This paper describes the prevalence of substance misuse in a population with chronic psychosis and compares the results with staff estimates. Keyworkers were interviewed using validated questionnaires.

The prevalence rate of substance misuse was higher than in the general population but significantly lower than staff estimates. Staff had little specific training or experience in treating substance misuse.

Substance misuse is a significant problem among patients with chronic psychosis. Service providers should ensure than staff working with these patients are adequately trained in the management of this problem.

Antipsychotic medication, an effective treatment modality in the management of psychiatric/behaviour disorders in people with learning disability, is often criticised because of poor clinical practice. Rational and judicious use, subject to evidence-based guidelines and systematic monitoring, is mandatory. A five-year clinical audit programme on the quality of prescribing for this clientele was undertaken.

Significant quality improvement with minimal resource consumption was demonstrated.

Clinical audit facilitates high-quality prescribing: pragmatic and economic, it can easily be integrated into routine clinical practice.

A cross-sectional survey was performed on 318 patients receiving depot medication. The presence or absence of a depot site reaction was recorded by psychiatric nursing staff on a standardised form.

Seventeen per cent of patients were found to have clinically significant depot site reactions. Such reactions were associated with increased frequency of injection and increased total volume of depot administered in the previous 12 months. The severity of a depot site reaction was unrelated to the concentration of depot preparation administered.

Depot site reactions may be reduced by maximising the interval between injections and using low volume (highly concentrated) preparations of depot neuroleptic medication.

A retrospective case note study of 43 patients who were residents of a locked ward in 1970, augmented by a cross-section of the ward's current residents was undertaken.

The study established a profile of the 43 patients in 1970 and determined their outcomes. A brief comparison of the use of medication then and now was also undertaken.

This view of the past aimed to provide a prospective on why and how the field has changed, and to facilitate planning for the future.

A retrospective review of the activity of a general practitioner employed specifically to provide a primary health care service to the residents of an ‘old long-stay’ psychiatric ward was undertaken.

All but one patient had a chronic physical health problem requiring active management. Presenting pathology covered all organ systems. The review indicated that these health problems had not previously been satisfactorily managed by psychiatrists. This service was acceptable to and valued by patients.

The success of the service was only achieved by dedicating specific resources to meet primary health care needs. The extent to which this model could be extended to ‘new long-stay’ populations located in dispersed hospital hostels is less certain.

Non-attendance at psychiatric outpatient appointments has a substantial financial cost, and may also have clinical significance. To prevent non-attendance and formulate effective responses, its determinants need to be understood. Patient dissatisfaction with services has been suggested as a reason for non-attendance, we therefore investigated the role of patient satisfaction in attendance at psychiatric out-patients appointments. All patients booked for adult psychiatric out-patient follow-up appointments in a three-month period were studied using a brief, self-report questionnaire.

Sixty-three per cent (340/538) of offenders and 54% (118/219) of non-attenders responded. Responders expressed high levels of satisfaction with their treatment (92% offenders, 91% non-attenders) and with the service (96% attenders 92% non-attenders). Despite adequate statistical power, there were no statistically significant differences in satisfaction between the two groups.

In conclusion, patient satisfaction with psychiatric out-patient care was reported to be relatively high and did not seem to be an important determinant of non-attendance. Further work is needed to determine the impact of variables such as relapse and social disorganisation on attendance.

Medical reports submitted to mental health review tribunals should be of a clinically acceptable standard. We examined 100 medical reports to assess whether they stated the four criteria for detention under Section 3 of the Mental Health Act 1983. We compared the standard of reports according to the seniority, qualifications and speciality of the doctor, and with the outcome from the tribunal.

The majority of the reports were written by junior doctors and did not fulfil the criteria laid down by the Mental Health Act 1983. Consultant and forensic psychiatry status were associated with completed reports.

This study was performed in one hospital only but highlights the ongoing need to review and improve the workings of the Mental Health Act before reform is considered.

Provision for patients with loosely defined anxiety disorders has been reviewed. During a two-week period. 66 of the 69 adult mental health practitioners working in a modestly sized community health care trust surveyed all patients with anxiety disorder currently under their care.

These practitioners were seeing a total of 758 patients who fitted a loose definition of anxiety disorder. A further 134 patients had been treated in anxiety management groups during the preceding year. Disparate treatments were being used, reflecting idiosyncratic approaches to this otherwise homeogenous group of patients.

Less than one-tenth of the estimated population of anxiety disorder patients were receiving specialised treatment. Among those that were, choices of treatment were arbitrarily determined and idiosyncratic. It was clear that the management of these patients does not fulfill the requirements of ‘evidence-based practice’.

The aim of this study was to elicit views from UK consultants in old age psychiatry concerning changes that were taking place in long-term care for older people with mental illness (especially dementia) and their views on a draft consensus statement produced by the Faculty for Psychiatry of Old Age on behalf of the College. A postal questionnaire was circulated as part of a wider survey of 472 consultants and a single postal reminder was sent to non-responders.

Two hundred and forty-two (51%) consultants responded. Nearly nine out of 10 respondents were in favour of continuing NHS consultant-supervised long-stay beds and three-quarters of them preferred a return to national numerical guidelines for bed numbers, though at a level approximately half of previous guidelines and provision. This was accompanied by a view that such beds should no longer be ‘for life’ with over three-quarters of respondents supporting discharge if, for example, behaviour problems resolved. If Government policy continued to support ‘eligibility criteria’ rather than guidelines, 60% were in favour of national rather than local criteria. There was very strong support for the draft consensus statement (now published in modified form as College Policy) and the ‘eligibility criteria’ it contained. Agreed criteria for waiting times in acute beds for continuing NHS, nursing home or residential care were not widely used.

Consultants want to continue to be responsible for some longer-term care and efforts should be made to develop the role of NHS longer-term care within the 'spectrum of services' provided for older people with psychiatric disorder, perhaps by acting as local ‘centres of excellence’ in dementia care as well as by providing services for patients with the more difficult behavioural problems. The more widespread use of ‘agreed waiting times' for patients in acute beds requiring longer-term care should be explored.

A retrospective review of death certificates issued at a large psychiatric hospital in North Cheshire during the 1980s and 1990s.

Dementia, which was the recorded clinical diagnosis in 78% of all deceased, was reported in 31% of death certificates, while other psychiatric disorders (22% of all deceased) appeared in only 2% of certificates. Autopsy appears to have very little or no value in improving the quality of death certificates in psychiatry.

The onus is on the clinicians to produce adequate death certificates. Recording chronic conditions present at death, such as dementia and other psychiatric disorders, in addition to those directly causing or contributing to death would improve the epidemiological value of death certificates.

The study aimed to assess the available data on the use of lamotrigine as a mood stabilising agent. We reviewed all published and unpublished data available to us through a Medline search from 1987–1998 and from our own files, which include reference materials presented at conferences as well as published reports.

Most of the data found were derived from case reports or open trials. We could find no published double-blind, placebo-controlled studies. The data from initial open trials suggest that lamotrigine may be effective in bipolar disorder, but futher data are required before specific treatment recommendations can be made.

At this early stage, there are too few data to recommend lamotrigine for first or second line therapy in bipolar disorder. However, initial reports are very promising and this agent may eventually be unequivocally shown to be useful in treating mania, hypomania, depression, rapid cycling and mixed affective states in people with bipolar disorder.

Electroconvulsive therapy (ECT) Is widely used In Britain and in most cases is administered by junior doctors. Many are inexperienced in its administration and the variety of machines available makes acquiring experience difficult. This report discusses a unique training programme involving a specially constructed ‘dummy patient’.

This allows trainees to experience the practical administration of ECT and also learn in detail about the working of the ECT machine and the interpretation of electroencephalograms prior to giving treatment to patients.

We believe this training device will have a significant positive effect on the way junior doctors are trained in ECT.

All third year senior house officers (SHOs) training in psychiatry in Scotland were canvassed by a postal questionnaire. They were asked about their views on training and the impact of the Caiman reforms in psychiatry.

Results showed that 33% of trainees were not receiving one hour of consultant supervision per week. The quality of teaching in day release programmes was rated as average or poor by 75%. Three-quarters had not seen a copy of A Guide to Specialist Registrar Training, but had a good knowledge of the changes it proposed. Most were satisfied with their clinical training but expressed concerns about the Caiman reforms.

The loss of the registrar grade has extended the time trainees spend as SHOs and there was concern that there would be a loss of breadth of training. We intend to repeat the survey in mid–1999, by which time the Caiman changes should be fully operational in psychiatry.