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A documentary survey of a national sample of males aged 25-34 on their first admission to a mental hospital in England and Wales for schizophrenia showed the usual excess of patients in social class V. However, the social class distribution of the fathers at the time of the patients' birth was very similar to that of the population as a whole. A clinical study of a representative series of consecutive admissions of male schizophrenics aged 15-30 living in a socially mixed area in outer London confirms these findings. It shows decline in occupational status both from father to son and in the patients' own history. The main evidence of individual downward "drift" is the ability of schizophrenic patients to win places at grammar schools, though they end in semi- or unskilled jobs. The employment histories showed that in their adolescence many patients pursued varied careers, a considerable proportion aiming at professional or technical jobs; they still fitted broadly with the career expectations of their home environment. The discrepancies in social performance between father and son could be mainly attributed to the disease process. Patients whose illness had an insidious onset at adolescence did not attain any professional or technical skill; those whose illness started acutely before admission dropped in social class shortly before admission; while those who were mentally subnormal as well as schizophrenic did not achieve any level of skill at all. This social drift appears to affect the highest and lowest social classes most severely. Only one patient out of 13 grammar school boys attained social class I or II status, and over half of those in social class V had dropped out of the labour market by the end of the survey. On the other hand, two-thirds of the patients in social classes III and IV survived in jobs requiring a moderate degree of skill. These findings suggest that gross socio-economic deprivation is unlikely to be of major aetiological significance in schizophrenia. On the other hand, occupational factors, yet to be defined clearly, appear to exert some influence on the course of the disease.

Following a consecutive series of male admissions under 30 from their admission to a district mental hospital for a mean period of 32 months, length of stay in the mental hospital was related to severity of illness, to work performance before and after hospital admission and to home circumstances before and after admission. Since this was a detailed clinical investigation, numbers have been too small for proper statistical treatment or for studying the effects of two or more factors in combination. Nevertheless, the findings are in general agreement with other work and point to the need for further studies of young schizophrenic patients. In Part I it was shown that: 1. Severity of illness was of importance in distinguishing the schizophrenic patients from patients suffering from other conditions. 2. Those who had been in regular work until shortly before admission spent a considerably shorter period in hospital than those who had worked very little or had long spells of unemployment. 3. There was no direct relationship in the schizophrenic group between the patients' work performance after discharge and the length of stay. Those who worked well had on average stayed almost as long in hospital as those who did practically no work at all. The explanation may be that those who worked well often had a long period of rehabilitation and work in hospital; while those who did no work at all had often discharged themselves prematurely against medical advice. 4. The more unfavourable the home, in terms of family relationships and presence of mental disturbance in other members of the family, the longer the stay in hospital. These findings suggest that ( a ) unfavourable home circumstances and ( b ) prolonged unemployment before admission may be predictive of a prolonged stay in hospital. On the other hand, a longish stay in hospital is not necessarily indicative of poor prognosis, since the ability to co-operate in hospital treatment and to establish regular work habits may well lead to a successful re-establishment in the outside world even if home circumstances are unfavourable. In Part II of the Study the patients' ability to work after discharge was considered in relation to various personal and social factors. It was shown that: 1. In both the schizophrenic and non-schizophrenic groups the majority of patients who worked for more than 75 per cent. of the time they were out of hospital had also had a good work record before their admission. 2. In both groups the majority of patients who appeared to be well at follow-up had a good work record after discharge. While in the not schizophrenic group a good work record was practically synonymous with recovery, this was not necessarily so in the schizophrenic group. 3. In both groups most patients who maintained a good work record started work with in one month of discharge. 4. Schizophrenic patients worked most steadily when they returned to their old jobs, or when their work was arranged while in hospital. This did not apply to the non-schizophrenic patients, who were more often capable of finding jobs for themselves. 5. The work performance of schizophrenic patients who returned to their parents was worse than that of those who went to other kin or into lodgings. This difference was not related to the severity or chronicity of the illness. The work performance of the non-schizophrenic group did not appear to be affected by the type of living group to which they returned. Disturbed family relationships and mental ill health among relatives were associated with poor work performance in the schizophrenic group. The non-schizophrenic patients appeared to be less affected by the disturbances in their home environment. These findings suggest that while both the stability of work habits before the onset of illness and the degree of recovery contribute to the schizophrenic patient's ability to work in the community, social supports after discharge are also of importance. Among these supports are the speed and smoothness of transition from rehabilitation to work, realistic expectations on the part of those with whom the patient lives, and an environment reasonably free from persistent unresolved emotional conflict. This last is thought to be a crucial factor and will be treated in greater detail in a subsequent paper. Several questions arise from these findings. Could the patients with long periods of unemployment before admission to hospital have been diagnosed and treated earlier? Could more skill and effort be devoted to the employment problems of schizophrenic patients both before and after discharge? Is it possible to modify the unfavourable home circumstances associated with poor functioning in schizophrenic patients? Any consistent attempt at this would involve considerable social work resources. Should more schizophrenic patients be encouraged to live away from their parental homes? This would entail more provision of hostel or lodging accommodation. Controlled experiments might demonstrate the effectiveness of these social measures in improving the functioning of young schizophrenic patients and in preventing frequent re-admissions to hospital.