The recent Eighth World Congress of the World Psychiatric Association (WPA), held between 12 and 19 October 1989 in Athens, was reminiscent of the previous World Congress in 1983 in Vienna, and the one before that in 1977 in Honolulu. Once again the issue of the Soviet political misuse of psychiatry reared its ugly head, and dominated the Association's proceedings. In 1977 the critical debate revolved around what position the WPA should adopt concerning the abuse. In a cliff-hanger vote, the WPA passed a resolution condemning the political misuse of psychiatry but explicitly citing the Soviet case (Bloch & Reddaway, 1984). In the absence of any improvement in the situation by the time of Vienna and in the virtual certainty that the Russians would have been expelled from the organisation, the Soviet Psychiatric Society resigned from its membership in January 1983. In order to forestall a precipitous and premature readmission, the Royal College of Psychiatrists proposed at the Vienna Congress that the Soviets would be welcomed back into the fold but only when they had demonstrated “sincere co-operation”, and when there had been concrete evidence of “amelioration” of the abuse.

In October, public attention focused on psychiatrists gathering for the Eighth World Congress in Athens. Was psychiatry still being abused for political purposes in the Soviet Union (Bloch, 1990)? And were mental patients elsewhere being mistreated? At the Stadium of Peace and Friendship overlooking the Aegean Sea, delegates had the chance to meet and talk about these important issues concerning human rights and human dignity.

Psychiatry is unique in already being subject to statutory external audit through regular visits to psychiatric hospitals and units by the Hospital Advisory Services and Mental Health and Mental Welfare Commissions. These organisations do comment on aspects of the standard and quality of care. Reports of their findings undoubtedly facilitate change. By their programme of repeated visits they are in a position to observe the implementation and outcome of altered patterns of practice brought about by their reports. The Codes of Practice being prepared by the Mental Health Commission (England and Wales) and Mental Welfare Commission (Scotland) is another step that will significantly influence clinical practice. Finally, the Royal College of Psychiatrists' postgraduate training scheme accreditation exercise, like those of the other Royal Colleges and Faculties, has had an impact on quality of clinical care through its policy of gradually increasing the standard of postgraduate clinical training requirements. Locally based audit clearly complements these external exercises and local psychiatric services are now expected to organise systems of regular internal audit as are the other clinical disciplines (Department of Health, 1989).

There has been little economic evaluation of the costs of closing long-stay institutions. Studies that have been undertaken have rarely had the opportunity to study the before and after effects of complete closure. Most attention has focused on the mentally ill not the mentally handicapped. This study followed a sample of residents leaving Darenth Park Hospital which was closed in 1988.

A need for improved communication between the social sciences and psychiatry is being expressed from many quarters. Interest in social and cultural issues is not, of course, new to psychiatry, but collaboration between the two approaches has not always been easy. Recently one social science in particular has become popular with psychiatry. This is social anthropology, and many psychiatrists consider that the inclusion of anthropological data and methods, particularly in cross-cultural research, can be useful and informative to psychiatry. What then is the relationship between anthropology and psychiatry and what are the problems which professionals face in attempting interdisciplinary research?

In daily clinical practice, out-patient non-attendances are, unfortunately, regular occurrences. With the current trend towards community based care, out-patient facilities have become increasingly important, and the failure of patients to attend is both disruptive and worrying for professionals in this area. It is difficult to predict which of the non-attenders will progress to join the ranks of those “lost to follow-up”. This study was conceived in an attempt to clarify this question, in the setting of adult general psychiatric out-patient services.

The growing realisation that health care resources are limited has led to increasing concern about the wastage caused by the failure of patients to keep their psychiatric appointments. Generally, non-attendance following psychiatric referral is particularly high (e.g. Baekland & Lundwall, 1975), although in the north-east of Scotland the rate is roughly similar to those reported by other specialties (Alexander & Hillis, 1989). However, little effort has been made to elicit the views of non-attenders themselves or to consider what aspects of the referral system may contribute to this failure to attend.

Recent papers regarding failure to keep appointments at child psychiatry clinics (Plunkett, 1984; Gould et al, 1985; Cottrell et al, 1988) suggest from 15% to 50% failing to keep their first appointments. Benson, Novick & Rembar (1981) calculated an attrition rate of 85.4%, obtained by considering cases of non-agreed termination of treatment at any stage of the referral/treatment-uptake process.

Out-patient clinics are widely used to asssess and treat patients. In psychiatric practice, out-patient clinics are used both to assess new referrals and follow up existing patients. More than three-quarters of psychiatric out-patient attendances are for follow-up (DHSS, 1984). With modern emphasis on community psychiatry, the role of out-patient clinics may become less prominent and more refined. Very little appears to have been published on the subject of psychiatric follow-up clinics.

The Mental Health Services have been accused of providing a ‘soft option’ to offenders and this charge is highlighted in cases where the mentally disordered offender absconds (hereafter called the absconder) from the hospital. Society just about manages to accept the disposal of disturbed offenders to hospital, which it sees as providing at least some limited incarceration, but in the event of an offender absconding the whole dilemma of offenders considered to be in need of treatment is thrown into question. The Responsible Medical Officer (RMO) is concerned with issues of treatment, public safety and his/her responsibility to the Courts and society; and thus finds himself/herself in the conflicting roles of a doctor and an agent of social control. This paper attempts to address some of the issues surrounding the areas of the rights of the patient, the dilemma faced by the clinicians and the rightful use of the powers of the doctor and of the State in relation to Hospital Order and the absconder.

Bereavement counselling is one of the few examples of preventive psychiatry to have proved its worth in well conducted random allocation studies (Raphael, 1977; Parkes, 1981). If, as the work of Paykel (1974) and Brown & Harris (1978) suggests, major losses are the life events most often associated with the onset of clinical depression, then psychiatrists would do well to involve themselves in the work of any organisation which aims to meet the psychological needs of the bereaved.

Thailand, unlike many Asian countries, never experienced colonial or imperial subjection and thus lacked the portal through which psychiatric services usually gained entry. As a result, progress in this field was initially slow. The first mental hospital was established in 1889, a century later than in India. The country has been fortunate inasmuch as it has been spared involvement in the wars, revolutions, and other social upheavals that have plagued Asia in the 20th century. Recent national stability and impressive economic growth have provided a sound base for the development of health services, and progress has been rapid in comparison with many neighbouring countries. Due attention has been paid to family planning, maternity and child welfare services. The provision of comprehensive primary health care in urban and rural areas is improving all the time. The education of children is universally regarded as important. Schooling is compulsory and attendance satisfactory.

The Dutch have a tradition of tolerance and pragmatism in the fields of social policy, and nowhere is this better illustrated than in their policy and practice in the field of drug misuse. Indeed often exaggerated accounts of Dutch ‘liberalism’ are promulgated, and articles in the press have suggested a backlash is now occurring in Holland to these ‘progressive’ policies (Williams, 1989). The award of a Council of Europe Fellowship gave me the opportunity to spend two weeks in the Netherlands in October 1989, visiting drug services and talking to a wide range of people with responsibilities for such services. I was particularly interested to see how the Dutch were responding to the challenges of HIV infection in drug users (Fleming, 1989).

Medical practice can be reframed in terms of research and teaching, possessing and using the relevant knowledge, skills and attitudes. The doctor's curiosity and the diagnostic challenges of medical practice (and in particular of psychiatry) demand a capacity to think systematically, measure comprehensively and accurately and analyse the information obtained within the consultation as a preamble to management and treatment. The word ‘doctor’ means ‘teacher’ and the same communication skills are essential to both professions. Psychiatric practice is especially dependent upon them. They are also often essential for good clinical research.

The role of the clinical tutor may differ from that set out in the helpful guidelines given by the Royal College of Psychiatrists. It may differ depending on the setting of the training for instance. I was made clinical tutor some three and a half years ago for a large, mainly rural area – North Wales. The area does not have its own medical school, but is associated with the University of Wales College of Medicine, at Cardiff, some 150 miles away.

I was appointed clinical tutor at Knowle Hospital seven years ago with little idea of what my responsibilities would be. From the College literature (which I have not found very helpful) it seemed I was responsible in a more or less indirect way for the psychiatric education of most of those working in the hospital as well as of those local general practitioners who might refer patients here. In addition, all medical students in the place are my responsibility – a considerable number of young people. To complicate this task, our academic unit had moved out of Knowle two years before my arrival and new trainees were advised that Knowle Hospital (usually described as a ‘traditional Victorian mental hospital’) would be closing in the near future as modern community services were provided. Finally, the advent of proper management, welcomed by me, was spoiled by an indifference to psychiatric education which bordered on absurdity.

Horton Hospital, Epsom, has many claims to fame; but none so worthy of communication than the unique contribution towards the relief of suffering made by the Horton Laboratory, the name by which it became universally known.

A psychiatrist's interest in human suffering is not restricted to daily work. Trainees in Oxford, asked to pick out six novels which had been important to them, chose books concerned with “alienation, sexuality and suicide” (Harrison & Day, 1988). Respondents to such a survey in the future might well include The Comforts of Madness (Sayer, 1988), surprise winner of the Constable Trophy for fiction in 1988 and subsequently the coveted Whitbread prize. It is former psychiatric nurse Paul Sayer's first book. He started writing in his twenties after taking a break from nursing to run a corner shop with his wife. In his spare time he read. He explains, “I was standing in the corner shop one day, and I just felt this urge to write” (Winder, 1989). He returned to nursing and at the same time, started to write about a world that was familiar to him.