The Maudsley Bequest lectures have traditionally been intended for trainee psychiatrists. No previous lecture in the series has been concerned directly with epidemiology, and the trainee who seeks enlightenment in the British textbooks of psychiatry is likely to be disappointed or misled, for the standard view of the subject is epitomized in the statement which appears in their weightiest representative: ‘In this field the epidemiological approach concerns itself with investigation of the frequency with which definable forms of psychiatric disorder occur in carefully delineated populations' (Slater and Roth, 1969). While this aspect of the discipline is central to the interests of workers in the field of public health and administration, the notion of epidemiology as primarily an exercise in head-counting is unlikely to suggest the relevance of the discipline to clinical activities, especially if these are conceived as being focused primarily on the individual patient. In this lecture I propose to try and correct this impression and indicate the provenance and scope of epidemiology as a major branch of scientific inquiry which is indispensable to clinical psychiatry.

Is there an increased relative risk of death in severe neurosis? 1,482 patients from three psychiatric units in different hospitals in Birmingham were followed-up after a mean of 10.9 years. 91 per cent of the sample were traced and 139 patients were found to have died; a highly significant increased mortality for both sexes for all causes of death. Although suicide and accidents contributed disproportionately, particularly in early follow-up, there was still a markedly increased mortality from the combined categories of nervous respiratory and cardiovascular disease, more evenly distributed in time.

A semantic differential technique was used to elicit concepts of anxiety, depression and irritability from twenty patients suffering from neurosis and ten experienced psychiatrists. It was found that psychiatrists hold concepts of these unpleasant affects that are much more differentiated than those held by patients. In particular, the psychiatrists' concepts of anxiety and depression showed a correlation of zero, whereas the patients' concepts of these affects overlapped to a considerable degree.

Patients were unable to discriminate between anxiety and depression on the basis of 11 somatic symptoms, but were able to use these symptoms to distinguish anxiety and depression from irritability. The psychiatrists were in close accord with the patients over the somatic symptoms that distinguished anxiety from irritability.

Phobic avoidance has been widely accepted as the central feature of the agoraphobic syndrome, and the presence of agoraphobia has been used to define groups of subjects for clinical research. A review of the evidence suggests that agoraphobia should not be classified with the phobias; several lines of inquiry point to the conclusion that it is a variable feature of patients suffering from anxiety neurosis. Implications for research and problems with the present classification of neurotic affective disorders are noted.

In a sample of men remanded into custody for medical reports during a three-month period, it was found that those who received recommendations for treatment had a diagnosis of acute mental illness, had in the past been admitted more frequently to mental hospitals and had spent a longer period as in-patients. They were also assessed as being difficult to manage, i.e. they were considered to be nuisances, were threatening and potentially violent. The men who were not recommended for treatment had a history of excessive drinking and drink-related offences; they also had more extensive criminal histories and a diagnosis of psychopathic disorder.

Over a three-month period, 634 men were remanded into custody at Brixton Prison for medical reports; 87 received recommendations for psychiatric treatment and 82 individuals were actually referred to hospitals for treatment. Fourteen months later nearly three-quarters of the men who went to hospital had been discharged. They fell into three groups by outcome: men with acute psychoses for whom treatment was definitely beneficial; men who remained behaviourally disturbed after receiving treatment although their mental states improved; a group with chronic disorders for whom admission was not beneficial. The two groups with improved mental states represented only 5 per cent of the initial receptions to Brixton Prison.

Thirty-two couples with the presenting problem of female sexual unresponsiveness were treated in a controlled study using a balanced factorial design. Treatment involved a combination of drug therapy and counselling. Half the subjects received testosterone and half diazepam, half received weekly and half monthly counselling. They were assessed before treatment, at the end of treatment and at six months follow-up.

Those receiving testosterone did significantly better on a number of behavioural and attitudinal measures than the diazepam group. There were no notable differences in outcome between the two counselling regimes. There were no undesirable side-effects with the testosterone.

Further work is needed to establish the indications for testosterone therapy for unresponsive women.

Teachers' comments in the childhood school records (grades K-12) of 143 psychiatric patients and their matched controls were coded along 23 bipolar dimensions. Two methods of grouping these scales were compared: rational clusters and factor analysis. Factor analysis yielded more numerous and narrowly defined behavioural groupings. Schizophrenics, personality disorder patients, neurotics, and depressives were compared to their matched controls on each of the cluster and factor scores. Both schizophrenics and personality disordered patients were significantly less agreeable in childhood than their respective controls. Pre-schizophrenics also were significantly more unstable. Depressives were more independent than their controls, while neurotics did not differ significantly in any respect from normals in childhood. The data suggest that schizophrenia may have specific developmental patterns of possible aetiological or early diagnostic significance.

The season of birth distribution of 1,039 sibs of Canadian schizophrenic patients was compared with that of births in the Canadian general population over the same time period. The excess of winter births observed among the schizophrenics was not found among their sibs.

A prospective study was undertaken on 374 out-patients receiving depot fluphenazine or depot flupenthixol to determine the incidence of tardive dyskinesia. In three years the percentage showing the bucco-linguo-masticatory syndrome rose from 8 per cent to 22 per cent, though patients had received various neuroleptics for a mean of 13 years previously. Fluphenazine and flupenthixol were equally involved though 75 per cent of affected patients had the condition in mild degree. Six additional cases of generalized chorea were all receiving flupenthixol. Reduction of dose or the substitution of pimozide produced marked improvement, but results suggest that it is unlikely that this will be permanent. Substitution of depot fluspirilene also produced favourable results. Careful monitoring, minimal neuroleptic dosage, and periods of neuroleptic abstinence are recommended.

The Problem

Over the last two decades increasing attention has been paid to the rights and safety of the subjects of clinical research. A key safeguard against any abuse has been the requirement to obtain the subject's informed, valid or true consent, which has been defined by the Medical Research Council as ‘consent freely given with proper understanding of the nature and consequences of what is proposed’ (M.R.C., 1962–3). However, it has been recognized by the M.R.C. that it may not be possible to obtain such consent from, among others, some subjects who are mentally ill. Whether or not a research project should be carried out on such subjects should depend, they say, on whether or not ‘there are reasonable grounds for believing that a particular new procedure will contribute to the benefit of that particular patient…’, and further, ‘when true consent cannot be obtained, procedures which are of no direct benefit and which might carry a risk of harm to the subject should not be undertaken’ (M.R.C., 1962–3).

Psychotropic drugs are but one of our tools in treatment and when appreciating articles or books about these compounds, it is always stimulating to see that the author(s) know as much about people and the disorders they are treating as about the drugs which they are using. It is also helpful when the separation between symptomatic and curative treatment is made, and “comfort” and “cure” are distinguished. Papers which help doctors help patients rather than those of somewhat esoteric interest have more appeal, and I think we may ask: Does the author relate this to the work of the clinic and ways to assist the next patient?