Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from POSTGRAD. MED. J. (1965), 41, 401 STUDIES OF SOCIAL ATTITUDES AND VALUES IN RELATION TO PSYCHIATRIC

K. RAWNSLEY, M.B., M.R.C.P., D.P.M.

Professor of Psychological Medicine, Welsh National School of Medicine, (formerly member of scientific staff, M.R.C. Social Research Unit, Llandough, Penarth, S. Wales).

FOR MANY years the annual rate of first admis- cases are defined in the community, recognised sions to psychiatric hospitals in England and by community members and by medical and Wales has shown a steady rise (Registrar social agencies, and dealt with by one means General 1964). Changes in the legal and ad- or other. Studies of this kind are very relevant ministrative arrangements for the care and treat- to the epidemiology of since, ment of mental disorders are probably account- by the nature of such illness, the detection and able for the greater part of this rising influx. The enumeration of cases is intimately linked with Mental Treatment Act 1930 established volun- prevailing social "yardsticks" pertaining to the tary admission and enabled local authorities to acceptable bounds of "normal' behaviour and set up out-patient clinics. The development of experience and also to the categorisation of the National Health Service brought a sub- deviant behaviour as falling within the doctors' stantial enlargement of the specialist establish- province. by copyright. ment in psychiatry. More recently the Act 1959 has abolished the special status Attitudes to the Psychiatric In-patient of psychiatric hospitals and has removed all A feature of post-war British psychiatry has formality from the admission procedure for all been the mobilisation and rehabilitation of except a minority of patients. many long-stay patients in mental hospitals. These changes in social policy towards the The increasing number of cases with residual mentally ill may arise in part out of rather symptoms living either with their families, or at widespread changes in attitudes towards mental institutions in closer proximity to the local illness among the general population. Imple- population than traditional mental hospitals, http://pmj.bmj.com/ mentation of the policies must, in turn, serve demands much tolerance and sympathy from to generate modifications in social attitudes. relatives, friends, neighbours and members of The passage of patients into and out of the the general public. The Mental Health Act specialist mental health services and the factors 1959 emphasised the desirability of developing which play upon and determine this movement a comprehensive scheme of care and treatment represent one stage of a cycle which begins in the The success of this with the earliest the individual community. policy recognition by will depend, in part, on the attitudes which on September 29, 2021 by guest. Protected patient (or by his relatives) that something is prevail towards mental disorder in the wrong. The process continues when the abnor- community. mality is reckoned by the patient, or by his An enquiry was carried out in S. Wales to family, to have medical significance, and when examine the attitudes of relatives to a family a decision is made to seek advice, usually from member in a mental hospital and especially the general practitioner. A further stage is those attitudes which may influence family encountered in the appraisal of the case by behaviour if and when the time comes for the the G.P. and in his diagnosis and treatment, patient to leave hospital (Rawnsley, Loudon and in his decision whether to handle the case and Miles, 1962). The survey was based himself or to refer the patient for a psychiatric upon all patients, 230 in number, who were in opinion. mental hospitals at the time of the enquiry Part of the work of the M.R.C. Social and those whose home addresses on admission Psychiatry Research Unit (S. Wales detach- lay in one of three defined areas in S.E. Wales ment) has been to examine certain aspects of -a mining valley, a rural area, and a small the elaborate social process whereby psychiatric town. Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from 402 POSTGRADUATE MEDICAL JOURNAL July, 1965 Patients were assessed by the hospital staff in better prospects of accommodation on discharge terms of their social capabilities and poten- than do single schizophrenics. This finding tialities. Attitudes of relatives were studied illuminates earlier statistical enquiries into the principally by home interviews conducted with differential probability of discharge for single a sample of relatives from each family and by and married patients. Thus Norris (1956) the examination of records of contacts-visits, showed that amongst schizophrenic admissions letters, parcels--between relatives and patients. in 1947-49 to some London hospitals, single Twenty per cent of the patients, many of patients had the greatest chance of retention them with very long hospital stay, were found for two years and that the married had least, to lack any contact with their families for the with the widowed and divorced occupying an past year or more. It was a little surprising, intermediate position. Brooke (1959) showed therefore, to discover relatives of these that 19%/ of single schizophrenic first admis- patients-usually close relatives-living locally. sions in England and Wales in 1954-56 were Furthermore, offers of accommodation in the still alive and in hospital two years later, while event of discharge were forthcoming in a 12% of the patients who had been married at quarter of the cases where contact had been some time were likewise retained. Wing, lost for so long. Denham and Monro (1959) found that single 6.1% of the patient sample had been con- schizophrenic patients in two cohorts of admis- tinuously in hospital for a year or more, were sion to Long Grove Hospital had a worse fit to live at home (according to the hospital prognosis for discharge within two years than staff) and had a home waiting for them (accord- married patients. ing to the family). Although on the face of it Comparison of the attitudes of relatives to these patients would appear to be promising patients from the three geographical areas in candidates for rehabilitation, certain reserva- S. Wales indicates that despite equivalence of tions must be entered. There is evidence that "active interest" revealed

through visiting,by copyright. contact with close relatives at home may have patients from the town have a substantially a deleterious effect upon schizophrenics lower proportion of relatives willing to house (Brown, Carstairs and Topping, 1958). Disquiet- them on discharge than have patients from the ing reports have also been published of the dis- rural area. Patients from the mining valley are rupting effects on the family of the returning intermediate in this respect. patient with residual disability (Wing, Monck, One important factor not systematically ex- Brown and Carstairs, 1964). amined in this study is the attitude of the These studies, carried out in an area where patients themselves to their future and, in the community aftercare services were inade- to the of particular, prospect leaving hospital.http://pmj.bmj.com/ quate, indicate very plainly the need for inten- Although many patients would undoubtedly sive supervision of the partially remitted prefer an early discharge, others are too appre- schizophrenic after leaving hospital. hensive or too settled to want it. Folkard In the S. Wales investigation, analysis of (1960) found that the expectations of a group frequency of visits by relatives and of their of selected chronic patients regarding prospects willingness to accommodate patients in the of discharge and level of performance after event of discharge by age of patient and by discharge, were more optimistic than those duration of stay in hospital indicates that, expressed by their relatives. Wing, Bennett and on September 29, 2021 by guest. Protected although interest expressed through visiting is Denham (1964) have shown that the desire of sustained in the elderly group of patients, this is some chronic male schizophrenics to leave not matched by willingness to house them. hospital can be substantially sharpened by Judging by the response of relatives, it is clear exposing them to an Industrial Rehabilitation that a policy which seeks to discharge long-stay Course at a of Labour Unit. elderly patients of either sex must look for Ministry accommodation outside the family. The pro- The General Practitioner vision of special hostels for the elderly long-stay Patients with psychiatric illness form a subs- patient with mild symptoms is an obvious tantial fraction of the G.P.'s case load. In a solution. Social work with families would be survey carried out by the General Register best reserved for the younger group whatever Office in collaboration with the College of their length of stay in hospital. General Practitioners (Logan and Cushion, Married schizophrenics of less than two- 1958) 171 volunteer G.P.s kept an account of years' stay command a higher level of active their contacts with patients, including a record interest (as judged by visiting frequency) and of the nature of the illness, for one year. Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from July, 1965 RAWNSLEY: Social Attitudes and Psychiatric Epidemiology 403 During the year, 5% of all patients on the positive association was found between level practice lists consulted their doctors for an of interest and the proportion of patients placed ailment regarded as psychiatric. This is an in each of the categories 2, 3 and 4 separately. average value for a large number of practices. Having recognised or suspected the existence Other studies by individual G.P.s reveal a large of a psychiatric disorder, what factors weigh variation in the estimates of psychiatric morbid- with the G.P. in his decision to refer a patient ity in different practices which can be accounted for psychiatric opinion and treatment? In a for, in part, by the way the frequency of cases study by Kessel (1960), neurotic patients has been calculated and expressed (Kessel and referred to hospital by a group of G.P.s did Shepherd, 1962). Several other factors probably not differ in the form of their illnesses from contribute to this variation and the influence many of those not so referred. It was difficult of any single factor is difficult to assess. The to decide what factors had led to their referral. practice populations may differ in their dis- In the enquiry reported by Mowbray and others tribution by sex, age, occupation, social and (1961) a series of G.P.s' letters referring patients geographical mobility and other characteristics to a psychiatric clinic were analysed. The find- known to be related to the occurrence of ings suggested that few practitioners referred psychiatric disorder. The range of psychiatric patients on the basis of a positive diagnostic disorders included in the count is subject to appraisal, tending rather to stress abnormalities wide variation, depending on the aim of the of conduct, the existence of social problems enquiry and the views of the observer, and is or inappropriate responses to medical attention difficult to control because of differences in the as reasons for referral. It was concluded that usage of diagnostic terms. variation in type and number of referrals could In addition, doctors probably differ in the be due to a wide variety of attitudes to psy- extent to which they perceive a particular chiatry on the part of practitioners. as if the condition psychiatric, especially An interesting opportunity occurred in by copyright. patient presents initially with what appear to S. Wales to make a close comparison of the be "physical" symptoms, such as pains in the factors influencing referral of patients to psy- abdomen, back or head. The influence of chiatric services from six general practices, certain characteristics of the G.P. upon recogni- including eight practitioners, situated in the tion of psychiatric cases has been elegantly same mining valley (Rawnsley and Loudon, demonstrated in the report by Mowbray, Blair, 1962, a and b). Information about cases Jubb, and Clarke (1961) of a pilot study by referred during the period 1951-59 was gathered the West of Scotland Faculty of the College of from hospital and clinic records. This included

General Practitioners and the Department of clinical data, name of G.P. and a statement http://pmj.bmj.com/ Psychological Medicine, University of Glasgow. as to whether the patient was referred directly Fifteen G.P.s in seven groups or practices by the G.P. to a or came by way sampled their practices at the point of of another specialty, e.g., the general medical termination of each transaction with a patient clinic. Data about the practice populations (including obvious terminations and also, was gathered principally from a private census where less obvious, points at which there taken throughout a defined area in the mining was no undertaking to see the patient Professor A. L. Cochrane of the

valley by on September 29, 2021 by guest. Protected within a period of one month). Diagnoses were Medical Research Council Epidemiological categorised as 1. physical illness (62%); 2. Research Unit. One of the items on the census psychological factors in physical illness (21%); schedule requested the name of the G.P. The 3. psychosomatic illness (5%); 4. psychiatric populations of the six practices were found to cases (3%); 5. personal problems (2%); 6. be closely similar in their distributions by sex, other category (7%). A significant negative age, occupation, number in household, place correlation (r = -0.7) was found between of birth and education. number of years since medical qualification and Despite this homogeneity, the rate of referral the proportion of patients placed in combined of patients directly to psychiatric services shows categories 2 and 3. The corresponding correla- a subtantial variation among the practices, tion between years since qualification and so that, for females, the highest rate (36.8)* proportion in category 4. was also negative, is almost twice the total average (19.4) and but not significant ;(r = -0.27). The level of more than three times the lowest (10.8). One interest in psychiatry of the 15 doctors was reason for this diversity of rates could be the rated on a 5-point scale by an official of the *Average annual rate of direct referrals per 10,000 College who knew all the participants. A population at risk. Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from 404 POSTGRADUATE MEDICAL JOURNAL July, 1965 selective recruitment of psychiatric cases their cue for referral from the relatives' attitude to those G.P.s regarded by the population or from that of the patient. To this extent, as being especially competent or sympathetic therefore, referral will depend in part upon in handling such problems. This hypothesis the attitudes prevailing in the populations to is not supported by evidence available illness, to doctors in general, and to psychiat- from the material. It may be supposed rists in particular. There may well be varia- that doctors differ in the criterion of clinical tions in such attitudes which are related to severity which they apply in deciding to refer sex, age, social class, area of residence and a patient, or in the relative proportions of other factors. diagnostic categories referred. The findings, The study of the relationship between the however, show no significant difference bet- prevalence of mental disorder measured by ween the six practices in either of these factors, direct survey of a population and the complex nor in the distribution of referrals by age, web of social attitudes, values and standards civil state or occupation. which also prevail in the same population A clue to the factors which may influence raises difficult issues both theoretical, method- referral came from interviews conducted with ological and technical. the G.P.s themselves. The commonest reported Detection of the common psychiatric ail- factor was the failure to respond to treatment ments-neuroses and personality disorders, for provided by the G.P. However, a medley of example-depends upon reports of behavioural "non-clinical" factors was also mentioned, each anomalies or of changes in inner experience of which appeared to weigh in varying degree which will, in turn, be governed by the stand- with individual doctors. Examples are, 1. pres- ards of "normal" behaviour and experience of sure from relatives for something else to be or subscribed to their done; 2. request by patient to see a specialist; patients themselves, by 3. serious of relatives or by other members of their social impairment patient's working world. Quite apart from the awareness ofby copyright. the capacity; 4. lack of emotional support for existence of abnormality, attitudes of diffidence patient from members of the family; 5. G.P.'s arising from the possibility of stigmatisation opinion that the patient may find it more lead to concealment of such disorder acceptable to be told he has nervous trouble may by a specialist, rather than by his own doctor. even during special enquiry. Beliefs concerning It was not possible to make a quantitative depression or morbid anxiety may cause a estimate of the influence of each of these factors denial of such phenomena. Potent in this re- separately upon referral practice. Their divers- gard may be the notion that these manifesta- even the G.P.s tions are 'not of medical importance but rather ity, however, among eight http://pmj.bmj.com/ studied was noteworthy. The varying weight indicate moral defect or a weak character. accorded to these non-clinical factors by differ- The neurotic may be held personally responsible ent G.P.s could perhaps account, in part, for for his symptoms which are seen, in the last the variation in direct referral rates. analysis, to be susceptible of voluntary control The variation in rates of referral to psy- in a way which does not apply to manifestly chiatric services shown in the above study "organic" symptoms. has implications for epidemiological research An opportunity to study the influence of the in psychiatry based on specialist-treated cases. social climate upon the pattern of psychiatric on September 29, 2021 by guest. Protected Since the G.P. is the principal agent by whom symptomatology arose when the entire popula- patients are passed to the mental health services, tion of the South Atlantic island of Tristan da he must exercise a powerful influence on mental Cunha was evacuated to England in 1961 hospital and clinic morbidity statistics. The following a volcanic eruption (Rawnsley and habits of G.P.s in referring cases may well be Loudon, 1964). determined, in part, by the nature of the Although there has usually been fairly training in psychiatry received at the medical regular contact between Tristan and the rest school. The psychiatric morbidity statistics of the world, the community may be regarded for a large population might be influenced by as closed in that, for half-a-century before the the teaching policy in psychiatry in the medical volcano erupted, there had been virtually no school which produces a substantial propor- permanent migration in or out of the island. tion of the doctors for the area. The nature and circumstances of life on Tristan -close proximity of residence in a corner of Attitudes Values and Symptom Patterns an inhospitable island mountain; universal The findings suggest that some doctors take inter-relatedness through blood or marriage; Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from July, 1965 RAWNSLEY: Social Attitudes and Psychiatric Epidemiology 405 an economic life requiring much co-operation of the 19 individuals known to have had in certain processes-had led to a remarkable hysteria 25 years previously, 16 now stated homogeneity in social values and attitudes and they were subject to headaches associated with a low tolerance for departures from generally worry. Only three members of a control group accepted standards. of 19, matched for sex and age, had headaches In 1937 the population was subject to an of this kind. epidemic of major hysteria which was ex- Sixty per cent of the islanders who reported tremely well documented by the doctors of a headaches denied the influence of anxiety or Norwegian expedition which arrived shortly worry in provoking attacks. In considering the after the epidemic began (Christophersen, physiogenic as well as the psychogenic basis 1946). Twenty-one islanders were affected, of the Tristan headaches one is reminded of 11% of the population. It was possible to the experimental work by Holmes, Goodell, identify these cases by name from the details Wolf and Wolff (1950) on responses of the provided in the Norwegian report and 19 of nasal mucosa to a variety of stimuli in normal them came to England as evacuees, almost subjects. Swelling of the turbinates, hyperaemia, 25 years later. increased secretion, obstruction, lowered pain The hysteria took a variety of forms-faints, threshold, and sometimes the development of convulsions, "sleeping spells", "fighting spells" a rather characteristic headache occurred in and "choking spells". The epidemic gradually response to the following: pain elsewhere in subsided over a period of several months and the body; cold; bright lights; menses; allergens although sporadic cases have occurred since, and certain emotional states, notably anxiety, the condition has never recurred on the same resentment, anger, guilt, humiliation, frustra- scale. It is difficult, in retrospect, to say what tion. To recapitulate: the precipitating causes factors may have precipitated this outbreak. of headache reported by the islanders were Strained relationships between families; sexual worry; bright sunshine; strong winds; and by copyright. rivalries and jealousies; the isolated monoton- menses. ous life, are among the causes mentioned both Two hypotheses may be advanced but can- by the Norwegian investigators and by members not be resolved on the evidence provided by of the community. In the early stages, at least, this survey:- this series of dramatic exhibitions attracted a 1. A great deal of attention and evoked much high proportion of the population is interest in liable to nasal congestion with consequent the population. headache i'n response to a number of provok- In a socio-medical survey conducted in 1962 ing agents. Those of neurotic

disposition may http://pmj.bmj.com/ by a social anthropologist (J. B. Loudon) and find that their undue load of anxiety or other a psychiatrist (K. Rawnsley), the investigators morbid affect is especially potent in producing were impressed early in the course of the the response. enquiry by the high frequency of headaches 2. There is a nucleus of people, perhaps quite (59% of adult population) and by the remark- a small with manner in one, headache due to nasal ably stereotyped which these were congestion. In addition, however, there are described. They were bifrontal in distribution, islanders without a the often a who, physiogenic mechanism position being indicated by cha- of this kind, 'have adopted the headache res- on September 29, 2021 by guest. Protected racteristic gesture. They were common both ponse to anxiety as a convenient, socially on Tristan and in England and sufferers were acceptable, commonplace symbolic reaction. accustomed to have them every week or two. The homogeneous nature of Tristan society, Sometimes they were disabling, causing the together with the high degree of social inter- patient to cease work for a while, but usually have said not action, may powerfully influenced the they were to interfere with life act- establishment and spread of this symptom. If ivities. They were not associated with eye one accepts the Norwegian figures for preval- symptoms or vomiting and were relieved by ence of The commonest headache in 1937, it must be concluded aspirin. provoking factors that this malady has become much more ex- were exposure to strong winds or bright sun- and tensive in recent years. Headache may now shine; menses; worry. have become, in part, an endemic neurotic An association was found between the occur- symptom modelled on a physiogenic disorder, rence of headache, especially of worry-provoked but spreading through the community in a less headache, and a history (from the Norwegian dramatic though more enduring fashion than report) of previous hysterical attacks. Thus, the convulsive hysteria of 1937. Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from 406 POSTGRADUATE MEDICAL JOURNAL July, 1965 The association between certain social at- ciations between the complex web of social titudes and the prevalence of symptoms has values and attitudes (viewed as elements in the been studied in the much more complex, much social structure and organisation of a popula- less homogeneous society of a rural area in tion) and the pattern of psychiatric S. Wales. The work of a social anthropologist symptomatology. in this population (Loudon 1961, 1964), to- It was predicted that there would be positive gether with the private sociological census made associations between the social attitudes (of in collaboration with Professor Cochraine's Unit sympathy, and of readiness to seek a doctor's laid -the basis for a division into population advice) in a section of the population towards sections which differed socially in many respects. particular symptoms and the prevalence of A comparative survey has recently been these symptoms in the population section. The made of the prevalence of a large number of social anthropologist, deploying his skills symptoms in random samples drawn from initially at the "micro" level of observation of each of the social sections of the rural popula- social relations, behaviour and values, was able tion. Special techniques were devised for appli- to proceed at the "macro" level to the construc- cation in home interviews for the assessment tion of an ad hoc social classification of the of symptoms and of associated attitudes. The entire rural population yielding divisions attitudes measured were (a) level of sympathy peculiarly relevant to the purpose of the enquiry. manifested towards certain symptoms; (b) ex- The psychologists devised techniques for the tent to which the same symptoms are regarded quantitative estimate of both attitudes and as proper objects of medical care. symptoms with built-in safeguards to offset Symptoms were assessed using techniques the prejudices of the interviewers and to reduce designed to minimise the observer's active the influence of response "sets". The psy- participation with the consequent distortion chiatrist, using more conventional clinical skills, due to prejudice and bias in the observer. For was able to provide data for comparison withby copyright. comparative purposes, main reliance was placed the psychological measures. on two "objective" procedures-a modifica- Sir Aubrey Lewis (1961) has bemoaned the tion of the Cornell Medical Index Health dependence on symptom counts in psychiatric Questionnaire which, in its original form com- surveys rather than on diagnoses. He regards prises some 200 questions (to be answered such a state of affairs as "humiliating because 'Yes' or 'No') about physical and psychological it throws us back to the infancy of medicine; symptoms; and specially designed scales for a it aligns us with the school of Cnidus, so sharply limited number of symptoms (Ingham, 1965). rebuked by the rival Coans twenty odd The scales had an advantage over conventional centuries ago for differentiating a host of typeshttp://pmj.bmj.com/ questionnaire forms in providing a method of of disease solely according to the subjective grading the severity of the symptom. They also, symptoms complained of, without regard to by their design and method of presentation, what examination might reveal or a common served to reduce the influence of certain cause underlie." Nevertheless he concludes, "It spurious response "sets", e.g., a tendency to must be sadly admitted that we cannot escape answer "Yes" to questions whatever the con- it in our state." tent, which present might otherwise yield spurious Progress in the epidemiology of mental dis- on September 29, 2021 by guest. Protected variations between social categories. orders hinges in the first place upon the Other measures of morbidity were also em- sharpening of methods for the reliable and ployed, including re-interview of a subsample valid estimation of psychiatric morbidity. by a psychiatrist who was ignorant of the Attempts to design such methods quickly performance on the first interview; special evoke fundamental questions concerning the observation by G.P.s for a period of three nature and definition of psychiatric disorder. months; records of attendance at The or clinics in psychiatric answers involve, inter alia, consideration hospitals recent years. of social values and attitudes pertaining to The results of this investigation have yet human behaviour. In addition to influencing to be published, and no attempt will be made the recognition and disposal of the psychiatric to present them in this paper. The survey is case by the G.P. and affecting the fate of the mentioned principally in order to draw attention patient in hospital, social attitudes may make to the outline strategy and design of a particu- a powerful contribution to determining the lar research project aimed at uncovering asso- occurrence and content of psychopathology. Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from July, 1965 RAWNSLEY: Social Attitudes and Psychiatric Epidemiology 407 Grateful acknowledgment is made for the facilities LOUDON, J. B. (1961): Kinship and Crisis in S. Wales, and help provided by Professor A. L. Cochrane, Hon. Brit. J. Sociol. XII. No. 4, 333. Director of the M.R.C. Epidemiological Research LOUDON, J. B. (1965): Religious Order and Mental Unit, and by Dr. J. C. Gilson, Director of the Disorder: a Study in a Rival Community in M.R.C. Pneumoconiosis Research Unit. The work S. Wales in "The Social Anthropology of Complex in South Wales owes a great deal to the inspiration Societies", A.S.A. Monograph 4. London: and support provided constantly by Sir Aubrey Lewis. Tavistock. MOWBRAY, R. M., BLAIR, W., JUBB, L. G., and CLARKE, REFERENCES A. (1961): The General Practitioner's Attitude to BROOKE, E. M. (1959): A Longitudinal Study of Psychiatry, Scot. med. J., 6, 314. Patients First Admitted to Mental Hospitals, Proc. NORRIS, V. (1956): A Statistical Study of the Influ- roy. Soc. Med., 52, 280. ence of Marriage on the Hospital Care of the BROWN, G. W., CARSTAIRS, G. M., and TOPPING, G. Mentally Sick, J. ment., Sci., 102, 467. (1958): Post-hospital Adjustment of Chronic Mental RAWNSLEY, K. and LOUDON, J. B. (1962a): Factors Patients, Lancet, ii, 685. Influencing the Referral of Patients to CHRISTOPHERSEN, E. (ED.) (1946): Results of the by General Practitioners, Brit. J. prev. soc. Med., Norwegian Scientific Expedition to Tristan da Cun- 16, 174. ha 1937-38, Oslo: Det Norske Videnskaps-Akademi. RAWNSLEY, K., and LOUDON, J.B. (1962b): The FOLKARD, S. (1960): Comparative Study of Attitudes Attitudes of General Practitioners to Psychiatry. to the Rehabilitation of Psychiatric Patients, Brit. Sociological Review Monograph No. 5, University J. prev. soc. Med., 14, 23. of Keele. HOLMES, T. H., GOODELL, H., WOLF, S., and WOLFF, RAWNSLEY, K., and LOUDON, J. B. (1964): Epidemio- H. G. (1950): The Nose, Springfield, Illinois: logy of Mental Disorder in a Closed Community, Charles C. Thomas. Brit. J. Psychiat., 110, 830. INGHAM, J. G. (1965): A Method for Observing RAWNSLEY, K., LOUDON, J. B., and MILES, H.L. Symptoms and Attitudes, Brit. J. Soc. Clin. Psychol. (1962): At'itudes of Relatives to Patients in Mental 4, 131. Hospitals, Brit. J. prev. soc. Med., 16, 1. KESSEL, W. I. N. 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(1962): by copyright. in Hospital and General Practice, J. ment. Sci., 108, The Industrial Rehabilitation of Long-stay Schizo- 159. phrenic Patients. Medical Research Council Memo- LEWIS, A. J. (1961): "Mental Disorders in Britain" randum No. 42. London: H.M.S.O. -in "Comparative Epidemiology of the Mental WING, J. K., DENHAM, J., and MONRO, A. B. (1959): Disorders" ed. Hoch, P. H., & Zubin, J. New York Duration of Stay in Hospital of Patients Suffering and London: Grune and Stratton. from Schizophrenia, Brit. J. prev. soc. Med., 13, 145. LOGAN, W. P. D., and CUSHION, A. A. (1958): WING, J. K., MONCK, E., BROWN, G. W., and "Morbidity Statistics from General Practice", Vol. I CARSTAIRS, G. M. (1964): Morbidity in the Com- (General): General Register Office: Studies on munity of Schizophrenic Patients Discharged from Medical and Population Subjects No. 14., London: London Mental Hospitals in 1959, Brit. J. Psychiat., H.M.S.O. 110, 10. http://pmj.bmj.com/ on September 29, 2021 by guest. Protected