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The third approach, the longitudinal study, is themost expensive and time-consuming of the three butthe most likely to yield valid results. Longitudinalstudies are few in number. One such is that of Cobb and

Kasl," who followed two workforces for two years andstudied the psychological stresses associated with

anticipating unemployment and then becomingunemployed.Case-studies are investigative tools that do not fit into

the above classification. In these a great many data are

gathered from a few people. Case-studies can be usefulwhen a new area is to be examined because they mayfacilitate the generation of hypotheses which shouldthen be tested. The best known is Fagin’s studyl2 of 22families with an unemployed male breadwinner. Thiswas intended as a pilot study. Some interesting findingson psychological changes emerged but Fagin wascareful not to make broad generalisations. As is the

’

danger with all case-studies this work has now beenabsorbed into the mythology of unemploymentresearch and is widely cited as having producedsubstantive findings rather than merely being a sourceof ideas.

It is not here possible to review all the publishedwork on unemployment and its effects on mental

wellbeing, but enough has been said to indicate thatthere are serious difficulties in combining and

interpreting evidence in this sphere. Many questionsremain unanswered.13 Not the least of these concernthe instruments used to measure psychological ill-health and the ways by which these measurements maybe translated into readily assimilated incidence andprevalence data. There are here profoundphilosophical and methodological difficulties, 10related in particular to the definition of minor mentalill-health. Great care needs to be taken withinstruments that were designed for other purposes.Also, it is not sufficient to show in field studies thatcommonly used instruments give highly correlatedresults. For example, Newson-Smith and Hirsch14found that the product moment correlation betweenGHQ scores and Present State Examination’ 1,16 scoresis around 0-8. This correlation is not as strong as itseems: either scoring system can only "explain" about64% of the variation in the other. This may besufficient consistency for some," but it does not showthat either system is measuring what it purports tomeasure.

Most people already "know" or believe that

unemployment makes people unhappy, leads to

11. Cobb S, Kasl SV. Termination: the consequences of job loss. Cincinnati: United StatesDepartment of Health Education and Welfare (NIOSH), 1977.

12. Fagin L. Unemployment and health in families: case studies based on familyinterviews—a pilot study. London: Department of Health and Social Security, 1981.

13 Kasl SV. Strategies of research on economic instability and health. Psychol Med 1982;12: 637-49.

14. Newson-Smith JG, Hirsch SR Psychiatric symptoms in self poisoning patients.Psychol Med 1979; 9: 493-500.

15. Wing JK, Sturt E. The PSE-ID-CATEGO system, supplementary manual. London:Medical Research Council Social Psychiatry Unit, 1978.

16. Wing JK. The use of the Present State Examination in general population surveys. ActaPsychiatr Scand 1980; 285: 230-40.

17 Bebbington P, Hurry J, Tennant C, Sturt E, Wing JK. Epidemiology of mentaldisorders in Camberwell. Psychol Med 1981; 11: 561-79.

relative poverty, and causes a sense of futility. It wouldbe surprising if these effects did not sometimes causestress and psychological ill-health. What has beenadded by the efforts of research-workers? Good causesdeserve good science, and research-workers must eithershow that they can benefit the unemployed or provethat their work is adding fundamental knowledge.Otherwise the money might better be diverted directlyinto projects of demonstrable benefit to the

unemployed. The scale of unemployment is such thatonly initiatives from the centre can hope to succeed. IfGovernment excuses inaction by claiming that it awaitsthe outcome of research, academics should not

connive. Not for the first time, we conclude an editorialby declaring that "more work is needed". But on thisoccasion we are not thinking of research work.

THE CHALLENGE OF ADDICTION

"MUCH of the responsibility for ensuring his own goodhealth lies with the individual", declared the DHSS in a 1976report.’ Mastery ofour own fate is of course a fine ideal-ifwecan achieve it. But Prof Griffith Edwards, University ofLondon professor of addiction behaviour, in an Upjohnlecture at the Royal Society last week, argued that much thatbefalls us will be determined by social and economic forcesoutside the immediate control of most individuals. He usedthe example of addictions to illustrate the general point that awide range of socioeconomic influences bear on theindividual’s capacity to handle his personal responsibility.The question is how society is to act in our support, and thechallenge is to find a meeting point between individualfreedom and society’s responsibility for building a socialenvironment within which health can be enjoyed by all.

Is it responsible, he asked, for society to continue to allowcigarette advertising and sports sponsorship by cigarettemanufacturers when cigarette smoking is contributing to50 000 premature deaths a year? Cigarettes are an example ofa recreational drug which is embedded not only in socialcustom but also in the national and international economic

fabric, and smoking-related diseases are the most seriouspublic-health issue of our time. The challenge with whichcigarette smoking confronts us, Professor Edwards declared,is the political priority which society will accord to health.Cannabis, once known as the "non-drug of the century",

may not be as free of health risks as was formerly supposed. Itcan cause short-term psychosis, impair driving ability, andreversibly impair short-term memory, and there is evidencethat it may be potentially addictive. As Professor Edwardssees it, the challenge that cannabis exemplifies is the need toensure that debate is adequately informed rather than anautomatic taking of sides-a matter of being for or against"permissiveness" with the real facts of a serious issuedrowned in a sea of rhetoric.Another cautionary tale is to be found in the

benzodiazepine story. Though a fatal overdose is hard toachieve with these drugs and they have few side-effects, it isnow clear that benzodiazepines can give rise to normal-doseaddiction. Withdrawal effects are all too likely to be mistaken

1. Department of Health and Social Security. Prevention and health: Everybody’sbusiness. London: HM Stationery Office, 1976.

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for a return of the original anxiety, with the result thatprescriptions tend to become repeat prescriptions. With theintroduction of the benzodiazepines in the early’60s medicalpractitioners, Professor Edwards observed, rather too easilyallowed themselves to dispense minor tranquillisers as "a pillfor every ill". The challenge to doctors now, he said, iswhether they will continue passively to do this, or whetherthey can educate themselves, and share in the education ofsociety, towards the view that health is not often to be boughtin a bottle of pills.The "social drinker" who wants a society in which people

have the freedom to order their own lives may not care tothink much about the 700 000 people in the UK who are introuble with their drinking. The overall level of drinking is,Professor Edwards added, a legitimate cause for public-health concern, because any increase in this level-and itdoubled between 1950 and 1976-is matched by at least aproportionate increase in alcoholism. If society wants toprevent a further climb in alcohol-related problems, it willhave to seek means of moderating alcohol consumption. Themost readily available control measure is taxation on alcohol,which the Royal College of Psychiatrists in 1979

recommended should be intentionally employed in theinterest of health. Though some would say that eachindividual should set his own limit, it is clear, ProfessorEdwards maintained, that a laissez-faire attitude to thecontrol of drinking results in havoc and misery on a grandscale.With heroin it is not just the present prevalence of use that

is worrying but the rate at which it is rising. Part of the reasonfor this alarming trend is undoubtedly the availability ofcheap imported heroin; but Professor Edwards is convincedthat rearing young people to unemployment and in failingcities has much to do with drug abuse. Breeding people tofrustration or sheer hopeless passivity, he said, puts society atrisk of heroin or glue or any one of a dozen other chemicalmanifestations of a society gone wrong. And he put the heroinchallenge squarely on the politicians. If they get the social andpolitical job wrong, then no amount of customs officers,police enforcement, consultant sessions, or lecturing to

schoolchildren will be able to pick up the broken pieces."Those who from secure positions preach freedom ofchoice", he concluded, "should be very sure that they are notmerely subverting the slogan of freedom in defence of drift,neglect, profit, revenue-gathering and exploitation".

MANAGEMENT OF THE ACUTE BACK

PAIN due to lumbar intervertebral disc prolapse, severeenough to warrant thoughts of surgery, is not the commonesttype of back pain though often taken to typify it. Patients witha disc prolapse are not difficult to diagnose and they have beenthe subject-material for several well-conducted studies. Fore-most among them has been a series from the Ulleval Hospital,Oslo, for which patients, all investigated and consideredsuitable for surgery, were randomly allocated either to

conservative therapy or to an operation.I-3 Current teaching

1 Weber H. Traction therapy in sciatica due to disc prolapse J Oslo City Hosp 1973; 23:167-76.

2. Weber H. Lumbar disc herniation: a prospective study of prognostic factors including acontrolled trial. J Oslo City Hosp 1978; 28: 33-64, 89-113.

3. Weber H. Lumbar disc herniation: a controlled prospective study with ten years ofobservation. Spine 1983, 8: 131-40

on the management of acute disc prolapse owes a great deal tothese studies because of their careful planning and because ofthe duration and completeness of the follow-up. At one year,the surgically treated group had done rather better. After fouryears the advantages of surgery over conservative therapywere less clear, and after ten years there was little difference.Of the original group allocated to conservative therapy, 17out of 66 were subsequently operated on but the improve-ments in the remainder led Weber2,3 to speculate that up to60% of the surgically treated patients may have had an unnec-essary operation. He therefore paid particular attention to theprognostic factors and was, at the same time, studying theeffects of lumbar traction on these patients.

In the past decade, four different techniques for applyingtraction have been studied for their effects on patients withdisc prolapse confirmed by radiculography.4 For all fourmethods, patients were allocated either to traction or to simu-lated traction, the results being assessed without knowledgeof the method used. The authors found no evidence thattraction therapy influenced the course of the disease. Theytherefore discounted any suggestion that it should invariablybe tried before a patient is operated on, but they wereconvinced that traction had a place in the assessment andprognosis. Of the four methods they preferred traction

manually applied.In a study in South-East England, patients with sciatic

symptoms sent for outpatient physiotherapy were the subject-material for a multicentre trial designed to look at the

therapeutic management of a broader diagnostic group thanthat in the Norwegian studies-at a stage before preoperativeinvestigations were called for. 5 Intermittent traction,Maitland’s mobilisation, exercises, and a corset were thetreatments studied, alone and in combination. Each methodhad some advantage over the control treatment but none wasconsistently better than the others; nor did any clearindications or contraindications emerge for any one method.It is therefore tempting to suppose that ifphysiotherapeutiGmethods other than traction had been studied in Oslo, theoutcome might have been much the same-no methodmandatory for the preoperative management of acute discprolapse but all of value in assessment and prognosis.Amongst the criteria for assessing the results in the

physiotherapeutic management trial5 was the need for

subsequent treatment. This was significantly less in patientswho had received a combination of treatments rather than one

technique alone-an added reason for not restricting thephysiotherapist to an evaluation of the patient based on asingle method of treatment, but giving a wider discretion andthus a broader basis for assessment before deciding whetheror not to operate.At a number of centres, preoperative assessment now

includes psychological testing. This tends to have been used,particularly in North America, as a screening technique toavoid operating on "unsuitable" patients rather than as aguide to therapeutic management. One of the screeningtechniques consists of testing for a set of "non-organicphysical signs"’ of what may be called exaggerated painperception. This appears to be something to which back painpatients, in particular, may be susceptible and there are

4. Weber H, Ljunggren AE, Walker L Traction therapy in patients with herniatedlumbar intervertebral discs J Oslo City Hosp 1984; 34: 61-70.

5. Coxhead CE, Inskip H, Meade TW, North WRS, Troup JDG. Multicentre trial ofphysiotherapy in the management of sciatic symptoms. Lancet 1981; i: 1065-68

6. Waddell G, Main CJ, Morris EW, Paola M di, Gray ICM. Chronic low-back pain,psychologic distress, and illness behavior. Spine 1984, 9: 209-13.

7. Waddell G, McCulloch JA, Kummel EG, Venner RM. Non-organic physical signs inlow back pain Spine 1980; 5: 117-25.