Dependency refers to an individual's attachment to and reliance on others. There are at least two different kinds of dependent behaviour. Person-oriented dependency includes close physical proximity, affectionate contact and verbal interchanges. Task-oriented dependency is concerned with help given for personal activities such as dressing and assistance with jobs around the house (Maccoby and Masters, 1970).

This paper reports some aspects of a survey made of the training experiences of a group of recently appointed consultants in general psychiatry; it is the third such survey made by the author. The original enquiry was a postal one and asked about the training and education received by all consultants who had been appointed for the first time to a post in general psychiatry, with at least 6 N.H.S. sessions, between 1 October 1963 and 30 September 1969 (R.M.P.A., 1969). A second survey, using a questionnaire much modified from the first, was made of consultants appointed between 1 October 1966 and 30 September 1969, using the same criteria of eligibility as the first group (Brook, 1972, 1973). The present enquiry used a postal questionnaire almost identical to that used for the previous group, which was circulated to consultants in general psychiatry appointed between 1 October 1969 and 30 September 1972.

In 1966 a census was carried out of the epileptic population in prisons and borstals in England and Wales (1). This indicated that there are at least 7.1 epileptics/1,000 men in these institutions, a figure higher than that expected from general population estimates. The present paper reports an attempt to explain this higher prevalence using an interview study of a representative sample of epileptic prisoners together with a similar study of non-epileptic prisoners matched for institution and date of reception into prison.

Shortly after the advent of modern psychopharmacological agents in the 1950s it was noted that their clinical use led occasionally to galactorrhoea (Gäde and Heinrich, 1955; Winnik and Tennenbaum, 1955), to menstrual disorders (Polishuk and Kulcsar, 1956), and to false positive pregnancy tests (Foxworth and Lehman, 1957; Marks and Shackcloth, 1966). The drugs were also shown to have a profound effect upon the oestrous cycle (Cranston and Segal, 1960) and breast activity (Sulman and Winnik, 1956; Sulman, 1970) of laboratory animals. Most published reports incriminated the phenothiazines, especially chlorpromazine, and the literature pertaining to this drug was reviewed in detail by De Wied (1967); but similar effects have been noted with several related psychotropic substances (Shader and Di Mascio, 1970). These side effects are generally accepted to result mainly from the action of the drugs on the hypothalamus (De Wied, 1967), but the precise mechanisms involved are not fully understood.

It is a paradox that during the years of psychosocial development each man has to achieve an identity, a role in which he can feel secure, and yet poets and philosophers tell us that man is forever seeking to diminish the isolation which a personal identity imposes. Without the development of a personal identity and a role in life the individual remains a social isolate, a dependent parasite or a social deviant. Yet, once achieved, identity brings a new awareness of separateness from others and a need to merge the self with others, to identify with someone or something else. This would seem to be a main objective of love. It has been said that human love is the supreme act of communication with another, a merging of identity, and poets speak of communicating with nature or with God in like terms. Romantic and sacred literature abound in metaphors and images describing the bliss which such activity offers. If it is true that while we have a need to develop a sense of personal selfhood, an identity and a role, we have a further need to diminish the separateness such awareness imposes, how do we go about it? The contemporary answer is, of course, by communication, by relating to others. The better the communication we have with others, the greater our sense of belongingness, the less the pain of individual isolation. It is not necessary to emphasize that a cardinal feature of all severe mental illness is either a loss or a distortion of the individual's communicative capacity. But I would like to emphasize that the debate as to whether failure of communication is either a cause, or an association, or a consequence of mental illness is not my theme.

The National Health Service has entered a period of substantial change. The impending reform of local government (1974) will coincide with considerable reforms in the administrative structure of the N.H.S. (1). In addition, our subject matter—the mental health services—has been the subject of various Government White Papers and policy decisions (2). These reforms are an attempt to increase the efficiency of the service, and throughout their pages reference is made to the need for scientific management and administrative efficiency.

Mortality rates in psychiatric patients have been reported as higher than those of the general population in Scandinavia (Odegaard, 1952), the United States (Gorwitz et al., 1966; Babigian and Odoroff, 1968), and Scotland (Innes and Millar, 1970). These findings may be related both to a greater prevalence of physical disease amongst psychiatric patients (Kay and Roth, 1955; Culpan et al., 1960; Shepherd et al., 1964; Kay and Bergman, 1966; Eastwood and Trevelyan, 1972) and to a greater frequency of suicide (Stenstedt, 1952; Stenstedt, 1959; Pokorny, 1964).

In England, public intoxication has been a criminal offence ever since an Act of Parliament was passed in the reign of James I, somewhat over three and a half centuries ago. Edwards (1970) compiled some figures on these offences for the last two hundred years, showing that the rate of arrest was much higher in the nineteenth century than at present. For example, in 1878 there were 70 arrests per 10,000 of the population, compared with a comparable figure for 1968 of 16. Nevertheless, the latest available figures from the Home Office (1971) show that 82,961 persons were found guilty of simple or aggravated public drunkenness in 1971. In the U.S.A., with its apparently much larger alcoholism problem, there were nearly one and a half million arrests for this group of offences in 1966 (Pittman, 1969); this accounts for one third of all arrests in that country (Chafetz, 1971).

There is ample evidence that high doses of phenothiazines and other neuroleptics depress the pituitary-gonadal axis in experimental animals (De Wied, 1967), but the effects of these drugs on sex hormones in human subjects are still controversial (Shader and Di Mascio, 1970). Literature concerning growth hormone (GH) is even more controversial, since phenothiazines have been found to inhibit GH release in rodents (Muller et al., 1967) but to increase it in the rhesus monkey (Meyer and Knobil, 1967). In human subjects phenothiazines have been reported to depress both basal levels of GH and the response to hypoglycaemia (Sherman et al., 1971), while others have found that this response is enhanced (Schimmelbusch, Mueller and Scheps, 1971). Studies of prolactin levels are more consistent, showing raised prolactin both in experimental animals and in human subjects following administration of phenothiazines (Apostolakis et al., 1972; Hwang et al., 1971; Kleinberg et al., 1971; Sulman, 1970).

In a number of previous papers in this series (Roth et al., 1972; Gurney et al., 1972; Kerr et al., 1972; Schapira et al., 1972) evidence was adduced to suggest that depressive illnesses and anxiety states could be clinically differentiated from one another. It was shown also that with the aid of appropriate statistical techniques patients exhibiting these disorders could be separated into two distinct groups with relatively little overlap. The possibility that these findings were due to diagnostic preconceptions or other forms of bias was excluded by the results of follow-up studies conducted over an average period of 3.8 years in which the outcome of the entire patient population was evaluated by independent observers. The clinical picture found was consistent over the period of observation, with little diagnostic interchange between the groups. Moreover, the outcome of the depressions was significantly better than that of the anxiety states, and this provided external and independent validation of the view that the groups initially separated with the aid of clinical observation were indeed distinct from one another.

Of patients with ‘conspicuous psychiatric morbidity’ in British general practice, 5 per cent annually are seen by psychiatrists, roughly equal numbers are referred to non-psychiatric specialists (Shepherd, Cooper, Brown and Kalton, 1966), and cross-referral rates are low (Mezey and Kellett, 1971). The clinical, as opposed to the social, reasons why so few patients are referred to psychiatrists must be inferred from the indirect evidence of epidemiological surveys (Shepherd et al., 1966), studies of patients already referred to an out-patients clinic (Kreitman, Sainsbury, Pearce and Costain, 1965), doctors' referral letters (Mowbray, Blair, Jubb and Clarke, 1961), and surveys of doctors' attitudes (Shepherd et al., 1966; Mezey and Kellett, 1971). Few studies of referral have been prospective (Kaeser and Cooper, 1971) and none has been by interview of patients before referral has taken place. Meanwhile, detailed clinical studies of psychiatric illness continue to focus almost exclusively on patients already in care of psychiatrists. It follows that more knowledge is needed of the clinical factors which lead to specialist referral; otherwise the significance of hospital-based studies for the wider context of psychiatry in general medical practice cannot be properly appreciated. This need is particularly acute with respect to the so-called minor affective disorders which are common in general practice but of which only a minority come to the notice of psychiatrists (Watts, 1966; Taylor and Chave, 1964).

It has repeatedly been asserted, mainly on clinical evidence, that mothers of school-phobic children are overprotective, even when their youngsters are of secondary school age (Berg, 1970). The project reported in this paper was carried out to see if an objective method of assessment would support this view.

Despite the monumental follow-up studies of patients with manic-depressive illness by Lundquist (1945), Rennie (1942), Hastings (1958), and more recently, Shobe (1971), the development of the concept of unipolar and bipolar forms of affective disorders with clinical (Brodie and Leff, 1971), genetic (Dunner et al., 1970; Winokur et al., 1969), and biologic differences (Buchsbaum et al., 1971; Cohn et al., 1970), has necessitated a revaluation of the question of outcome in this psychiatric illness. The availability of lithium carbonate for both acute and prophylactic treatment of mania (Schou, 1968; Coppen et al., 1971), and possibly depression (Goodwin et al., 1972), has also increased the clinical importance of the unipolar-bipolar distinction. The purpose of this study is to provide further information regarding the course of bipolar manic-depressive illness by reporting the level of functioning, recurrence of episodes, and quality of life at follow-up assessed in a group of patients formerly hospitalized for mania at the National Institutes of Health.

Diminished sexual activity among individuals dependent upon the opiate drugs (heroin, morphine, methadone, etc.) has been noted by Freedman (1967) and by Jurgensen (1966). A study of four populations of male patients (controls, abstainers, heroin addicts and patients maintained on methadone), suggested that although factors other than the specific drug effects may be important determinants of sexual difficulties, that the drug itself may act as a specific determinant (Cushman, 1972). This was supported by the fact that all patients claimed to have been normal before narcotic use, that heroin reduced sexual performance and desire, and that a reversal to normal sexual function rapidly occurred during enforced withdrawal. Other observations by Ding (1972), and Scher (1967) support these findings. Berzins et al. (1971), and Mott (1972) have noted that drug-dependent subjects tend to have problems of sexual identity, and Hobi (1972) suggests that psychosexual immaturity is frequently seen in drug-dependent subjects.

The accurate classification of causes of death is fundamental to progress in preventive medicine. Classifying death by poisoning may be specially difficult because the exact distinction between deliberate and accidental poisoning is inherently difficult for the coroner to make. Thus figures for suicidal poisoning are likely to be under-estimated because of ambiguous evidence and because of the stringent legal definition of suicide which coroners must apply. An examination of the drugs involved in poisoning cases, comparing their frequencies in the suicide and accident categories, may throw some light on the validity of coroners' present methods of classifying and provide evidence about the limits of error of under-estimation of the suicide rate.

People who kill themselves are grouped together as suicides on the basis of that one action, yet they can hardly be considered to be a homogenous class. Attempts to define sub-categories among suicides can be made in a number of different ways, none by itself entirely satisfactory. Differentiation by psychiatric diagnosis is one possibility, but is difficult to achieve and throws little light on the undoubted contribution of social factors. Sociological studies have usually persisted in regarding all suicides as intrinsically similar, and have sought to relate variations in rates between different sections of the community in terms of general social variables such as status integration, social isolation, anomie and the like. Yet suicides are not a uniform group, and relatively little can be achieved while this fact is ignored.

A prospective study (Fahy, 1974) found that depressed patients referred to psychiatrists by family doctors differed from depressives not so referred in being more often difficult to reassure, diffusely anxious and subjectively retarded. Single men were selectively referred. Absence of hypochondriacal features characterized prompt referrals only. Generally, psychiatric referrals were obviously depressed in mood and showed a wealth of psychiatric symptoms, predominantly of ‘endogenous' type and not associated with overt physical stress-at-onset. For lack of data with a direct bearing on reliability, the repeatability of this study was uncertain and the question of a possible qualitative difference between depression in hospital and in general practice was left unanswered.

The major emphasis in psychoanalytic literature has been on the aetiology of male, rather than female, homosexuality (Socarides, 1968; Wiedeman, 1962). Those psychoanalytic writers who deal with the parent-child relations of homosexual women present a wide diversity of contrasting descriptions and explanations (Bacon, 1967; Bene, 1965; Fromm and Elonen, 1951; Socarides, 1963). One systematic research approach that has evolved from the psychoanalytic literature involves the evaluation of the ‘triangular system’ hypothesis (Bieber et al., 1962). This hypothesis was formulated as an explanation for male homosexuality, and most of the studies to date that relate to it report on male samples (Siegelman, 1972b). The family pattern of the ‘triangular system’ depicted for male homosexuals is a close-binding, intimate, controlling mother and a detached, hostile, rejecting father (Bieber et al., 1962). Kaya et al., (1967), using questions and methods quite similar to Bieber et al., found that homosexual, compared to heterosexual, women patients had fathers who were close-binding and intimate—the converse of the parent behaviour noted for male homosexuals. Kaya et al., however, found that the mothers of the lesbians did not differ in behaviour from the mothers of the non-lesbians. In a study of 25 adolescent lesbian patients, Kremer and Rifkin (1969) found that the fathers of the homosexual women were hostile, exploitative, detached, and absent, but they were not close-binding. The mothers in the Kremer and Rifkin study were described as overburdened and inadequate in handling their responsibilities. Using 27 items from the Bieber et al. (1962) study, Thompson (1971) discovered that the mothers of non-clinical homosexual women were close-binding and intimate, while their fathers were hostile and detached. Many of the Bieber et al. (1962) questions were also used by Gundlach and Riess (1968), who reported that the parents of non-clinical lesbians were not different from the parents of non-lesbians.

Family studies of schizophrenia have indicated familial differences between paranoid schizophrenia and other Kraepelinian subtypes of schizophrenia. Kallmann (1938) noted the lower morbid risk for schizophrenia in the families of paranoid probands as compared to the families of hebephrenic and catatonic probands. This finding was confirmed for siblings by Hallgren and Sjögren (1959).

Since Freud's remark that unavailability of a strong and friendly father figure favours the development of homosexuality, the notion has prevailed that, in males, homosexuality and/or ‘femininity’ are due either to the father's physical unavailability or to a disturbance of the father-son relationship. If this hypothesis were valid, one would expect that such gross defect in male role learning as appears in transsexual males should be quite clearly associated with unreplaced father loss or various forms of gross deficiency in father-son relations.