The rehabilitation service for West Gloucestershire utilises a range of facilities to accommodate the long-term severely mentally ill. Group homes, supported lodgings, long-stay rehabilitation hostels and an inpatient slow stream rehabilitation ward provide increasing degrees of support according to levels of dependency. The findings of this study support the use of the Clifton Assessment Procedures for the Elderly Behaviour Rating Scale (CAPE BRS) as an aid to assessment of appropriate placement for the long-term severely mentally ill of all age groups in the community, both at the time of placement and to monitor ongoing need.

Over nine months, 57 consecutive newly referred and previous out-patient attenders to two community psychiatric out-patient clinics located in a deprived inner city area of London were interviewed to elicit demographic information, psychiatric details and obtain their views about their preferred location for the out-patient clinic. The majority (94%) preferred a community out-patient setting to a hospital out-patient clinic, with 76% preferring a community out-patient setting to a home assessment. The overall attendance rate was 89%. A 10% higher rate of attendance was found at the community mental health centre compared with the general practice and 15% higher rate for new referrals. Patients preferred to attend a psychiatric out-patient clinic based in the community. This suggests that introducing community-based psychiatric clinics would make a substantial improvement on the current high rates of non-attendance at hospital psychiatric out-patient clinics.

Services for deliberate self-harm patients in the general hospital are unsatisfactory in many respects. A survey of activity and quality in a district general hospital confirmed recent trends observed elsewhere and highlights areas in which service provision can be improved.

High rates of deliberate self-harm (DSH) are a public health problem. A study in Oxford showed rising rates among young women during the late 1980s, and a threefold increase in the proportion due to paracetamol poisoning between 1976 and 1990 (Hawton & Fagg, 1992). A multicentre European study found a trend of increasing peak age, a declining female to male ratio, and unexplained differences between regions (Platt, 1992). In the year following DSH, 9% repeat (Hawton & Fagg, 1992); and suicide rates reach 1.1 to 1.3% of patients in the three years following an episode of DSH (Owens et al. 1991).

‘Failed discharge’ was used as a measure of service efficacy on a psychogeriatric unit. Thirty-eight failed discharges from hospital were compared with 38 controls. Failed discharge was associated with a diagnosis of depression and a greater number of previous admissions. Possible underlying causes are discussed.

In the current NHS climate, it is increasingly important to measure the outcome of medical care. In psychiatry, the most appropriate methodology is not clear-cut (Garden & Oyebode, 1989). Tailed discharge’, or readmission to hospital within a short period of discharge, has been advocated as a possible outcome measure (Jones, 1991). This point prevalence study, of patients under 65 years, yielded a ‘failed discharge’ rate of 27%. Recurrence of original symptoms, poor treatment compliance and failure of follow-up arrangements emerged as important factors.

Recent studies have highlighted deficiencies in ECT service delivery. This audit was set up to monitor and improve the ECT administered in a large psychiatric service. In the first phase of the audit Information was collected regarding stimulus adjustment in response to brief seizures. This highlighted inconsistencies In clinical practice and an education programme was instigated to correct these deficiencies and to bring practice into line with the Royal College of Psychiatrists guidelines. A repeat audit was performed and a marked improvement in the quality of stimulus adjustment was shown.

Substantial changes are taking place to undergraduate psychiatric curricula, in response to recent General Medical Council recommendations. The overall aim is to provide a training in core knowledge and skills that enables students to become competent junior house officers. These developments will inevitably affect clinicians' involvement in undergraduate teaching. How change is being implemented in Nottingham –and the success and challenges so far – is discussed.

An experience by two senior registrars of a social skills group for five 9 to 11-year-old children with peer relationship difficulties at school is reported.

Few would challenge the view that the contribution made by Cruse to the welfare of the bereaved is a very important one. Much effort is put into the training of Cruse counsellors but little is known about the impact of this training. An assessment of 30 prospective counsellors by means of questionnaires and ‘clinical’ vignettes to assess their knowledge of and attitudes to various matters pertaining to grief and bereavement is reported. While the results are encouraging In many respects, they also highlight areas of ignorance and bias which seem resistant to the influence of training.

“Hogarth's Rakes's Progress paintings, which I saw in 1947 on a chance visit to the Chicago Art Institute, immediately suggested a series of operatic scenes to me.” (Stravinsky & Craft, 1960). By 1947 Stravinsky's career, which had started so brilliantly and stormily with the revolutionary Rite of Spring, was almost totally becalmed. Since emigrating from Paris to California in 1940, he had written a couple of untempestuous orchestral pieces, Circus Polka, “composed for a young elephant”, and little else. He was depressed by the lack of originality of his work and was eager to write an opera in English. When he saw the paintings of the Rake's Progress, he seized his opportunity.

If one is to believe the histrionic and sensationalist media coverage that preceded the release of Oliver Stone's satirical film Natural Born Killers, and which ironically paralleled events in the film, a busy time may be expected for our colleagues working in forensic psychiatry. It would not be surprising if viewing of the film was to be adduced by a desperate defence lawyer as an incitement to commit acts of violence. Hopefully, no such argument would be deemed admissible as the film's formal qualities deliberately militate against audience identification with on-screen characters and incidents.

Albert Ellis formulated what is now known as rational emotive behaviour therapy (REBT) in 1955. The Institute for Rational Emotive Therapy (IRET), a not-for-profit organisation chartered by the Regents of the University of the State of New York, opened in its current mid-town Manhattan site in 1965.

“In cottage gardens sweet flowers drink Last dregs of colour from the fading light. Their scent floats on the dusk, to link With the now distant thunder of the engines In a strange deceit; As if the world went well …”

Hong Kong is an international trade and finance centre situated on the southern coast of China, offering a unique blend of Western culture and Chinese tradition. With a largely private primary health care system, psychiatric services here have been predominately hospital centred. Following the 1992 Government Review of Rehabilitation Program Plan (Secretary of Health and Welfare, Hong Kong, 1992) development of community-based services has become the major local issue. Psychogeriatrics is the first sub-speciality to have achieved major progress in this area. Such a development illustrates how local psychiatrists faced the challenge of applying Western models to suit an Oriental population with a different socio-cultural value system.

On a recent visit to the UK, Dr Guiseppe Dell Acqua, a leading exponent of the Italian psychiatric reforms, heard the ‘Med 3’ band play and extended an invitation to visit Trieste and give a concert. ‘Med 3’, the name being an allusion to the medical certificate, were formed in 1992. A Mental Health Week was held in the City of Portsmouth that year. In association with the Arts Connection, a local organisation promoting the arts to a wide audience, and the Portsmouth Care Consortium who were organising the event, artists in many fields ran workshops for mental health service users. Guy and Emma Heape, session musicians, ran a workshop at the Social Service Mental Health Day Centre and it was so successful it led to a band being formed. The band achieved recognition by winning a Mental Health Task Force award in 1993. An invitation to accompany the band to Trieste was readily accepted.

I should like to draw to the attention of psychiatric colleagues the guidelines for the use of PPG assessments. These were produced by a working group of forensic psychologists drawn from the special hospitals, NHS regional and district forensic services, the Prison Department and youth treatment centres.