ten years has been vigorous; they now have more than 120 branches in the United Kingdom and these branches attracted over 50,000 clients in 1969. The Samaritans' aims have been described in detail by Fox (1968), but their most important aim is still the prevention of suicide. Their success in attracting the suicidal and preventing their subsequent death must therefore be the criteria of their effectiveness.

‘Psychogenic infertility’ refers to the state of childlessness in which psychological factors play an aetiological role. Use of the term ‘psychogenic’ implies that there is a reluctance or an ambivalence on the part of one or both partners towards conception. There is a considerable literature on psychogenic infertility, which has been reviewed elsewhere (Noyes and Chapnick, 1964; Mai, 1969). Although much of this literature is conflicting and inconclusive, it does suggest an association between disturbed sexuality and infertility in the female. Such a causal relationship might be mediated by two types of mechanism.

Hormone treatment for impotence and impotentia ejaculandi (delayed or absent ejaculation in the presence of normal erections and desire) (Johnson, 1965) is based on two assumptions: namely—that (1) potency in the male is androgen dependent and (2) impotency is due to relative androgen deficiency (Miller, 1968; Margolis et al., 1967; Sobotka, 1969). The synthetic preparations most frequently used are methyl testosterone, various esters, including the propionate, deconate, enanthate, etc. (Tuthill, 1955; Kupperman, 1967) and more recently a number of testosterone- ‘aphrodisiac’ combinations (Margolis et al., 1967; Cooper et al., 1971, etc.). Despite some claims of therapeutic success for the various regimes, the administration of exogenous hormones has several pharmacologic disadvantages. For instance methyl testosterone, which has to be taken sublingually or bucally, may be associated with severe toxic effects such as cholestatic jaundice, etc. (Goodman and Gilman, 1965). Parenterally administered testosterone esters, although less toxic and more certainly absorbed than methyl testosterone, have all the drawbacks of the intramuscular route; also their rate(s) of tissue release may not be optimal for metabolism. Additionally, all these synthetic compounds may inhibit endogenous testosterone formation and spermatogenesis by suppressing pituitary gonadotrophins. Long term administration may result in Leydig cell inactivity and even disuse atrophy. Recently Harkness et al. (1964, 1968) have observed that clomiphene (Fig. 1), a non-steroid triethylene derivative which in females stimulates the anovulatory ovary to secrete oestrogens (Bishop, 1970), significantly raised the levels of urinary steroid metabolites, including testosterone, in a proportion of ‘normal’ and corticosteroid deficient males. This unexpected testosterone elevating effect suggested its possible ‘experimental’ use as an alternative drug treatment in impotence. Accordingly a limited pilot study on five ‘primary’ (non-organic) impotent males was conducted: its main aims were (a) to assess the potential clinical utility of the drug and (b) to study its effects on the ‘pituitary-testes-axis' as reflected by plasma testosterone levels.

The tricyclic antidepressants are established in therapy but not in mode of action. Effects on mouse or rat brain of single and relatively enormous doses provide the basis for theories. Yet it may be inferred that the clinical use of tricyclic antidepressants relies upon an induction of brain changes on a time-scale of weeks. Studies of tricyclic drug actions upon human brain physiology are as scanty as are easily-measurable human brain functions. Electrophysiological techniques, however, can conveniently be applied during one principal brain-state, namely sleep, when there is a relative freedom from uncontrollable extraneous variables.

Pitts and McClure (Pitts and McClure, 1967; Pitts, 1969) have recently suggested that all symptoms of anxiety and anxiety neurosis itself are caused by a raised blood and body fluids lactate level. As the biochemical mechanism underlying anxiety neurosis they proposed that the excess lactate complexes with, and reduces, the concentration of ionized calcium at the surface of excitable membranes to an extent that causes a disordered nerve activity to manifest itself in the form of anxiety symptoms. In support of this speculation, according to which anxiety neurosis is a biological disease essentially brought on by a lactate-induced hypocalcaemia, Pitts and McClure (1967) quote investigations that have shown that on standard exercise anxiety neurotics tend to produce higher blood lactate levels than do normal controls, and their own lactate infusion study. As pointed out elsewhere (Grosz and Farmer, 1969), neither the former nor the latter, however, can be considered satisfactory evidence.