Psychiatric emergencies are common and each case presents particular problems and difficulties. This article focuses on one subset of psychiatric emergencies, that of severe depression, and on the role of and use of antidepressant treatments in these conditions. The clinical situations to be discussed in this article include active suicidality, severe psychomotor retardation (with associated problems of hydration and nutrition), affective psychosis, bipolar depression and behavioural disturbance.

One-third of our lives is spent asleep, but the reasons why we sleep are not yet fully understood. Sleep is a state of inactivity accompanied by a loss of awareness and a markedly reduced responsiveness to environmental stimuli. When a recording is made of an electroencephalogram (EEG) and other physiological variables such as muscle activity and eye movements during sleep (a technique called polysomnography) a pattern of sleep consisting of five different stages emerges. This pattern varies from person to person, but usually consists of four or five cycles of quiet sleep alternating with paradoxical (active) sleep, with longer periods of paradoxical sleep in the latter half of the night. A representation of these various stages over time is known as a hypnogram, and one of these derived from a normal control subject is shown in Figure 1. The quiet sleep is divided further into four stages, each with a characteristic EEG appearance, with progressive relaxation of the muscles and slower, more regular breathing as the deeper stages are reached. Most sleep in these deeper stages occurs in the first half of the night.

The scientific study of sleep and its disorders is essentially just a few decades old, but during that time impressive advances have been made in the biological knowledge of sleep. There has been recognition and treatment of a wide range of sleep disorders from which many people in all sections of the population suffer. The common adverse consequences of persistent sleep disturbance (at personal, educational, social and occupational levels) for members of the public at large have become clear (Dement & Mitler, 1993), as have the special risks of such problems to which certain groups are exposed – notably people with chronic psychiatric or physical disorders or learning disabilities.

Sleep disorders are common among elderly people, affecting about 50% compared with about 26% of younger adults. About two-thirds of residents in long-term care have sleep disturbance (Karacan & Williams, 1983; Becker & Jamieson, 1992). This high prevalence of sleep disorders results in excessive daytime napping, fatigue, cognitive impairment, increased psychiatric morbidity and increased prescribing of hypnotics, with an associated increase in mortality (Kripke et al, 1979). Karacan & Williams (1983) quote figures varying from 26 to 100% for the prescribing of hypnotics to residents in institutional care. This has major implications. There is a risk of both accidental and deliberate overdose. There may be interactions with other drugs and a hangover effect can impair daytime functioning. Excessive sedation can make the patient difficult to rouse in an emergency. Dependence may occur and the drugs may further disrupt sleep. They also increase the likelihood of sleep apnoea.

The main aim of genetic counselling is to inform about disorders that may have a genetic basis. The following definition is a helpful starting point:

Do busy psychiatrists need to pay any attention to the history of their discipline? Surely clinicians should concentrate on keeping up-to-date with the latest developments in their field. Medical history may provide amusing anecdotes about practice in the past, but can it inform modern treatment? Such a response, although familiar, seems rather strange, coming from psychiatrists, who, after all, spend their clinical day, taking ‘histories'. By doing so, they seek to understand their patients' problems in the context of their life history. They try to make sense of the present by reference to the past, whether it be events in the patient's childhood, previous conflicts or the individual's genetic inheritance. Given such a perspective, it seems reasonable that psychiatrists might also take an interest in the history of their profession. By attending to the history of its development, its past disputes and its intellectual inheritance, the psychiatrist can reach a deeper understanding of the current state of psychiatry.

Dental disease and psychiatric illness are among the most prevalent health problems in the Western world. While the dental needs of mentally ill people are similar in type to those in the general population (Markette et al, 1975) there is some evidence that patients suffering from mental illness are more vulnerable to dental neglect and poor oral health (Stiefel et al, 1990; Armstrong, 1994). Sims (1987) reports that physical health problems are more common in psychiatric patients. They seem to be poorly recognised by psychiatrists, and oral health is no exception (Hede, 1995). Oral health is an important aspect of quality of life which affects eating, comfort, speech, appearance and social acceptance (Nordenram et al, 1994).

Behaviour therapy, namely exposure and response prevention, has for many years been the treatment of choice for most patients with obsessive—compulsive disorder (OCD). However, at least 25% of patients with OCD refuse exposure and response prevention or drop-out early. Of those who do comply, about 75% make reasonable gains and maintain them in the long-term. This means that 50% of patients who are offered treatment by exposure and response prevention either refuse, drop-out or show little improvement. Many patients find exposure distressing and this is probably the main reason for dropping-out early. Treatment failures tend to be associated with a depressed mood, over-valued ideation, slowness, mental compulsions and severe degrees of avoidance.

Recommendations by Lord Woolf for the reform of the civil justice system in England and Wales include proposals which are already beginning to influence the provision of expert evidence to the courts. Lord Woolf has himself been instrumental in the establishment of an Expert Witness Institute which has caused some controversy in medical circles. It is no coincidence that all of this is happening at a time when the courts are delivering judgments which are particularly critical of some expert witnesses.