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.

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).

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.

Whereas there are many reports from Western societies on the prevalence of psychiatric disorders few systematic studies are available for a culture such as the Indian. Certain efforts in this direction have been made recently, and a few reports have emerged. Dube (1970), in a psychiatric survey conducted in Agra City and its suburban areas found a period prevalence of 18 per 1,000. In a study of 184 families of a rural community in India, Elnaggar et al. (1971) observed a prevalence rate of 27 per 1,000. In a study of 300 urban families, Sethi et al. (1967) found a psychiatric morbidity rate of 72 per 1,000 whereas this rate was only 39 per 1,000 in a surveyed population of 500 rural families (Sethi et al., 1972a). We also observed (Sethi et al., 1972b) that psychiatric disorders were commoner in the migrant families. The present study was undertaken to estimate the extent of mental illness in an urban society in India and to find out the relevant variables associated with various psychiatric disorders.

The Tavistock conference model of Group Relations Training, described in some depth by Rioch (1970) and O'Conner (1971), provides participants with a focus on the problems of leadership and authority as they develop and emerge in a variety of relatively unstructured group contexts within a time-limited laboratory setting. The major conference experience involves participation in ‘here and now’ groups with the use of staff in a consultative role, i.e. the staff function being to focus exclusively on the covert or unconscious processes in the group. So the usual consultant role involves no comments to individuals but a rigorous focus on the dynamics of the group as a whole; a role which has been described in more clinical settings by Bion (1968), Coffey (1966) and Ezriel (1950). ‘One of the major aims of the conferences is to contribute to people's ability to form serious work groups committed to the performance of clearly defined tasks …. A second major aim … is the development of more responsible leadership and fellowship in group life’ (Rioch, 1970, p. 347).

R. D. Laing has offered a challenge to society and to psychiatry which is difficult to accept, for it implies that ‘sane’ society and psychiatry as its instrument actually perpetuate rather than alleviate certain kinds of mental illness. In spite of Laing's growing popularity with the counter-culture, there is a conspicuous lack of consideration of Laing's thought in the psychiatric literature. This may be taken as a rejection of what Laing says, a sort of professional passive aggression. Indeed many would suggest that Laing has passed the limits of sanity; he is certainly deviant. Yet psychiatry's reticence may reflect the difficulty in responding appropriately to Laing's indictment. Apparently there is much truth in Laing's analysis. It is existential, and his considerations involve each of us as persons, not just as members of a corporate group, psychiatrists or sane citizens. Furthermore there is a temptation either to accept or to reject what Laing says as a whole without careful attention to the implications of his arguments.

The use of unilateral ECT as a method of exploring differences between the functions of the cerebral hemispheres has been suggested by Pratt et al. (1971). These authors found a greater impairment on a test of naming and a tendency to slower return to consciousness after left-sided than after right-sided treatments. Assuming that these effects depend on left hemisphere language specialization, they went on to use them as possible indicators of cerebral dominance for speech in left handers. The present enquiry was designed to explore these differences further by comparing patients immediately after right-sided and left-sided ECT for their ability to name objects and to make visual discriminations and for their time of recovery. Handedness was assessed through a measure of relative manual speed as well as by the usual questions of preference and family handedness. The speed differences give a continuous measure of degrees of right and left handedness which can be correlated with measures of differences between the effects of right-sided and left-sided ECT.

Opinions differ on the effectiveness and the risk involved in treating depressive illnesses with combinations of monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants. Some authorities, including the Food and Drug Administration in the United States, the former Witts Committee in this country, and the pharmaceutical firms producing antidepressants, have given serious warnings against combining MAOIs with tricyclic antidepressants. These warnings have been repeated more recently by Beck (1967), Malitz (1966) and Shepherd et al. (1968).

It is known that different mental symptoms may occur as early symptoms of acute viral meningoencephalitides. In herpes virus (HSV) infections of the central nervous system (CNS) the appearance of these symptoms is well documented (Juel-Jensen and MacCallum, 1972). The recurrence of psychotic symptoms in cases of recurrent HSV infections has also been described (Shearer and Finch, 1964; Drachman and Adams, 1962). In recent years serological observations of the prevalence of HSV antibodies in patients with psychiatric disorders have suggested a possible association of HSV infections with aggressive behaviour (Cleobury et al., 1971), as well as with psychotic depressions (Rimon and Halonen, 1969).

Determinations of acid monoamine metabolites, such as homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA), in cerebrospinal fluid (CSF) give valid information on the metabolism of the corresponding amines in the brain tissue (Moir et al., 1970; Roos, 1970). The monoamine metabolites in the CSF are related to age. The concentrations of HVA and 5-HIAA increase with age (Gottfries et al., 1971). Probenecid blocks the elimination of HVA and 5-HIAA from brain tissue to blood (Neff et al., 1964, 1967; Werdinius, 1966) and from CSF to blood (Guldberg et al., 1966; Olsson and Roos, 1968). Probenecid thus normally induces an increase in the concentrations of the acid monoamine metabolites in the CSF, which is related to the turnover of monoamines in the brain tissue.

For genetic characteristics controlled by a single locus which are such that the degree of dominance is not dependent on the environment, statistical methods of determining the mode of inheritance and the gene frequencies are now well understood in principle. If, however, there is incomplete penetrance, depending on the environment (taken in the wide sense), the problem becomes much more difficult, especially in human genetics. The situation is even worse if the character is dependent on several or many loci and such characteristics are often very dependent on environmental factors. This seems to occur in man in some psychiatric diseases and is certainly the case for intelligence. The genetical analysis of such phenomena is very difficult, and it is essential that the mathematical and statistical bases of such investigations be carefully understood by anyone who undertakes such work.

The theory that some male homosexuals might have female chromosomal constitution (Lang, 1940) became untenable when techniques for studying sex chromosomes were developed. Amongst others the work of Pare (1956) and Raboch and Nedoma (1958) showed that male homosexuals had normal male chromosomes. The latter authors in the same study also reported on 36 male patients with a female type of sex chromatin (i.e. chromatin positive) and could not detect any homosexual orientation: 32 were definitely heterosexual and the remaining 4 were considered ‘infantile’, They assumed that the finding of a chromatin-positive homosexual would be coincidental and that there was no causal relationship between this sex chromosome abnormality and homosexuality. Money and Pollitt (1964) searched for a genotypical abnormality in a related psychosexual disorder, namely transsexualism, but although they collected six cases in the literature where Klinefelter's syndrome and transsexualism occurred together, the correlation was not statistically significant. In fact, it would now appear to be established that there is no specific correlation between sex chromosome abnormality and psychosexual disorders (Slater and Cowie, 1971).

The presumed carcinogenic and chromosome-breaking potential of d-lysergic acid diethylamide (d-LSD 25) in human somatic cells has been reviewed by Fernandez et al. (1973). Reports concerning its teratogenic effect in experimental animals and man have been either contradictory or inconclusive. The following possible teratogenic mechanisms may be considered: (1) A direct effect on organogenesis of LSD ingested by the mother during early pregnancy; (2) A similar disturbance of organogenesis by a persistent metabolite of LSD ingested by the mother at some time prior to the pregnancy; (3) Chromosome damage or point mutations in parental germ cells exposed to LSD before initiation of a pregnancy.

The development of techniques for studying sex chromatin from oral mucosa (Moore and Barr, 1955; Marberger at al., 1955), and chromosomes from peripheral blood (Moorhead et al., 1960), has made it possible to undertake population surveys to identify individuals with abnormal sex chromosomes. The present knowledge of psychiatric effects of the sex chromosome abnormalities has been derived mainly from comparing their frequency in the psychiatric population with that in the general population.