The key test for HoNOS is that clinicians should want to use it for their own purposes. In general, it has passed that test. A further possibility, that HoNOS data collected routinely as part of a minimum data set, for example for the Care Programme Approach, could also be useful in anonymized and aggregated form for public health purposes, is therefore testable but has not yet been tested.

In spite of the new methods of treatment and care introduced during the past fifteen years, schizophrenic patients are still liable to relapse with a recurrence of florid symptoms such as delusions, hallucinations and disturbed behaviour, and great suffering can be caused to all concerned (Brown et al., 1966). It has been shown that the onset of florid symptoms is often preceded during the previous three weeks by a significant change in the patient's social environment (Brown and Birley, 1968; Birley and Brown, 1970). Other studies have focused on the influence of more persistent environmental factors, such as the emotion expressed towards the patients by relatives with whom they were living. In an exploratory survey of discharged long-stay men it was found that close emotional ties with parents or wives indicated a poor prognosis (Brown, Carstairs and Topping, 1958; Brown, 1959). In a further study, patients were seen in hospital just before discharge, and their relatives were interviewed at home at the same time, and both were seen together at a joint interview shortly after discharge. It was found that those patients who returned home to live with relatives who were highly emotionally involved with them (as judged by ratings of the relatives' behaviour) were more likely to suffer a relapse of florid symptoms, even when the severity of psychiatric disturbance at the time of discharge was taken into account (Brown et al., 1962). Ratings of the patient's own expressed emotion showed much less involvement, and were much less highly associated with subsequent relapse. There was also a suggestion that short-term and long-term influences might have a cumulative effect; for example, that a raised level of tension in the home made relapse more likely in the event of a critical change in the patient's social environment (Brown and Birley, 1968). These facts, together with the contrasting but just as handicapping reaction of schizophrenic patients to an under-stimulating social milieu, were brought together in a more general theory of environmental influences on the course of schizophrenia (Wing and Brown, 1970). This also took account of the high physiological arousal which had been found in the most withdrawn schizophrenic patients (Venables, 1968; Venables and Wing, 1962). It was argued that in a socially intrusive environment acting upon a patient whose thought disorder was in any case liable to become manifest whenever circumstances became too complicated, a patient would tend to attempt to protect himself by social withdrawal; but this process might easily go too far, both in hospital and outside it, leading to complete social isolation and inability to care for himself. The optimum social environment, for those who remained handicapped, was seen as a structured and neutrally stimulating one with little necessity for complex decision making.

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Provided that training needs can be met, HoNOSCA represents a satisfactory brief outcome measure which could be used routinely in child and adolescent mental health services.

Much of the literature on the family of the schizophrenic patient has suggested that a number of common features are present in the personalities of the parents, and that these are significant in the aetiology of the illness. Most studies have been concerned with the parent-child relationship and only a few with the adult patient and his parents. Tietze's description of mothers as generally' over-anxious, obsessional, and domineering is typical (Tietze, 1949); and Fromm-Reichmann (1948) coined the term "schizophrenogenic" to describe such women. The more systematic work has indicated a high frequency of domineering and over-solicitous behaviour among mothers (Mark, 1953;Freeman and Grayson, 1955;Gerard and Siegel, 1950; Kohn and Clausen, 1956). Two studies, however, have produced negative evidence (Neilsen, 1954;Hotchkiss, Carmen, Ogilby, and Wiesenfeld, 1955) and the second of these was the only one in which the behaviour of the mother and patient was directly observed.Even if differences exist between the mothers of schizophrenics and other mothers, this need not be of aetiological importance. The possibility must first be excluded that behaviour such as "overprotectiveness" may be the result of the patient's unusual behaviour influencing the parents (Kasanin, Knight, and Sage, 1934). Once an illness has developed in one member of a family, a heightened level of tension is probably common. Once established, tense relationships in turn may have an important effect on the later stages of the illness. Some evidence that family relationships can influence the course of schizophrenia was provided by a previous study, which showed that re-admission of long-stay patients was related to the type of living group to which they returned (Brown, Carstairs, and Topping, 1958;Brown, 1959). Patients who lived with wives and parents showed a higher re-admission rate than those going to brothers, sisters, or more distant kin, or in lodgings. There was evidence that the risk of deterioration in clinical condition was increased when prolonged contact with close relatives in the house was unavoidable-when, for example, both patient and mother were unemployed. Results could not be explained entirely by the length or past severity of illness or by differences in clinical condition at the time of discharge; and it was concluded that it might not always be best for the schizophrenic patient to return to the close emotional ties of affection or hostility often found in parental and marital homes.These close emotional ties are not, of course, confined to households of any particular kinship category. It was therefore decided to continue the work by studying the relationships within each home to which discharged patients returned. The majority of patients in this second study were short-stay schizophrenics, and a different survey method was used. Patients and their families were interviewed at the time of discharge and during the year, if the patient was re-admitted, as well as at the end of the follow-up period. In this way the diff...

SynopsisWe report the development of a new procedure for assessing the needs for treatment and care of the long-term mentally ill. This procedure covers 21 areas of clinical and social functioning, and in each of these specifies appropriate interventions. Decision rules are described which permit problems in functioning to be primarily classified as a met need, an unmet need, or as involving no need, and which allow the identification of various secondary needs. We report preliminary data on the reliability and validity of this procedure and discuss its potential applications in the care of the long-term mentally ill.

SYNOPSISA two-stage psychiatric survey of a random sample of adults aged 18–64 from Camberwell is described. Agency interviewers carried out the first stage (N = 800), using the shorter form of the Present State Examination (PSE). MRC interviewers, using the full PSE, saw a stratified sample of these (N = 310) in the second stage. A second interview was sought with all those of Index of Definition (ID) level 5 and above at the first interview (‘cases’) and with a random sample of those below that level. 20·9% refused or were never available for the first interview. Of the 800 subjects successfully interviewed, 10% refused a further interview and 12·4% of those finally selected for this interview were either unavailable or changed their minds. The MRC data, weighted to represent the whole sample, are used in our analyses. The prevalence of psychiatric disorder as defined in our study was calculated at 6·1% for men and 14·9% for women. Women shared a higher prevalence of disorder in the age-groups 25–34 and 45–54, but in men there was no significant association with age.In contrast to the findings of Brown & Harris (1978), social class did not have a strong association with disorder. Single men had much higher rates than married men, while the reverse was true in women. In both sexes employment was associated with lower rates of disorder. An attempt to explain the high prevalence in women in terms of their role in marriage and child-care was only partly successful.