Freud spoke excellent English (and AJL spoke German), an encounter between the two might have been a memorable one. However, Anna Freud is said to have been 'active and sensible' in work with children. Stengel -who was later to join AJL at the Maudsley -is described as practically the only analyst still working at the university clinic. Lewis's shrewd summing up was that analysts there 'treat character disturbances very much more than actual neurotic illness' and that consequently 'they are not much interested in therapy and practical problems of the out-patient department'. Some of AJL's critics would later say similar things about him, however.

Altogether, the state of European psychiatry -specifically in its postgraduate and scientific aspects -was not found to be encouraging. It was partly a problem of boundaries. Nearly everywhere, the relationship with neurology was a barrier to the emergence of psychiatry as a respectable and independent discipline. In Britain, those doctors dealing with mental health who were of higher status emphasized their role in the Royal Colleges of Physicians, and so had an identity crisis about being psychiatrists. Mapother urged trainees to obtain the MRCP, although the pass rate was then under 10%. In most countries, neurology was firmly in the ascendant in academic centres. The second boundary was with mental hospitals, and it was mostly an impermeable one, so that clinical case material in academic centres was limited -as was trainees' experience. There were a few outstanding exceptions, such as Gjessing's research at a mental hospital outside Oslo.

This volume is a rich historical seam. It was written at a time when physical treatment methods were beginning to emerge and so end the long night of therapeutic nihilism that had separated psychiatry from more hopeful aspects of medicine. Sakel's first account of insulin coma had just been published, but was not yet widely known. ECT was to come in two years' time. Revisiting this time-sample, with its detailed information and accompanying commentaries, is a significant step in the historical understanding of modern psychiatry. The editors are to be congratulated on bringing it to us. The Norfolk Lunatic Asylum, or St Andrew's Hospital as it later became, was relatively unique in its longevity. Established following the permissive legislation of 1808 and opened in 1814, it was one of the pioneer county lunatic asylums. It was also one of the last of the great nineteenth-century asylums to be abandoned, at the end of the twentieth century. As Steven Cherry sets out to demonstrate, its history serves as a virtual microcosm of the rise and fall of institutional psychiatry over the last two centuries. Some histories of a single institution have tended to become overparochial and excessively celebratory, particularly when written by former members of medical or other staff. This is a trap that Cherry, as a medical historian, largely avoids, although his researches have clearly led him to adopt a sympathetic but not uncritical approach towards the institution and those who have played a part in its unfolding story. He has been careful to set the narrative within both the national and the regional context, while highlighting the local elements that distinguished this from other comparable asylums. In particular, he demonstrates how the character of the asylum, as determined by patients and staff, has tended to reflect the predominantly rural culture of the county of Norfolk.

HUGH FREEMAN Green College, Oxford

The book is laid out chronologically, with the chapters on the nineteenth century phased according to particular management eras and those on the twentieth divided by war and peace, the inauguration of the NHS, and the development of community care. Within each period, Cherry considers the key determinants of the asylum experience -the physical fabric of the building; the rising numbers of patients and consequent overcrowding; changing approaches to therapeutics and patient management; and the doctors, managers and attendants or nurses who created and maintained the regime. A considerable amount of detail is provided, perhaps a little too much when it comes to some of the minutiae of administrative and financial management.

Some distinct themes emerge. From the outset, the asylum was bedevilled by the county justices' insistence on rigid financial economy in its management, an approach that recurred in various guises right to the end. This had a deleterious effect on staffing levels, on dietary provision and on the nature and quality of medical input provided. Nevertheless, there was one area where the Norfolk Asylum appears to have been ahead of most contemporaries; it was an early successful proponent of probationary leave for patients, and remained at the forefront of promoting discharge on trial.

The penultimate two chapters, which examine the gradual demise of the hospital in the context of the development of community care, are of particular interest. The information gathered from official sources is supplemented by oral testimony from former staff and, where possible, patients. The predominating impression is one of regret for what has been lost. The reader, however, is left bewildered by the evident picture of administrative chaos arising from successive organizational upheavals and associated policy shifts, and one can only be amazed that any sort of cohesive mental health service has emerged at all in the wake of hospital closure.

Cherry's overall approach is very much in the post-Scull mode, which in some quarters might be construed as 'revisionist'. He adopts a pragmatic stance, defending the Norfolk Asylum against perceived critics (including this reviewer), while at the same time objectively analysing its deficiencies at different stages of its development. Although the story of the institution largely follows the now-familiar pattern, this in no way detracts from its historical value. On the contrary, it is only through the assembly of such particular histories that a true picture of the birth, growth and death of the asylum can be assembled. In recent years, historical interest in idiocy has been seeping surreptitiously through the veins of Anglo-American historians of medicine. Since the early 1990s in particular, a flowing stream of doctoral dissertations, journal articles, edited volumes and monographs has been effectively charting shifting medical and educational models of intellectual disability, the establishment of novel institutional provisions, changing legislative responses to the perceived social and economic problems posed by those nowadays referred to as people with learning difficulties, and the emergence of increasingly vocal agitation for greater receptivity to the stories and arguments of self-advocates. In some instances, people with learning difficulties have themselves been instrumental in raising awareness of the political and historical dimensions of past efforts to care for and control those previously labelled 'idiotic'. Dominated by historians of medicine, recent literature on idiocy, imbecility and feeble-mindedness has focused predominantly on medical and legislative approaches and has not pursued broader cultural representations of mental deficiency in sufficient depth. Martin Halliwell's Images of Idiocy attempts to redress that imbalance by focusing almost exclusively, and with great originality, on the treatment of 'idiots' in both fiction and films throughout the nineteenth and twentieth centuries. After a temperate introduction setting out the methodological framework for reading literary and cinematic images and a brief outline of the longer history of idiocy from the cognitive aspirations of the Enlightenment to the romantic visions of the Victorian period, the book proceeds to tackle the representation and meaning of idiot figures in a range of literature, from Flaubert's Charles Bovary through Dostoevsky's Myshkin to Rohinton Mistry's Tehmul. In each case, close analysis of the literary texts is complemented by careful discussion of the gaps between literary images and subsequent film adaptations.

There are perhaps two central theses running through Images of Idiocy,

  Steven Cherry. Mental Health Care in Modern England: The Norfolk Lunatic Asylum / St Andrew's Hospital c.1810-1998. Woodbridge: Boydell Press, 2003. Pp. xi + 335. ISBN 0 85115920 6. £45.

  LEONARD D. SMITH Centre for the History of Medicine University of Birmingham Martin Halliwell. Images of Idiocy: The Idiot Figure in Modern Fiction and Film. Aldershot: Ashgate, 2004. Pp. x + 270. ISBN 0-7546-0265-6. £47.50.


Michael S Goldstein

 Jeffrey A. Schaler (ed.). Szasz under Fire: The Psychiatric Abolitionist Faces his Critics. Chicago and La Salle, IL: Open Court, 2004. Pp. xxv + 450. US$ 36.95. ISBN 0-8126-9568-2. The 'Under Fire' series allows controversial authors to respond in detail to an array of their critics. The format holds immense potential for both productive exchange, as well as intellectual and academic fireworks. It is difficult to imagine a better way to initiate the series than with the work of Thomas Szasz. Both students and well-established professionals will find much to enjoy and ponder in this useful volume which brings together 12 separate critical essays about specific aspects of Szasz's work, each with a response from Szasz specially written for the volume, as well as a very informative autobiographical sketch and an extensive bibliography of his work. While the editor's introductory essay is adequate, it will be insufficient for a reader not already familiar with Szasz's views. Szasz is absolutely first rate when it comes to clear writing, logic, passion and the telling example. When Szasz is dissecting the foolishness, unintended consequences, inconsistencies, intellectual pretensions and confusion inherent in topics such as the insanity defence or American drug policy, he is hard to beat. In some cases his job is made easier by the critics (for example, Peele's piece on addiction and Simon's on the insanity defence), who seem not to have read Szasz or made any attempt to deal with what he actually believes. Other essays vary from vague and rambling (Lieberman on 'pharmacracy'), to irrelevant (Hagen on PTSD), to focused and highly appreciative of Szasz despite very different conclusions (Battin and Spellecy on physician-assisted suicide, Bentall on schizophrenia). The acuity of Szasz's responses has a high correlation with the acuity of the attacks. Some, like Slovenko's essay on 'the therapeutic state' and Szasz's response have the feel of a bored old married couple going through the motions of a fight they have had so often that each could do the other's lines to perfection. There is also ample opportunity for a variety of old scores -relating to publications, court testimony and job threats -to be resurrected. The volume ends with a set of letters from 1962 about an attempt to dismiss Szasz from an academic position. Their presence more than 40 years after the event is a reminder of how bitter the animosity between Szasz and some of his adversaries remains.

For most readers the high points of the volume will come in the more general discussions about the nature of disease, and what it really means to call mental illness a 'myth'. Here Szasz is very much on the defensive and, despite his rhetorical skill, it becomes increasingly clear that his time has past. The essay by Kendell effectively demonstrates that Szasz's understanding of illness and disease is simplistic, antiquated and naïve. He shows (pp. 33, 38, 41-2) how Szasz's view of 'real' disease excludes, for example, hypertension, diabetes and many other chronic and acute conditions. To this, Szasz has no real response (p. 51). Szasz's rhetoric relies heavily on examples, but examples are not proof, and many of those to which Szasz returns again and again (e.g., the Hinckley case) are in no way representative. Perhaps the best piece in the volume is the one by Engelhardt clarifying Szasz's view that the 'myth of mental illness' is a moral claim, not an empirical or metaphysical statement. Engelhardt manages to be both highly appreciative and critical in assessing Szasz. For once, Szasz's response is one of agreement, with phrases such as 'I am grateful', 'exactly right' (p. 377) and 'faultless representation of my approach to therapy' (p. 387) setting the tone. It is good to see that, while Szasz and so many of his critics are still locked in their decades-old disputes, progress is possible.

MICHAEL S. GOLDSTEIN University of California, Los Angeles


Ruth Kloocke

Heinz-Peter Schmiedebach
email: p.schmiedebach@uke.uni-hamburg.de

Stefan Priebe Queen

Psychological injury in the two World Wars: changing concepts and terms in German psychiatry

Keywords: history, military psychiatry, models of illness, post-traumatic stress disorder, psychogenic, psychological, shell-shock, society, trauma, 'war neurosis', World War I, World War

This paper describes how German psychiatrists in two World Wars treated psychologically injured soldiers, and the concepts of related illnesses which they developed. The literature is reviewed, and symptomatolgy of patients and therapeutic practice in the wars are compared. By 1916 German psychiatrists had already established a concept of illness that continued to be used until World War II and beyond, albeit with a changing terminology. The vague term 'war neurosis' was commonly used, but covered different, partly overlapping concepts. Psychiatrists considered the disorder as a psychogenetic reaction based on an individual predisposition and denied a causal link between the experience of war and subsequent psychopathology. It may be concluded that psychiatrists developed theoretical models and practical treatment methods in a manner that met the social and military requirements of the time.

Introduction

The two World Wars represented watersheds in the way the psychiatric profession dealt with psychological traumas. It was the first time that these occurred in the context of war action in socially relevant numbers. Not only was there a substantial burden on the state through pension claims, but discipline and fighting morale in the Army were jeopardized by the quasi infectious spreading of the so-called 'war neuroses'. This mass phenomenon changed the attitude of psychiatry in a significant way. The practice of treatment and compensation was increasingly aligned to the norm of what was socially acceptable. The rejection of applications for compensation became standard practice among psychiatrists. The therapeutic goal was, above all, to restore the patients as far as possible to fitness for work. The involvement of the medical profession in the two World Wars can be seen as part of the process that the German social historian Lutz [START_REF] Raphael | Die Verwissenschaftlichung des Sozialen als methodische und konzeptionelle Herausforderung für eine Sozialgeschichte des 20[END_REF] dubbed 'Verwissenschaftlichung des Sozialen' (the handing over of social problems to science). This applied particularly to psychiatry, which had by now become established in modern medicine and was scientifically legitimized to control social and cultural relations. 1 In the course of this development a change appeared in the models of illness -or rather in the terms used by German psychiatrists to talk about psychological trauma -which lasted for decades. Terms which suggested a causal link between an experience and psychological reaction were replaced by a terminology which pointed to the constitution of the person affected. This development began shortly after the outbreak of World War I and continued into World War II. Three important moments can be identified which were significant for the development of the changed concept of the illness: the so-called 'Kriegstagung', a conference of leading German psychiatrists and neurologists on the war, held in Munich in 1916; legislation on insurance in 1926; and the banning of the term 'war neurosis' in 1944. The model of illness established by the end of WWII, which described symptoms as 'abnormal reaction' on the basis of individual disposition, determined the practice of assessment and therapy in German-speaking countries for decades.

There are already valuable publications in medical history on the way psychological trauma was handled in the two World Wars. 2 The aim of this contribution is to build on these publications, to delineate and compare the changes in the concepts of the illness and to discuss the nebulous term 'war neurosis'. We argue that the uncertainty in the use of the term and concept of 'war neurosis' was due to the combined effects of social aspects, medical knowledge, professional interests of psychiatrists and psychotherapists, and political and military goals. We would also like to consider the spectrum of the various conditions which determined the psychiatric discussion on what was called 'war neurosis'. First, we give a brief overview of the type of patient, the symptoms observed and the therapeutic measures adopted.

Patients and symptoms

According to contemporary sources during the early months of WWI, 'war neurosis' did not exist. Although there were a number of soldiers who had experienced nervous breakdowns, this was not yet seen as a real threat to the strength of the Army. By the end of 1914, however, with the Army digging trenches across the Western Front, an epidemic of 'war neurosis' began to materialize. 3 Symptoms included uncontrollable shaking, and disturbances of speech, vision, hearing or gait, all without a detectable organic basis. A number of concrete traumatic situations seemed to be linked to the emergence of these symptoms. For example, there were soldiers who developed blindness after a gas attack and others who became deaf after enduring long periods of shellfire. Soldiers who were forced to crouch down in a shell crater covered by the torn body of a comrade reacted by developing dumbness; being buried alive for hours or days could induce uncontrollable shaking, trembling or spasms [START_REF] Binswanger | Die Kriegshysterie[END_REF]. However, despite the obvious correlation between traumatic events and the emergence of symptoms, by no means all those who had to endure such incidents developed these symptoms. It seemed that the particular mental disposition of the individual mediated between the traumatic event and the psychological symptom, so that trauma was not regularly followed by similar symptoms or indeed any symptoms at all.

Although there are official records for nervous illnesses in WWI, exact numbers are difficult to establish. The official records identify 613,047 cases who suffered from 'nervous illness' during WWI (Heeressanitätsinspektion des Reichswehrministeriums [hereafter HR], 1934: 145; see also Hilpert, 1995: 70-1). Neurological illnesses, e.g., epilepsy or progressive paralysis, also came under this heading. The records on the percentage of psychogenic disorders ('hysteria', 'psychopathy', 'nervous shock') vary from 65 to 80%, i.e., the total number may well have been in the order of 400-490 thousand. This figure does not take into account multiple admissions and omits those who were never treated. The population of all patients with nervous illness out of all casualties increased from 2.2% in 1914/15 to 3.5% in 1916/17, with a slight reduction to 2.9% in 19172.9% in /18 (HR, 1934: 146): 146). The term 'war neurosis' does not feature in the official records. Based on the official records, Paul Lerner (2001: 141) estimates 200,000 'war neurotics', without specifying which diagnostic labels he includes in this number. Blaßneck (2000: 12, 34-9) points out that there is no official record of the military casualties in WWII. There is an unpublished 'Vorläufiger Sanitätsbericht des deutschen Heeres 1939-45' (preliminary medical report) by Hans Müller in the Archives of the Sanitätsamt der Bundeswehr in Bonn.

Müller reports a consistent frequency of the diagnosis 'war neurosis' of about 3-5% of all admissions to military hospitals between 1939 and 1945. Other authors state an increasing frequency of the diagnosis, for example, Oswald Bumke in 1942 (quoted by Schneider, 1984: 65; see also Hilpert, 1995: 70-3). Roth (1987: 72) calculates a figure of about 20-30 thousand persons suffering from 'war neurosis' between spring 1941 and the beginning of 1944, and assumes that at the beginning of 1945 the number amounted to up to 100,000 persons. Roland Müller (2001: 150) has a much higher estimate of at least 472,500 'war neurotics' in WWII.

Although the number was considerable in WWII, the disorder did not have the same relevance as in WWI. Until spring 1941, 'war neurosis' did not plague the German armies as it had done in WWI. Soldiers suffering from mental and physical strain more often showed psychosomatic reactions, for example peptic ulcers (Berger, 1998: 112). Eventually, there were so many of them that they were put together in special 'stomach battalions' in which all soldiers shared the same diet. What can be observed here is a shift or transformation in the nature of psychological injury from the hysteric expressive type prevalent in WWI to a more inward-oriented type. It is difficult to find a convincing explanation for this shift. One possible reason is that, based on lessons learned from WWI, all young recruits had to undergo an extensive medical examination, which considered their mental health as well as physical fitness (Blaßneck, 2000: 31). Potential recruits deemed mentally unfit were not taken into the Army. Another reason could be that 'war neurosis' is intimately linked with a particular type of warfare, i.e., trench warfare. Mobile warfare, which was used more extensively in WWII, may not have promoted the same type of psychological response. However, from spring 1941 onwards, the picture changed. 4 The 'war neurosis' that had been epidemic in WWI began to reappear. Age seemed to be a predisposing factor: very young and very old soldiers were those most affected.

In summary, it can be stated that to some extent similar reactions to the mental and physical strain of warfare occurred in both the World Wars. However, there was a significant change in the type and frequency of symptoms: in WWI, disorders of perception and shaking were most frequent, while in the early months of WWII psychosomatic reactions of the locomotion and gastrointestinal systems were predominant, and they persisted despite the resurgence of 'war neurosis' from 1941 onwards.

Treatment

Until 1915/16, most soldiers suffering from psychological injury due to warfare were discharged from military service and received pensions. In 1917, however, the same patients were re-examined, and in some cases pensions were withdrawn [START_REF] Hoffmann | Über die Behandlung der Kriegshysterie in den badischen Nervenlazaretten[END_REF]; see also Riedesser and Verderber, 1996: 70). Patients originally discharged and pensioned were required to appear before so-called 'Invaliden-Prüfungs-Geschäfte' (invalid examination boards) (Lerner, 1997: 135).

Re-examinations occurred annually, and many of the 'neurotics' who had been previously discharged as incurable were subjected to a new system of treatment. Treating war neurosis was endowed with particular significance for the economy and the war effort of the nation. The doctors were at the centre of a dynamic system that sought to improve reduced human performance and to use the remaining working capacity as efficiently as possible. Healing was conceptualized as enabling the patient to work. Patients were classified into different groups depending on their remaining abilities to fight or to do useful work in civilian areas. The acts of diagnosing, treating, and rehabilitating were separated, and hospital stays were kept as short as possible. The hospital was viewed as an unfavourable place for neurotics. Throughout Germany, workshops were added to military hospitals and new hospitals were constructed in agricultural settings and near factories. A rational system regulating the flow of 'neurotic' soldiers was introduced. Akin to an assembly line -to use Lerner's phrase -'neurotics' were first separated from malingerers and the chronically mentally ill (Lerner, 2000: 18). Then individuals for whom treatment was deemed worthwhile were sent to specialized stations where so called 'active treatment' was administered, alongside certain forms of psychotherapy. Different forms of aversive therapy were included under the heading of 'active treatment'. These were effective with a mixture of hypnosis, discipline and punishment. 5 The best known methods were the techniques of suggestive hypnosis developed by the Hamburg neurologist Max [START_REF] Nonne | Über erfolgreiche Suggestivbehandlung der hysteriformen Störungen bei Kriegsneurosen[END_REF] and the so-called 'Kaufmann cure' (1916). Nonne's particular method of hypnosis worked through suggestion. He listed three conditions necessary for his method to succeed: absolute self-confidence on the part of the doctor, complete subordination on the part of the patient, and the creation of an atmosphere in which the success of the cure was a foregone conclusion. Nonne's method gained national attention after he demonstrated his technique at the 1916 Conference in Munich (Lerner, 2003: 76).

The second method of 'active treatment', Kaufmann's technique, combined painful sensations caused by electric current with military exercises and commands. It consisted of four components: first the patient was informed that the treatment would be painful, but successful; second, the patient experienced a series of painful sensations caused by electric current followed by physical exercises; third, military subordination was enforced and the patient had to follow military orders. The fourth component was the doctor's conviction that the treatment, once started, must not be terminated before a complete remission of symptoms was achieved. If the doctor relented, the symptoms would become fixed and irreversible. Kaufmann claimed that his method was superior to Nonne's hypnosis: it required less skill than hypnosis which always carried the risk -according to Kaufmann -that the treatment could cause the patient to be resistant to being cured. However, electrotherapy met growing opposition. Alarmed by reports of deaths and serious injuries in late 1916 and 1917, several doctors became concerned about its abuse [START_REF] Christen | Schädigung durch Sinusstrom[END_REF]. Patients took their complaints against particular doctors to their political representatives. Medical brutality in general was discussed in the Bavarian Landtag (Lerner, 1996b: 325). In June 1918, psychiatric therapy in the military and field hospitals in Germany was discussed in the German Reichstag (Lerner, 1996b: 326). In August 1918 the Bavarian War Ministry directed doctors to act with more moderation (Lerner, 1996b: 317). The Ministry was concerned that the impression was being given that some doctors were making diagnoses and treatment plans according to financial interests, i.e., reducing the cost of war pensions, rather than in the interest of the health of the patient.

Alongside these aversive treatments, doctors influenced by psychoanalysis became involved in the treatment of 'war neurotics' (Freud, 1919: 5). Particularly active in this field were Karl Abraham, Sandor Ferenczi and Ernst Simmel. They reported their experience at the Fifth International Congress on Psychoanalysis in Budapest in September 1918 (Zur Psychoanalyse …, 1919). Simmel practised the 'cathartic hypnosis' method, a precursor of the psychoanalytic method. Abraham and Ferenczi developed forms of short-term psychotherapy appropriate to military hospitals. As a theoretical model, Freud saw the symptoms as founded in a conflict within the ego. The conflict between the old peace-time ego and the new, martial ego of the soldier became acute as soon as the peace-time ego recognized the extent to which the actions of his newly-formed parasitic double endangered his life (Freud, 1919: 5). The healthy individual, however, was supposedly able to suppress his love for himself and his instinct of self-preservation in the service of overriding ideas, to 'sacrifice his ego for the whole' (Abraham, 1919: 34). The psychoanalytical idea of a 'flight into illness' as a mechanism working unconsciously in 'war neurotics' was soon adopted by established psychiatrists. The psychoanalysts involved saw the treatment of 'war neurotics' not least as a chance to prove the efficacy and practical relevance of the psychoanalytic technique and in this way to improve acceptance of psychoanalysis (Freud, 1919: 3). Official representatives of the Army attended the Congress in Budapest. The setting up of psychoanalytical research wards was planned, as Freud (1919: 3) reported -not without pride -but they were not realized because WWI ended.

With the beginning of WWII, psychiatrists made use of the experience of WWI (Roth, 1987: 33). Electrotherapy was used again, but in a modified form, and was in the tradition of the aversive treatments, often referred to as the 'torture methods', of WWI, (e.g., Berger, 1998: 108;Müller, 2001: 123-26;Roth, 1987). On the other hand, a psychotherapeutic approach was also favoured by the Heeressanitätsinspektion (Inspectorate for the Army Medical Services). A distinct rivalry developed between the two forms of therapy (Roth, 1987;[START_REF] Schröder | Die berufspolitischen Auseinandersetzungen von Psychiatern, Psychotherapeuten und Psychologen in der Wehrmacht zwischen 1938 und 1945[END_REF]. In the Air Force and in services with highly qualified experts, milder forms of psychotherapy, hypnosis, autogenic training or depth psychology were primarily used. It was obvious that treating a pilot with a painful current did not necessarily restore his ability to fly an aircraft. The Army on the other hand set up a strictly organized system of 'active treatment'. Friedrich Panse, a psychiatrist at the army hospital at Ensen, modified the 'Kaufmann cure'. 6 He used galvanic current applied to the whole body surface, combined with suggestive hypnosis. Patients resisted this procedure as it caused serious pain to the skin; it was therefore necessary to put them in shackles. In December 1940 it was still necessary to obtain the patient's consent for this form of therapy. In January 1943, however, when the military situation became more and more critical and the number of war neurotics increased, the Supreme Army Command revised its former policy and ruled that treatment with galvanic current did not require the consent of the patient (Hilpert, 1995: 44).

The continuance of the war resulted in an increasing number of military casualties, and a new system was established for re-evaluating the capacity of war neurotics to do military duty (Blaßneck, 2000: 55-67;Riedesser and Verderber, 1996: 172-4). Unlike the situation in WWI, the system of managing war neurotics was now no longer oriented towards work in the civilian sector. Instead, the focus was on the wide range of possible military missions for the 'psychopathic' soldier. An elaborate system of assignment was combined with a threat to the soldier's life. Moreover, unlike the situation in WWI, 'war neurotics' could not possibly be discharged with a pension. The intensified selection and treatment of 'war neurotics' began in the summer of 1942.

For physically and mentally exhausted soldiers, resting places and recreation areas were made available. The soldiers who did not recover were sent to special wards for people with nervous injuries or disorders in army hospitals where they were treated with the aim of making them fit for front-line duty again. Those who remained resistant to treatment (in general 'active treatment'), were transferred to one of the following: lunatic asylums with special wards for mentally ill soldiers, special services of the Reserve Army, or delinquent battalions. If they did not recover or were unable to carry out their duties, they were court-martialled or sent to a concentration camp. The special services of the Reserve Army functioned as training services for 'maladjusted' soldiers. If the soldiers were deemed to have resisted because of 'bad character', they were transferred to delinquent battalions.

The treatment of 'war neurotics' was basically similar in both World Wars. The military psychiatrists in WWII built on the experience of WWI, carried out an even more thorough sifting out of potential 'war neurotics' and set up strictly organized structures with the purpose of gradually re-integrating neurotics into active service. In both World Wars there was a strong, professionally motivated rivalry between psychotherapeutic approaches and the processes of 'active treatment'; psychotherapy, however, remained a marginal phenomenon, used on only a few 'war neurotics'. The aversive therapies used were based on the principles of discipline, deterrence and punishment. The increasing radicalization of the threatened measures also reflects the helplessness of the medical staff faced with a spreading epidemic of 'war neuroses'. The explicit target that affected soldiers should return to the front-line was only achieved for a few 'war neurotics', and even among those there were often relapses (Müller, 2001: 137). It becomes clear that the threat the 'war neurotics' faced, a threat which was integrated in the very concept of the treatment, reached a new dimension in WWII: the final step in the process for therapy-resistant persons was their possible annihilation.

Changing terms

'War neurosis', 'war neurotic' and 'the war neurotic question' are terms used in both the World Wars as well as by today's medical historians in the context of psychological disorders occurring in war after traumatic events. Quite different concepts of illness have been subsumed under these terms. It is not clear when the concept of 'war neurosis' was first used. 7 [START_REF] Lengwiler | Zwischen Klinik und Kasene[END_REF] does not mention 'war neurosis' at all in his history of military psychiatry in Germany and Switzerland in the period 1870-1914. Together with the laterobsolete 'war psychosis', he gives only the terms 'nervousness', 'male hysteria' and 'states of exhaustion' as diagnostic categories. [START_REF] Wollenberg | Nervöse Erkrankungen bei Kriegsteilnehmern[END_REF]Wollenberg ( : 2182) ) emphasized as early as 1914 'that there is no psychosis or neurosis that is specific to war'.

In the official statistics of the Sanitätsbericht (Report of the Medical Corps) for WWI, the term 'war neurosis' does not appear, nor does the colloquial term 'war trembler'. In this report, 'neurasthenia', 'hysteria' and 'psychopathic disorder' were diagnosed, and much less frequently 'nervous shock', 'psychasthenia' and unspecifically 'neurosis' (HR, 1934: 148). Bonhoffer (1914Bonhoffer ( : 1778)), in an article on 'Psychiatry and war', still refers only to 'hysterical conditions' on the basis of a 'psychopathic constitution'. It can be observed that the nebulous, almost popular-science term 'war neurosis', which did not really fit into the contemporary psychiatric nosology, appeared in academic discussion only when the tendencious element of the disorder was more emphasized, i.e., its closeness to malingering or to so-called Begehrungsreaktion (desires for gain reaction). 8 Equally one can postulate that medical historians use the term 'war neurotics question' most often when identifying presumed tendentious medical behaviour in the psychiatrists of that time, that is, showing how they allowed themselves to be used for political and social purposes. 9 Originally, what was understood by 'war neurosis' was a form of 'traumatic neurosis' in the [START_REF] Oppenheim | Der Krieg und die traumatischen Neurosen[END_REF] sense. The neurologist Hermann Oppenheim had introduced this term in 1889. 10 Using a study investigating injured industrial workers with mental ailments, Oppenheim delineated a distinct disease entity that he named 'traumatic neurosis' which reflected a causal relationship between trauma and subsequent medical disorder.

Oppenheim believed that the origin of the disorder was an undetectable microscopic change in the brain caused by cerebral concussion. However, he also accepted that psychological processes played an aetiological role [START_REF] Schmiedebach | Post-traumatic neurosis in nineteenth-century Germany: a disease in political, juridical and professional context[END_REF]. In 1916 a professional debate on the subject was held in Munich, and Oppenheim's position was rejected by a majority of the psychiatrists and neurologists attending. 11 The favoured approach was to view the disorder as a product of the mind, not the body. The success of hypnosis and suggestion in reducing symptoms fostered the acceptance of this psychogenic approach. The rejection of Oppenheim's position and the widespread acceptance of psychogenicism had a profound effect on the use of the term 'traumatic neurosis'; it was almost completely abandoned.

The expression 'war neurosis' now stood for disorders in the spectrum of hysterical and neurasthenic diseases and was used as a common collective term to cover various concepts of illness; see, for example, [START_REF] Lewandowsky | Was kann in der Behandlung und Beurteilung der Kriegsneurosen erreicht werden[END_REF]. On the one hand, by using the term 'war neurotic' one was able to avoid the diagnosis 'male hysteria' which was felt to be a stain on a man's honour. On the other hand, the term 'war neurosis' reflects the important influence of the psychological concept of neurosis. Psychiatrists treated psychoanalysis with considerable reserve, yet the implementation of the psychogenic approach in psychiatry did undoubtedly reflect psychoanalytic ideas (see Komo, 1992: 94-103;Roth, 1987: 17-33). According to the psychogenic approach, symptoms were caused by a more or less unconscious desire to flee from war into illness. These Begehrungsvorstellungen (desires for gain), such as the desire to stop fighting and receive a military pension, were seen as engendering a general disposition towards neurosis. Soon, doctors began to see this attributed 'constitution' as inferior and connected it with the so-called 'psychopathic constitution'. The doctrine of the 'psychopathic constitution' had become established at the end of the nineteenth century. It categorized socially deviant behaviour in terms of the prevailing values of order and selection (Raphael, 1996: 175). 'Psychopathy' was explicitly not given the status of illness; this constitution in a person simply did not fulfil a postulated norm or it led to a reduced ability to perform (Komo, 1992: 86). The deviation from the norm was attributed to an inferior genetic disposition. [START_REF] Aschaffenburg | Die konstitutionellen Psychopathen[END_REF] distinguished, for example, 'constitutionally depressive', 'compulsively ill', 'unrealistic', 'agitated', 'unstable', 'pathological liars' and 'sexual deviants'. To identify such individuals at an early stage and exclude them from military service was seen as an important task of military psychiatry, since as 'troublemakers' and 'failures' they would endanger the order and success of military operations (Komo, 1992: 87). The concept of 'psychopathy' was always subservient to the idea of performance, i.e., it was in essence an instrument for the optimal use of human resources through selection. The norm is not to be understood, as elsewhere in medical contexts, as a statistical norm, but as an ultimately ideological, normative value in the sense of 'socially desirable behaviour'.

Initially 'neurasthenia' also came under the heading of 'war neuroses'. It had originally been a fashionable late-nineteenth century diagnosis designating an understandable 'nervous exhaustion' as the result of unusual psychological strain. 12 In the description of their symptoms, 'neurasthenics' hardly differed from 'war neurotics with psychopathic constitution'. In retrospect, the borderline between 'natural', understandable 'neurasthenic' reactions to psychological strain and the allegedly genetically determined 'psychopathic' reaction seems arbitrary (Müller, 2001: 45). Characteristically, 'neurasthenia' was a diagnosis given to higher ranks whereas 'hysterical reactions' were restricted to the lower ranks, and this underlines the social implications of the diagnoses (Gaupp, 1922: 89). The criterion of the 'understandable' -the evaluation of behaviour as 'natural' -points to greater sympathetic acceptance on the part of the doctors. 'Neurasthenia' shared this greater level of acceptance with what was called 'acute reaction to shock', which designated short-term, psychological reactions to traumatic events -reactions that later disappeared completely. These were also considered 'understandable'. However, there were doctors at the time who demanded that 'war neurotics' should be taken seriously as sick men und who warned against the effect of a lack of acceptance on those affected (Komo, 1992: 79).

The professional controversies over methods of treatment had an effect on the use of the terminology: from today's perspective it is possible to note that only those patients who were deemed appropriate for 'active treatment' were called 'war neurotics', whereas those who were to be treated with rest and psychotherapeutic measures continued to receive the diagnosis 'neurasthenic'. This meant that in the course of WWI a clear standardization in the evaluation by experts took place, and the conceptual field of 'war neurosis' began to narrow down to 'psychogenic (hysterical) reaction' based on a socalled 'psychopathic constitution' (Gaupp, 1922: 86). The most important consequence drawn from the doctrine of 'psychopathy' was that 'war neuroses' were regarded as not requiring compensation. The genesis of the condition was decisively attributed to 'psychopathic constitution' as the socalled endogenous individual factor; a causality between the experience of war and the symptoms of illness was fundamentally denied. Any compensation or granting of a pension was considered to be detrimental to the course of the illness, since the symptoms might thereby become permanent. As early as 1916, at the War Conference of neurologists and psychiatrists in Munich, questions of compensation and pensions were discussed in this spirit. 13 The assessment of patients by expert witnesses changed during the course of the war. Ewald Stier saw the administrative treatment of nervous disorders as the central problem of the war pension administration. According to his account, the rejection of unjustified pension claims in the interest of the national economy was the main task of an expert evaluating cases (Stier, 1922: 186). 14 Neurotic illnesses were increasingly placed alongside the Begehrungsreaktion or malingering. The observation that 'hysterical reactions' hardly ever occurred among prisoners of war served as an important argument here. Gaupp's interpretation, for example, was to the effect that prisoners of war could expect no benefit from these symptoms, no benefit in the sense of a dispensation from front-line duties, compensation or pension. 15 On the other hand, in the case of active soldiers at the front a 'war neurosis' was, as a rule, a more or less conscious Zweckreaktion or reaction with a purpose, namely to get out of the danger zone or to gain other advantages. Similarly, 'pension wish neurosis' was also referred to [START_REF] Moser | Der Arzt im Kampf gegen "Begehrlichkeit und Rentensucht" im deutschen Kaiserreich und in der Weimarer Republik[END_REF].

The experiences of WWI left clear traces in the National Insurance Regulation passed in 1926. Following essentially the line taken by Stier and Bonhoeffer, the National Insurance Office made a formal decision on 24 September 1926 that inability to work, or disability based on 'the idea of being ill' or on 'more or less conscious wishes', did not require compensation (Feilchenfeld, 1927: 274). The forms of illness so far described as accident-, imprisonment-, war-and pension-neuroses were interpreted as 'reaction based on wishes' or 'psychologically understandable reaction to the fact of insurance and to the procedure for compensation as such' (Feilchenfeld, 1927: 275). Stier emphasized expressly that it is 'not a case of real illness . . . but only psychologically understandable reactions'. He claimed that the concept of hysteria was obsolete, whereas the term 'physical or psychological constitution' was of particular significance. Interestingly this position did not go unchallenged. In a circular from the Minister of Labour of 1929 the following guidelines were given, among others:

Objections have been raised to the practice of deducing a psychopathic disposition purely from the appearance of neurotic symptoms. … It has been found that the labelling of patients in short formulations such as 'psychopath', 'neuropath', 'pension hysteric', 'psychopathic', 'neuropathic disposition' were felt hurtful and insulting and these will cease to be used in expert opinions and records. (Horn, 1932: 79) This shows that contemporaries also noticed and criticized the bias of those writing psychiatric reports.

Many psychiatrists who had been active in WWI still practised in WWII and based their work on the same ideas. The 'Guidelines for the acquisition of military medical experience' first of all made a distinction between 'nervous exhaustion', which corresponded to the earlier 'neurasthenia', and 'hysterical reactions' (Berger, 1998: 110). 16 This categorization of psychological reactions, which was largely taken over from WWI, was modified a number of times in the course of WWII [START_REF] Valentin | Die Krankenbataillone. Sonderformationen der deutschen Wehrmacht im Zweiten Weltkrieg[END_REF], quoted by Berger, 1998: 110-12). Before the outbreak of WWII the expression 'neurosis' had been questioned as being vague and open to interpretation (Blaßneck, 2000: 14-17). There were many attempts and initiatives aimed at doing without the term neurosis altogether. In June 1944 the Supreme Army Command ordered that the term 'neurosis' should be dropped and replaced by abnorme seelische Reaktion (abnormal mental reaction). Labels such as 'war neurotic', 'war trembler' and 'war hysteric' were explicitly prohibited. 17 A distinction was made between 'abnormal reactions to experience' as purely psychological reaction and the so-called 'psychogenic functional disorders' (Blaßneck, 2000: 17). The latter covered traditional 'hysterical' symptoms such as trembling, psychogenic paralysis, etc., and also disorders of the bladder, stomach and intestines and similar complaints from the psycho-somatic field, which appeared in increasing numbers in WWII.

Various reasons can be identified as to why, in WWII, certain terms were discredited or given up as being derogatory. Characteristically the changes in terminology were brought about by regulation, i.e., it was an intentional change by the Heeressanitätsinspektion, although the implementation of the changes often lagged far behind. In essence, there were three different types of problems responsible for the change in terminology:

1. The discussions of the concept of neurosis reflect the fundamental dispute between the schools of psychiatry and psychotherapy. Roth (1987) and also [START_REF] Schröder | Die berufspolitischen Auseinandersetzungen von Psychiatern, Psychotherapeuten und Psychologen in der Wehrmacht zwischen 1938 und 1945[END_REF] showed that there was a decisive battle between the two groups over the treatment of 'war neurotics'. In the course of the discussion the psychotherapists were able to establish themselves successfully as an independent professional group of therapists. The concept of neurosis, originally coined by psychoanalysis, was, however, later superseded by the terms 'abnormal reaction to experience' or 'psychogenic reaction' as being neutral regarding their theoretical provenance. These concepts could be used both as part of a psychotherapeutic or a psychiatric model. In practical treatment both schools continued to operate alongside one another in unchanged form up to the end of the war (Roth, 1987: 73). Neither of the two schools of thought was able to establish itself finally as sole authority in the Army.

2. The banning of the terms 'war neurotic', 'war trembler' and 'war hysteric', which layman felt were derogatory, was a reflection of the the Heeresanitätsinspektion's fear of negative public opinion about the way doctors treated psychogenic illnesses. People remembered the end of World War One when there were mutinies following the use of electrotherapy, which the soldiers felt was torture and abuse, and when those affected went to court and brought lawsuits against the military doctors who had treated them. 18 These lawsuits generally had no consequences for the doctors concerned, but they did significantly modify the attitude of those politically responsible. The psychiatric consultants in the Army constantly admonished the doctors in the field to take these patients seriously as patients and warned against making moral judgements on the symptoms (Berger, 1998: 111). The army inspectors placed themselves so to speak protectively between patients and doctors but did not impose negative sanctions on what the doctors in fact did (Müller, 2001: 168-71). However, doctors practising in the military continued to see their main task as detecting malingerers and making those who came for treatment 'usable', that is, fit to go back to the front. The fact that this was not often successful did not alter the final aim at all. The doctors' identification with the public interest was stronger than their sense of responsibility to the particular patient. In his Marburg example, Roland Müller (2001: 146) was able to show with the aid of patients' files that doctors became downright opponents or persecutors of their patients.

3. The banning of the terms 'war neurotic', 'war trembler' and 'war hysteric' was also a continuing part of the debate on pensions. The military authorities intended to avoid any term that suggested a causal relationship between war and psychological disorder. From 1916, trauma as a causal element of mental disorder was consistently and continuously denied by psychiatric professionals. The Heeressanitätsinspektion tried on the one hand to limit the effect of the negative attitude to patients held by doctors in the corps. On the other hand, however, the doctors were not released from their task of acting in the public interest and fending off pension claims. The ambivalence of this task cannot be overlooked. The credo of the debate about 'pension-wish neurosis' -that the symptoms only arose from the possibility of getting a pension and that those affected would become fit for work as soon as they received notice of final refusal -conflicts with the encouragement given to take the 'war neurotics' seriously as 'real patients'.

Conclusion

The following concepts merged into the nebulous term 'war neurosis': the remains of 'traumatic neurosis' in the sense Oppenheim used it; a concept of neurosis with its notion of psychogenesis of physical disorders which was influenced by psychoanalytical terms; the traditional hysteria concept; and the psychopathy concept of constitutional inferiority. The gradually dying concept of neurasthenia also found its way into this concept field.

When we examine the question of the continuous existence of the one disease, we conclude that 'war neuroses' occurred in the First and Second World Wars in a similar way. Yet it is worth remarking that in WWII the symptoms shifted towards psychosomatic forms of reaction. The concept of the illness as formulated in 1916 by the overwhelming majority of German psychiatrists was an 'abnormal reaction' based on individual disposition, and this definition remained the consensus of opinion in WWII and after it.

Despite this conceptual continuity we find several changes in terminology. There were up to six terms in use at the same time. Psychiatrists created the different terms pointing to the alleged cause of the disorder ('war neurosis') or with reference to similar disorders ('hysterical reaction'). Some referred to constitutional factors ('psychopathic reaction') and others alluded to social and economic consequences. Thus we also find the expression 'war neurosis' in connection with the so-called 'pension neuroses' with their Begehrungsvorstellungen (desires for gain) and the question of malingering. The overtone of the concept 'war neurosis' always implies the socially undesirable, or a tendency to abusive behaviour requiring containment. This is the way in which it differs, for example, from 'neurasthenia' or 'acute shock reaction', which were seen as 'imaginable' or 'understandable'. Contemporaries were aware of the ambivalence of the concept field, and consequently there were many attempts to simplify the terminology and distance it from concepts with negative connotations.

Towards the end of WWII the leading military psychiatric authority established the more descriptive term of 'abnormal reaction to experience' as the official label for a purely psychological disorder and the term 'psychogenic functional disorder' for complaints with physical symptoms. The changes in terminology intended by the Heeressanitätsinspektion were aimed at avoiding certain areas of conflict in the discussion of 'war neuroses': Among the changes intended were the banning of the concept of neurosis, the abandoning of obviously derogatory terms and also the avoidance of terms that suggested any causal link between the war and the symptoms. This attempted standardization of terminology with a tendency towards a more descriptive form of expression was not, however, ultimately used and, in practice, polypragmatism prevailed in the use of terms. The terms 'war neurosis', 'hysterical reaction', 'psychopathic reaction', 'desire neurosis', 'pension wish neurosis' and even 'traumatic neurosis' were still in use after the end of WWII.

The treatment of 'war neurotics' in WWI embraced a rich spectrum of methods, including aggressive forms of treatment as well as psychotherapeutic approaches. The most frequently used aggressive methods led to public protests and rebellion at the end of the war. In order to avoid similar reactions or to prevent 'war neuroses' from appearing at all, an intensified sifting out of predisposed individuals was undertaken at the medical examination for military service. Despite this procedure medical and military authorities were forced to realize that psychogenic disorders appeared again in WWII. In the course of the war, methods of treatment of 'war neurotics' became increasingly radical. In 1942, at the latest, stricter selection of those affected was introduced. The threat of court martial or concentration camp meant potential danger to life -in other words, the threat exerted by the therapeutic arsenal took on a new quality.

The methods of treatment used by psychiatrists in both World Wars need to be seen against the background of the role played by psychiatry in Germany since 1870. Psychiatry was established in academia and, at the same time, claimed responsibility for defining the standards of mental abilities required to perform certain social and professional tasks in society. In the two World Wars psychiatrists saw a chance to apply this goal to one particular aspect of society: military efficiency. Psychiatric concepts, and particularly methods of treatment, were used to optimize human resources in warfare. In both World Wars individual health and performance was thus redefined in terms of the collective needs of German war efforts. Centralblatt, 35, 792-824 (1917); Psychiatrisch-neurologische Wochenschrift, 18, 262-5, 275-7 (1916/17). 12. On the history of the concept of neurasthenia, see: Gjiswijt-Hofstra and Porter, 2001;[START_REF] Radkau | Das Zeitalter der Nervosität[END_REF]. 13. Paul Lerner (2003: 33) explains Oppenheim's defeat at this Conference with the fact that, according to his approach, the 'war neurotics' would have had to be discharged from duty on a pension just like soldiers who had suffered physical injuries. 14. In fact, as Lerner (2003: 33) points out, the number of post-traumatic pension applications never exceeded 1-2% of all accident insurance claims. 15. See, e.g., Gaupp's speech on 22 Sept. 1916, reported by Mendel (1916: 797). 16. [START_REF] Berger | Die Beratenden Psychiater des deutschen Heeres 1939 bis 1945[END_REF] quotes the 'Richtlinien für das Sammeln kriegsärztlicher Erfahrungen ', 10 October 1939, Bundesarchiv-Militärarchiv Freiburg (RH 12-23, H.20/488). 17. Decree issued by the Oberkommando der Wehrmacht (Supreme Commander of the German Army), 30 June 1944; see Roth, 1987: 68. 18. Best known is the lawsuit against the Vienna psychiatrist and neurologist Julius Wagner-Jauregg, in which Sigmund Freud testified as expert witness [START_REF] Eissler | Freud and Wagner-Jauregg vor der Kommission zur Erhebung militärischer Pflichtverletzungen[END_REF].

Notes


Keywords: history, mortality and morbidity from mental illness, psychiatry, rates of detention, service utilization, 19th century, 20th century

The 1896 and 1996 populations of North-West Wales are similar in number, ethnic and social mix and rurality, enabling a study of the comparative prevalence of service utilization, as well as the morbidity and mortality associated with mental illness in 1894-96 and 1996. The 1996 data reveal a 15 times greater prevalence of admissions for all diagnoses, and three times greater prevalence of admissions by detention, compared with 1896. Patients now spend more time in a service bed than they did 100 years ago. Death as a direct consequence of mental illness is commoner now than 100 years ago. There is therefore a major disjunction between the rhetoric and the reality of mental health service utilization. General factors related to changing health care and expectations and specific factors linked to mental health appear to have led to an increased rate of service utilization in the modern period.

Introduction

From 1955, following the introduction of chlorpromazine, this inpatient figure started falling rapidly and progressively, resulting in a graph with its apex at 1955. This image dominates psychiatric practice today. Politicians may not have closed the asylums because of evidence such as this but, when required to justify their actions in closing the asylums, this is the evidence that is appealed to. This is also the evidence that, more than any other, is portrayed in the media as the basis for our current supposedly communityoriented policies of care towards the mentally ill [START_REF] Porter | Madness: A Brief History[END_REF].

The argument that a range of administrative changes happening in the asylums at the time might have contributed toward this decline have little impact. Few know, for instance, that after the introduction of chlorpromazine the asylum population in Japan quadrupled -indicating that there is no necessary connection between the new biological treatments in psychiatry and de-institutionalization [START_REF] Healy | The Creation of Psychopharmacology[END_REF]. The image of a graph with its apex in 1955 remains the image that commands the intellectual high ground and dictates both clinical practice and research priorities.

The North Wales Hospital was no exception to the general United Kingdom pattern. From the year of its opening in 1848 through to 1948, the inpatient population in the North Wales Hospital rose exactly in parallel with the general rise in the asylum population. But, in contrast to elsewhere, for a number of reasons the asylum and psychiatric services in North-West Wales offer opportunities to establish what was happening in Western psychiatry between 1840 and the present day. First, compared with elsewhere, NW Wales did not have a general increase in its population over this period. A census of the population broken down by age in 1891 showed that there were 232,000 people, and in 1991 there were 241,000 in the same area. For the critical age groups between 15 and 55, the respective populations were 117,000 and 119,000 people. Second, while there has been a shift in populations, so that it becomes uncertain whether it is possible to compare admissions to a rural asylum 100 years ago with admissions to an urban DGH Unit now, this did not happen in NW Wales.

Third, in other areas a variety of geographical and financial factors make it difficult to determine if those who accessed a service a century ago or do so today are representative of the whole population of the mentally ill, but geography and finance have conspired in NW Wales to ensure that patients effectively had only one point of access to services in both 1896 and 1996. Any geographical map of North Wales makes it clear that the areas being served are locked in by the Irish Sea on one side and the Snowdonian mountain range on the other. In 1896 it was simply not possible to access easily any other service within a hundred miles, other than the asylum at Denbigh. Similar constraints applied in 1996 with the extra proviso that National Health Service requirements meant that any patients from NW Wales accessing a service elsewhere in the country were liable to be returned for treatment. In 1896 NW Wales was one of the poorest areas of the country, and it remains so today. There was an essentially negligible amount of private practice in 1896, and this was still so in 1996.

These features of NW Wales have permitted us to institute a study of service utilization over 100 years. The first results were reported recently [START_REF] Healy | Psychiatric bed utilisation: 1896 and 1996 compared[END_REF], and we now extend this study by reporting data on lengths of stay in care in the 1896 and 1996 populations, as well as 5-year mortality rates in the two populations.

Methods

In NW Wales there are comprehensive and clear records from the Denbigh Asylum, from its opening in 1848 through to its closure. The historical background to the asylum, the populations involved in this study and the methods of data entry are set out in [START_REF] Healy | Psychiatric bed utilisation: 1896 and 1996 compared[END_REF].

As the number of admissions from NW Wales to the Denbigh Asylum was considerably lower in 1896 than in 1996, we have collected admissions from 1894, 1895 and 1896 into an 1896 sample; the annual figures presented below are means of the figures for these three years.

In the mid 1990s admissions from NW Wales were to a 60-bed District General Hospital (DGH) Unit, the Hergest Unit. At the time of this project, this unit had seven adult mental illness consultants delivering a sectorized service. It was a high morale service with few staff vacancies, a low bed occupancy rate (80%) compared to UK standards and well established and well functioning mental health teams.

Diagnosis

The 1896 and 1996 records from what would now be termed different sectors were given to the sector consultant looking after the geographical area from which the patients would now come. This meant that whatever biases an individual consultant may have applied to the 1996 sample was also applied to the 1896 sample.

The 1896 records contained the details of the behaviour and symptoms which had led to certification, as well as relatively clear descriptions of the mental and physical state of the patient at the time of admission, followed in most cases by detailed notes of the subsequent hospital stay. In the case of patients with prior or subsequent admissions, we were able to track down all earlier records back to 1865, and all further admissions through to 1940. When making a diagnosis on the 1896 sample, the sector consultants had all prior and subsequent records available to them, and accordingly diagnostic judgements were made on the overall career of the patient rather than simply on the details of the presenting mental state.

The 1996 comparative sample consisted of all admissions to a 60-bed DGH psychiatric unit, between 1 April 1996 and 31 March 1997. The area is sectorized with each sector covered by one consultant. Admissions could be through walk-ins, referral from the local DGH, referrals from general practitioners, from the police, from mental health teams or through the sector consultant. Admissions consisted of general adult mental illness cases (childhood, adolescent, learning disabilities and dementia patients went elsewhere). This service had access to support bed hostels, a generous provision of Elderly Mentally Ill (EMI) assessment, respite and long stay beds, and separate services for childhood disorders and learning disabilities.

The traditional methodological caveat about diagnosis in historical epidemiology concerns the validity of diagnoses made on a deceased sample. For the purposes of this argument, however, patients were categorized in such broad diagnostic groups -psychosis, affective disorder, personality disorder, and delirium or dementia -that this factor plays as restricted a role as can be expected in a study of this kind. We have not sought diagnostic refinements beyond these broad groups and we believe the data make it clear that there would have to be some extraordinary bias to overturn the results obtained using this approach.

An unrecognized methodological concern, however, must lie with the contemporary sample. Recent research [START_REF] Bush | Catatonia Rating scale and standardised examination[END_REF] suggests that up to 10% of patients going through a DGH unit today will have catatonic features. Catatonia, which has been obituarized extensively, in fact appears not to have gone away but, incredibly, modern psychiatrists simply do not see quite bizarre and striking features of the mental states of their patients under their noses.

As part of a study to estimate career lengths of stay in psychiatric facilities, we conducted a study between 1 October 1998 and 30 November 1998 aimed at mapping total career bed usage in a cohort of patients passing through the Hergest Unit (see below). Simultaneously, this sample of patients was screened for catatonic features. A comparable group of patients admitted to a regional psychiatric facility in Hyderabad, India, during the course of two weeks in March 1999 was also screened. Both groups had 13% of patients with catatonic features. Modern diagnostic procedures, it seems, do not capture these clinical features.

Analysis of data

We first compared the per annum admission rate in the 1896 and 1996 samples. We defined admission prevalence as the number of individuals admitted in a one-year period. Second, we examined the hospitalized incidence rates for schizophrenia, non-affective disorder psychoses and bipolar disorders. Third, we calculated the length of stay of patients and the numbers of prior admissions.

Fourth, we sought figures for both mean length of stay and overall usage of service beds by disease cohorts. Finally, we compared recovery, relief and mortality rates from the two samples.

As noted above, there was a similar age distribution between the populations in 1896 and 1996 across the 15-65 age groups, and in particular for the 15-55 age groups. As the 15-65 age groups account for the ages of origin for our incidence figures for syndromes other than dementia, we have only supplied the numerators for the main syndromes.

Based on criteria used in the 1896 sample, we developed operational criteria to categorize the course of the illness. In both 1896 and 1996 samples, there were four possible outcomes for patients. They could be discharged 'recovered'; such patients had to have less than 3 admissions in the 3 years prior to the first admission, to be discharged home with a clinical diagnosis of recovery recorded in their notes and no admission during the year after discharge. A second possibility was to be discharged 'relieved', in which case the clinical notes recorded that the acute symptoms had passed but the patient was not back to normal and was discharged to a hostel (1996) or to the workhouse or lodgings (1896). Such patients characteristically had 3 or more prior admissions in the 3-year-period before the first admission and/or an admission in the year after discharge. A third option was discharge 'not improved'. Finally, patients could die in care. Using these operational definitions, 7 patients designated as recovered in 1896 by their clinicians were re-designated as relieved on the basis of a further admission within a year of their apparent recovery.

In order to compare death rates between the samples, we followed the 1896 patient group after discharge into the community. It was clear from the records that some of those discharged relieved or not improved had in fact been discharged to die. All patients discharged were tracked in the 1896 and 1996 samples to 5 years from the end of the sample period. Rates are therefore expressed in terms of 5-year mortality rates. The 5-year mortality rates of the 1996 cohort were established by following up these patients through to 31 March 2002.

In order to establish the number of bed days occupied in 1896, we accessed all prior records of this cohort of patients and summed their lengths of stay. For the 1996 cohort we adopted the following procedure. In the case of all 112 patients admitted in October and November 1998 in North Wales, as part of the catatonia prevalence study outlined above, we accessed all prior records, and from these established the length of stay in any mental health service bed at any stage in their previous psychiatric career; these beds included hostel beds or any other bed paid for by the health service. From the mean lengths of stay in 1998 and the total length of stay for all bipolar disorder patients as a group, all non-affective psychotic patients as a group, all personality disorder patients as a group, etc., it was possible to construct an index linking length of stay in 1996 with career psychiatric service bed usage for each cohort of patients. Median lengths of stay in 1996 for each diagnostic cohort were multiplied by the length of stay factor for that diagnosis.

Results

At the end of 1896 there were 667 beds in the asylum. Patients from NW Wales accounted for 267 of these. In 1996 there were 60 acute mental illness beds, as well as 66 EMI assessment and respite beds, 8 longstay and 31 hostel beds, and 42 beds in registered residential care. There were a further 216 registered residential care for the elderly beds and an unknown number of other elderly residential care beds. Finally, there were 140 beds in a regional hospital for learning disabilities, of which 56 were occupied by patients from NW Wales.

Details on the numbers of patients admitted in 1896 and 1996 have been provided previously [START_REF] Healy | Psychiatric bed utilisation: 1896 and 1996 compared[END_REF]. A summary of these data and the diagnoses of patients is given in Tables 1 and2. Comparative data on the incidence of service utilization for the major psychosyndromes have also been provided previously [START_REF] Healy | Psychiatric bed utilisation: 1896 and 1996 compared[END_REF].

Comparative prevalence of hospital admissions

The 1896 figure minus dementias (28), organic disorders except GPI (29) and mental handicap (3) gives an average admission prevalence of 48 per annum for functional mental illness from 45 individuals. This contrasts with an admission prevalence of 713 (total minus 24 dementias) from 522 individuals in 1996. There were 6.7 admissions then for every 100 now, a 15-fold increase. The inclusion of dementias and learning disabilities does not shift the ratio in favour of the present day, if the admissions for dementia or learning disabilities to all facilities in 1996 are taken into account. Considering compulsory detentions only in 1996 gives a 3-fold increase compared with 1896.

Focusing on the seriously mentally ill (SMI) groups in both samplesexcluding dementias, organic psychoses, learning disabilities, alcohol and drug dependence, personality disorders and behavioural/neurotic problemsgave 42 individuals per annum diagnosed with SMI in 1896, with a mean age of 40 years; in 1996 there were 294 individuals with a mean age of 48.7 years. Of these 294, 111 had depressive episodes, 114 psychotic episodes and 69 other affective episodes. This is a 7-fold difference in admission prevalence (see Table 2).

In 1896 there were no individuals receiving a contemporary diagnosis of personality disorder, neuroses or behavioural disorders. Retrospective diagnoses yields 4 admissions. In 1996, 49 patients accounting for 83 admissions were diagnosed as having a personality disorder. Fifty-nine patients, accounting for 86 admissions, were diagnosed with a neurotic disorder and 52.5% of these had adjustment disorder; 47% were also diagnosed as having a significant personality component to their problems. Personality disorders and neurotic disorders accounted for 25% of all admissions in 1996. Admissions with a diagnosis of dysthymia (F341) represented a further 2% of the total. In the case of a majority of individuals admitted for substance abuse problems, secondary diagnoses of personality disorder were made. Adding these groups together, admissions with a significant personality element accounted for 40% of all admissions. These figures are in line with those reported by [START_REF] Dowson | Characteristics of inpatients without psychosis. Implications for service provision and the recognition of personality disorder[END_REF].

Comparative recovery, relief and mortality rates

Subtracting from the 1896 totals the 28 dementias and 33 organic disorders, who would not now be admitted to a DGH unit, left 138 subjects. These had a recovery rate of 38%, a relief rate of 23% and a chronicity rate of 17% with a death rate in hospital of 24%. Excluding the 32 deaths, the remaining 106 patients with serious mental illness had a recovery rate of 50%, a relief rate of 30% and a 20% chronicity rate. Of the 1996 sample of 542 individuals, at the point of discharge 193 were deemed to be recovered (36%), 331 were deemed relieved (61%), 2 were transferred to longer-stay facilities. Deaths within DGH units are comparatively rare now. To standardize the mortality from mental illness in 1896 and 1996, it is necessary to follow subjects up over a defined period of time. Following patients with serious mental illness from 1896 into the community, it became clear that from the total cohort of seriously mentally ill patients, 30% had died in a 5-year period from first admission. Many of those discharged relieved had in fact been discharged to die from tuberculosis or other infections contracted in hospital. The final figures for recovery, relief, chronicity and mortality for the 1896 sample based on this 5-year follow-up are shown in Table 3.

A similar exercise for the 1996 sample produced a 14% 5-year death rate and outcomes as laid out in Table 3. The greatest number of deaths in the 1996 sample came predictably from older patients in the age range over 70. However, a substantial number came from the 15-to 55-year-old age groups (N = 24; 4.4%). Of these the greatest single cause of death was death by suicide (9) followed by death from an illegal substance overdose (3). In total, therefore, in these age groups 54% of deaths stemmed from the patients' mental illness.

In scrutinizing 2892 records from NW Wales between 1875 and 1915, there were only 3 inpatient suicides and two suicides from patients recently discharged; the hospital recorded all suicides of patients who were discharged against their advice. The recent United Kingdom survey of suicides in psychiatric patients suggests that a comparable volume of patients today would give rise to 10 inpatient suicides and 240 suicides in the course of the year following discharge. Standardizing for length of stay might be expected to yield up to 100 inpatient suicides from a comparable volume 1996 sample (Department of Health, 1999).

Comparative lengths of stay

Table 4 gives the average number of prior admissions per patient for both 1896 and 1996 samples. It is clear that there is a substantial increase in the admission rate for the 1996 sample. Against that can be set comparatively briefer hospital stays in 1996.

In 1896, 84% of the patients were admitted for the first time. Of the total sample, 16% had a previous admission and 14% a subsequent one. From the serious mental illness group, 47 (58%) were admitted for the first and last time in 1896, while the remaining 33 (42%) had other admissions. In 1996, 25% of patients were admitted for the first time. Of the 737 admissions, 195 were repeat admissions that year (26%). Of these, 130 patients were readmitted once during the 12 months of the study, 47 were readmitted twice, 14 three times and 5 on more than 4 occasions. In addition, 311 patients had a previous admission (60%) and 110 had at least one subsequent admission to the Hergest Unit (20%). This figure excludes those patients referred to the day hospital, support bed units or EMI units after discharge from the acute services. Of the 294 SMI individuals in 1996, 24% were first admissions. The remaining 76% had up to 3 previous and/or up to 3 subsequent admissions or were referred to support bed facilities after discharge. Table 4 presents the mean length of stay of patients from different diagnostic categories during the course of their stay in hospital, including stays beyond the study period. This table also presents data using the index detailed in the Methods section. In the case of the 1896 sample, it has been possible to produce a reliable figure for bed-days occupied by each diagnostic cohort. In the 1996 cohort, the extrapolation yields figures that hold up to the end of 1996. These patients will go on to spend a further period of time in hospital. Ongoing analysis of the bipolar cohort of patients in the period from 1875 to 1914 compared with the modern period supports the validity of the figures drawn from this sample.

Discussion

This analysis extends the previous analysis of this database by offering figures on the length of stay of modern patients and their mortality rates. It does so in sets of historical and modern populations of service users almost completely free from economic or clinical selection factors.

As regards length of stay, the figures can be expressed as follows. Where an annual cohort of patients with schizophrenia were likely to spend 400 years (1896 cohort days scaled up to 1 million people) in a hospital bed in 1896 per million population, every million people today will have a schizophrenia cohort who at the time of writing will have already spent that length of time in a service bed and this cohort will spend several hundred more years in a service bed before they die. In the case of depression, any million population will have in their midst a cohort of depressed patients who have already spent 1000 years in a service bed. This cohort will spend a great deal more years in service beds before they die.

As regards mortality rates, it appears that, while patients in 1996 are less likely to die in the 5-year period after admission to a psychiatric facility, they are more likely to die eventually from their mental illness than they were in 1896. These figures are so much at odds with the contemporary rhetoric of mental health service delivery that they call for explanation.

First, there is the rather obvious point that the treatments we now have relieve rather than cure the conditions for which they are given. In 1956, just after chlorpromazine had been introduced, the NIMH organized a symposium under the auspices of Jonathan Cole and Ralph Gerard to discuss how to evaluate the impact of treatments like chlorpromazine and how to progress new drug development. The meeting endorsed the need for randomized trials, rating scales and all the paraphernalia of modern psychiatry [START_REF] Cole | Psychopharmacology: Problems in Evaluation[END_REF]. A rare dissenting view came from Evarts of the NIMH who argued that, but for some accidents of history, chlorpromazine might have been celebrated as a treatment of dementia paralytica [START_REF] Evarts | A discussion of the relevance of effects of drugs on animal behavior to the possible effects of drugs on psychopathological processes in man[END_REF]. If asked to build on chlorpromazine's utility for dementia paralytica, the field would then be advocating clinical trials and rating scales and drug development approaches of the sort that were being proposed for chlorpromazine in schizophrenia. This, he argued, would have produced a therapy, research and pharmaceutical establishment that probably would have been inimical to the recognition of the fact that penicillin rather than chlorpromazine was the cure for dementia paralytica. The figures from this study suggest that mental health services may have fallen rather dramatically into the pit that Evarts outlined in 1956.

In the light of these data, the changes demonstrated in RCTs for modern treatments stand quite clearly as evidence of treatment effects rather than evidence of efficacy. Modern treatments clearly allowed the discharge of many chronically hospitalized patients in the 1950s and 1960s, and contribute to shorter lengths of stay now than formerly, but from the start the use of these same treatments has been associated with an increased number of readmissions, a proportion of which may be associated with discontinuation syndromes or other complicating factors linked to treatment rather than illness relapse [START_REF] Battegay | Forty-four years of psychiatry and psychopharmacology[END_REF].

Modern treatments therefore appear to have set up a revolving door. As a consequence, a more accurate image of mental health service delivery to the image of hospital populations that has its apex in 1955 would be a graph showing a steep rise in admission rates, starting in the 1950s and possibly reaching a plateau in the 1980s. In this regard, the findings from our study have been replicated in other studies [START_REF] Mulholland | To Comfort Always[END_REF]. The current study offers an element of quantification lacking in other studies.

A second factor is the professionalization of care-giving during the period under consideration. If this professionalization plays a part in the growing number of admissions in mental health, then that increase might be reflected in an increased number of admissions to the rest of the medical services. In Wales in the period from 1955 to 1997 there was an increase in discharges and deaths from mental illness beds from 5656 to 17,588 per annum. In the rest of the medical services generally, there was an increase from 171,430 to 503,073 [START_REF] Healy | Psychiatric bed utilisation: 1896 and 1996 compared[END_REF]. The rise in admissions in psychiatry, therefore, was in line with -albeit slightly greater than -that happening in the rest of medicine.

During this period we have made drugs available on prescription only and have otherwise forced patients through a funnel in order to access medical care. It may well be that the true incidence and prevalence of the serious mental illness was just the same in 1896 as now, but that service utilization is dramatically greater now. Indeed, as the increase cuts across all illness groups, it seems less likely to stem from a change in the virulence of the illnesses and more likely to stem from other factors. These data offer some support to Scull's thesis that increased psychiatric bed occupancy/usage reflects an extension of services rather than an increase in hospitalized incidence of the index conditions [START_REF] Hare | Aspects of the epidemiology of schizophrenia[END_REF][START_REF] Scull | Was insanity increasing? A response to Edward Hare[END_REF].

However, while there may be a general factor affecting both mental health and general medical services, a greater proportion (up to 30%) of general medical service contacts stem from a rising old age population, with an associated set of morbidities, and this is not found in psychiatry. In contrast, there is apparently an explosion in the apparent incidence of mental disorders in young persons, with depression and ADHD leading to a much greater increase in mental health service utilization than is found among young persons for general medical service utilization.

As regards differences in length of stay in hospital between the two periods, the first admissions were considerably shorter in 1996 than they were in 1896. However, patient cohorts appear to spend longer in a service bed now than they did 100 years ago. This might arise for a number of reasons. First, there is an earlier onset of service utilization for the functional psychoses in the modern period. Second, aside from the flagship DGH beds, mental health services provide a range of community, hostel or other longterm hospital beds that are not typically factored into calculations of bed usage -although the increase in service usage proposed here holds true even when comparisons are limited to DGH unit beds only. Third, notwithstanding an increased rate of death by suicide, patients now are likely to live longer than they did in 1896.

The critical question, then, is whether the service utilization we have now is a good thing. In the rest of medicine iatrogenic injury and death is recognized as being one of the leading causes of injury and death [START_REF] Lazarou | Incidence of adverse drug reactions in hospitalised patients[END_REF]. It is clear from the figures reported here that in some respects this holds true for mental illnesses also. To what extent we simply do not know. The rhetoric of service delivery appears to preclude such considerations. There is some evidence, however, that life expectancy for schizophrenia has been falling in recent years [START_REF] Osby | Time trends in schizophrenia mortality in Stockholm County, Sweden: a cohort study[END_REF], and considerable evidence that modern antipsychotic drugs may lead to increased rates of suicide in schizophrenia (Healy, Harris, Tranter, Gutting, Austin and Roberts, in press).

The figures on mortality from mental illness in the nineteenth century reported here update the paradigmatic figures reported by William Farr (1975), who found death rates of 11% for patients of the better classes, 12% for paupers in Hanwell and up to 21% for paupers in other establishments (Healy et al., in press). Our 30% 5-year mortality figures for serious mental illness come from a population that had a 12% mortality rate in the year after admission. Grim though these figures are, when set against the modern comparator figure of a 14% mortality rate over 5 years the figures from the 1890s do not look bad, if it is taken into account that effective antibiotics would have led to a dramatic drop in the 1896 mortality figures.

One surprising aspect of the 1896 data is the relatively good recovery rates, which bear comparison with modern rates. Several factors may account for this. First, the availability of mental health teams today is trumpeted as a means of keeping patients out of hospital, but the regular monitoring of changes in mental state in current climates of risk management are always liable to lead to admissions that might have been less likely 50 years ago. This is particularly the case given a comparative destigmatization of mental illness. Second, the assumption that patients admitted earlier or with less severe problems should be easier to 'cure' may in fact not hold true. Third, the quality of modern remissions may not be as secure as we like to think, or alternatively we have become more demanding about the quality of clinical responses. Finally, current treatments may increase rates of relapse either in patients remaining on treatment or in those who discontinue and have consequent withdrawal-induced disturbances.

This study of service utilization factors makes no attempt to get at any 'real illness entities' that may underpin utilization. In one sense, studies like this will always resemble post-mortems, in that both are as likely to indicate what social bodies in the one case and human bodies in the other can live with, as they are to reveal what has afflicted them.

Whatever the relation between increased service utilization and illness entities, the relationship between service utilization and the number of psychiatrists is one that is amenable to further investigation. There were, for example, no forensic psychiatrists in Britain in 1966 whereas there are now over 250. This increase parallels an increase in the number of patients now locked up in secure facilities compared with 1966. Just as the increase in the number of cardiologists and cardiac surgeons leads to an increasing number of coronary artery bypass operations and other such procedures despite an absence of evidence that many of these procedures are effective, it might be naïve to think we could have expected that a massive increase in the number of psychiatrists would ever lead to anything other than the treatment of more patients than ever before.

  Psychiatric texts regularly contain graphs showing that the hospital population of mental hospitals in the Western world rose from the time of the opening of History of Psychiatry, 16(1): 027-041 Copyright © 2005 SAGE Publications (London, Thousand Oaks, CA and New Delhi) www.sagepublications.com [200503] DOI: 10.1177/0957154X05044604 the asylums around the 1840s through to 1955. The inpatient population in the UK rose progressively year on year despite changes in legislation such as the Lunacy Act of 1890 or the Mental Treatment Act of 1930 and despite a range of other psychosocial interventions of one sort or the other. By 1955 the inpatient population in the UK stood at 155,000 people.

Notes 1 .

 1 North Wales Department of Psychological Medicine, University of Wales College of Medicine, Bangor, UK. 2. School of Social Sciences, University of Wales, Bangor, UK.

TABLE 1 .

 1 Retrospective diagnosis for patients admitted in 1894-96 compared with contemporary diagnosis for patients admitted in 1996

	ICD-10 diagnosis			1894-96					1996
		F	M	T otal no. No. p.a. % of total	F	M	Total no.	%
	Dementias (F00-03)	5	23	28	9.3	14.3	15	5	20	3.7
	Organic disorder (F04-09)	11	22	33	11.0	16.8	5	5	10	1.8
	Alcohol/drug related disorder (F10-19)	-	2	2	0.7	1.0	33	63	96	17.7
	Schizophrenia (F20-20.9)	16	11	27	9.0	13.8	17	41	58	10.7
	Delusional disorder (F22-22.9)	3	4	7	2.3	3.6	10	14	24	4.4
	Other psychoses (F23-24, F28-29)	-	5		1.7	2.5	8	15	23	4.2
	Schizoaffective disorder (F25)	-	2	2	0.7	1.0	4	5	9	1.7
	Manic episode (F30-30.9)	13	15	28	9.3	14.3	12	6	18	3.3
	Bipolar disorder (F31-31.9)	10	10	20	6.7	10.2	25	12	37	6.8
	Depressive episode (F32-F33.3)	23	14	37	12.3	18.9	71	40	111	20.5
	Mood (affective) disorder (F34)	-	-	-	-	-	8	6	14	2.6
	Neurotic disorder (F40-49)	2	-	2	0.7	1.0	32	27	59	10.9
	Psychol. /behav. disorder (F50-59)	1	-	1	0.3	0.5	8	1	9	1.7
	Personality disorder (F60-66)	-	1	1	0.3	0.5	22	27	49	9.0
	Mental handicap (F66.1)	3	-	3	1.0	1.5	1	1	2	0.4
	No F classification	-	-	-	-	-	-	3	3	0.6
	Total	87	109	196	65.3	100.0	271	271	542	100.0

TABLE 3 .

 3

	5-year recovery, relief and mortality rates,
		1896 and 1996
		1896 sample	1996 sample
	Recovered	37%	30%
	Relieved	16%	52%
	Chronically hospitalized	17%	4%
	Dead	30%	14%

TABLE 4 .

 4 Average number of admissions/patient, mean length of stay in days (LOS) by diagnosis and total LOS per diagnostic cohort in1896 and 1996

			1896			1996
	Average no.	Median Career LOS/ Average no. Median Interim
	admissions/	LOS/	cohort to	admissions/	LOS/	career
		patient	patient	death or	patient	patient	LOS/
				final			cohort
				discharge			to death
							or final
							discharge
	Schizophrenia	1.4	817	31729	6.9	37	27394
	Other psychoses	1.4	236	10417	4.1	25	41496
	Bipolar disorder	2.7	265	9700	6.5	40	34839
	Depressive episode	1.1	204	12991	3.5	22	82251
	Personality disorder*	1.5	236	13194	3.3	11	66290

* Here, this includes personality disorder, neurotic disorders and substance misuse