With the possible exception of the proposed supervised discharge, the supervision register is the most controversial current government initiative within the mental health field. This paper presents both the guidance issued by the NHS Executive and the concerns that the psychiatric profession has expressed. Time will tell whether the supervision register turns out to be a visionary policy that successfully allays public concerns over community care or an example of a bureaucratic response to an issue of inadequate resources.

A survey of the prescribing practice of a group of psychiatrists working in a Bristol NHS trust found that their preferred choice of antidepressants was surprisingly similar, but reported doses of antidepressants often fell below generally accepted minimum levels. Clinicians used mainly newer antidepressants rather than tricyclics. The choice of antidepressant was based on side effect profile, overdose danger, training and personal experience of efficacy. Cost and drug company advertising had little effect on choice. Difficulties in involving depressed patients in treatment decisions are discussed.

This paper describes the experience of a general practitioner employed to provide physical care to 12 highly dependent residents of a group home. In the first year after their discharge from hospital the residents required a mean of 15 contacts each, 90% of which occurred during regular twice-weekly visits to the home. Previously unmet needs for physical care were identified on screening, including visual, dental and footcare problems which were usually correctable. Smoking and obesity were common and resistant to intervention. Shared care policies are described which were developed together with the nursing staff and visiting mental health professionals.

A postal questionnaire was sent to a random sample of 300 fund-holding general practices. Respondents were asked to indicate if they had links with a psychiatrist, community psychiatric nurse or psychologist; 210 (70%) general practitioners returned completed questionnaires. Out of 210 practices 161 (77%) had links with at least one specialist mental health professional. Community psychiatric nurses had links with more practices than psychiatrists or psychologists. Problems with time or space made it difficult for practices to form links.

The adolescents (n=57, age 13–19 years) attending the special schools for moderate and severe learning disabilities in a South East London health district and their families were assessed. The mothers of adolescents with severe learning disabilities in the transitional stage to adult services and development reported greater behaviour problems in their offspring, greater stress, more negative psycho-social family effects and more negative attitudes. Implications of the results for interventions, needs assessment and future research in family and adolescent functioning and the origins of psychiatric morbidity in young people with learning disabilities were discussed.

Activity and outcome data for two ‘ward-in-a-house’ projects for new long-stay in-patients are described. The results confirm that up to a third may be successfully resettled providing that good quality sheltered housing is available. However, a similar proportion appear to find such environments too demanding and may be transferred after an acute exacerbation of symptoms or a violent incident. The remainder need high quality, ongoing care.

A six year retrospective study was performed on the referrals to a fast stream rehabilitation unit in Plymouth (‘114’). In the wake of recent hospital closure, an historical perspective on the changes within the service and the model of our new rehabilitation service is presented. Clinical features, demographical details, outcomes and duration of stay were examined. New strains have been put on acute psychiatry resources and it was demonstrated that the rehabilitation process has had a beneficial effect on acute general psychiatric bed usage.

An audit was undertaken to assess the efficacy and efficiency of a community-based mental health service which attempts to prioritise the care of those with severe and enduring disorders. Referral patterns over a three month period and change in case-load over the subsequent 12 months were recorded. Seventy-five per cent of new referrals met the priority group criteria, allaying anxieties that community services unceasingly get drawn to the care of those with less severe disorders. Furthermore, at 12 months the service had maintained contact with all patients previously admitted to hospital and all those presenting with psychotic disorders (27% referrals). Some changes in service structure are also suggested as a result of this evaluation.

We describe a survey examining the use of clozapine in South Manchester since 1990. The aims were to determine the patient characteristics, type of illness, response to treatment and recording of this information. The case-notes of the first 25 patients to receive clozapine between 1990 and 1992 were audited. Guidelines about who should receive this drug and what objective assessments should be performed were agreed by the consultant group. The audit demonstrated that 24 patients suffered from chronic schizophrenia which had failed to respond to conventional neuroleptics. Routine mental state examinations were regularly performed but objective assessments using standardised rating scales were employed infrequently. Sixteen out of 25 improved on clozapine but at the end of 1992 only ten subjects were still receiving this drug. The majority had been discontinued because of side effects.

This paper describes the process of lithium audit at Dingleton Hospital, showing that improvements in clinical practice can be achieved and maintained by implementation of the audit cycle. Even our small audit involved all of the medical staff and several other professional groups and we found this multidisciplinary approach encouraged change.

“…; and the tone of the chapel bell, coming across the Valley of the Brent, still reminds me, morning and evening, of the weft-remembered and mingled congregation of the afflicted, and who are then assembling, humble yet hopeful, and not forgotten, and not spiritually deserted.”

As a function of the Christian ethic, monasteries in Britain from the Middle Ages onwards set aside a section for the care of the sick. The monastic tradition ensured that the spiritual needs of the physically sick were well taken care of: chapels formed an integral part of the building complex and chaplains were, of course, constantly on tap. The mentally sick were less well served, however. For example, the second building to be occupied by St Luke's Hospital, London, opened in 1787, did not even boast a chapel, a distinction shared with Bethlem, the other major charity asylum, then occupying a purpose-built structure in Moorgate in the City of London.

Little has been published by trainees of their involvement in the organisation of their academic curriculum. This article discusses the experience of two trainee representatives to the Post Graduate Training Committee (PGTC) in Fife with particular regard to three areas (academic programme, general assessment and exam preparation) over a one year period.

Paul Crichton reviews and reviles The Man Who, a ‘theatrical research’ inspired by the work of Oliver Sacks.

In April 1987, in a back-street bar in Cardiff, the rebel regime at Radio Wales were plotting a coup. Their secret weapon was a daily magazine programme of music and current affairs called Streetlife. The would-be front-men, Ray Gravell (British Lions centre) and Frank Hennessy (Cardiff-Irish folk singer) had just persuaded the Editor that it needed an ‘agony uncle'… when I walked in.

Discussion of the need to reform psychiatric services in former West Germany started relatively late. It was only in the late 1960s, when the government changed from the conservative Christian Democrats to a coalition of the Social Democratic and Liberal Parties, that psychiatry became a public issue for the first time since World War II. Parliament appointed an expert commission, which after four years gave a comprehensive report in which the inadequate care of mentally ill patients was criticised.

German psychiatry is emerging from a black past to a challenging future. Under the Nazis it is thought that about 100,000 psychiatric patients were killed and 300,000 were compulsorily sterilised. Services for the mentally ill had also been adversely affected by two world wars and recession. For 50 years there was little progress. By the 1970s, the government and other institutions took more interest in mental health. Community facilities began to appear such as day centres. Long-stay patients are now being discharged from hospitals and asylums have closed in some states.

The arrangement of medical services in Brazil is more akin to that of the USA than the UK. Private practice predominates but with a safety net of state funded hospitals. The majority of doctors working in state hospitals have contracts for 20 hours per week and are very poorly paid and they often have two or three jobs to compensate. These usually include working in a private clinic for part of the week and perhaps doing a period of on-call at another hospital. Some state hospitals are unable to fill vacant posts and there are frequent television reports of casualty departments having to close due to a lack of medical staff.

Recent years have seen considerable progress in understanding the genetic basis of many diseases. There has also been a welcome and informed public debate regarding the ethical and social implications of genetic research, including predictive testing of adult onset illnesses. The UK Huntington's Prediction Consortium, a forum open to scientists, clinicians and representives from patient organisations, has established protocols for testing and has facilitated development of clinical genetic services. It has been suggested that the Huntington's disease experience might prove informative for other conditions, and a meeting was held on 5 January 1994 at the Institute of Psychiatry, London, to discuss recent research findings and possible genetic testing in Alzheimer's disease (AD). Professionals from a number of disciplines took part along with representatives of the Alzheimer's Disease Society. It was decided to form a consortium that would meet regularly and produce guidelines for future clinical applications of possible genetic tests.