Mental health legislation must steer a course between Scylla and Charybdis. Scylla represents the notion of individual liberties; Charybdis represents the notion of safety and, in particular, public safety. At the time of writing a Green Paper is expected in 1999, so reform of the Mental Health Act 1983 is on its way. Meanwhile, does the new Code of Practice (Department of Health & Welsh Office, 1999), in force since 1 April 1999, give us any indication as to the course we might be steering?

In May 1999, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness published its first major report since it was reestablished at the University of Manchester (Appleby et al, 1999a). Entitled Safer Services, it presented findings from a two-year sample of suicides and an 18-month sample of homicides occurring in England and Wales, and on the basis of these put forward 31 recommendations for mental health services (Appleby, 1999b; Shaw et al, 1999). This article, modified from a chapter in Safer Services, discusses how services might deal with the risk of suicide and homicide or serious violence.

What is happening in and around psychiatric services that raises fears of a harmful separation between psychiatrists and the rest of the medical fraternity? The last National Health Service (NHS) reforms at the beginning of the 1990s split some mental health services into separate organisations from their local acute services. Paragraph 5.14 in the Government's White Paper The New NHS (NHS Executive, 1997a) seems to favour specialist mental health trusts. Combined whole district trusts are under threat. Shotguns are loaded to ‘encourage’ the marriage with social services. All this may seem to conspire against psychiatrists maintaining close professional relationships with physicians and surgeons in general hospitals. Instead it puts the emphasis on aligning psychiatric work much more closely with social services and primary care. Much restructuring is already afoot. It is a time for sober reflection on what is in the best interests of patients now and in the future (see Box 1).

Mental disorder and mental illness are common. Delinquency, offending and offending behaviour are widespread. The two things therefore occur frequently together, but are not always necessarily causally linked (Humphreys et al, 1994). Access to appropriate psychiatric services and care does not depend solely upon the presence of disturbed behaviour or offending that is obviously directly related to symptoms or signs.

Dr Humphreys is right to emphasise that the majority of offenders with mental disorder have not committed serious offences (conversely, a number of general psychiatric patients are admitted to hospital after incidents in the community which, in different circumstances, might have attracted official attention) and that the principles of treatment and management are the same as for patients in general psychiatry. However, psychiatric assessment of more serious offending does call for careful consideration of additional issues, such as ‘psychiatric defences’ to criminal charges (including fitness to plead, insanity, automatisms, and in cases of charges of murder, diminished responsibility) and the role of security in their management.

“Appropriately controlled and structured clinical trials have not yet revealed any pharmacological approach for rehabilitation of stimulant dependent individuals for which the risks have been shown to outweigh the assets.” (Schuckit, 1994)

In the sometimes sensational world of illicit drug reportage, there is one unsung villain. While heroin misuse remains the bête noir of tabloid journalism, ecstasy the demon of the dance floors and cocaine caricatured as the choice of the rich and famous, amphetamine misuse has lurked the shadows. Its use defies such simple categorisation and spans several groups in society. Bruce has provided a timely reminder of this neglected area in substance misuse literature and, in the process, has highlighted the relevance of basic information gathering as the most important tool in the armamentorium of drug misuse workers. The lack of prominence given to what they describe as a “hidden epidemic” is striking. Could this be because amphetamine misuse is a less prevalent problem than that of other illicit drugs? Evidence suggests otherwise. Amphetamine is the second most common illicit drug seized in the UK (after cannabis). It is easily produced and used in a variety of modes, and recent research confirms a high prevalence of misuse in this country reflecting that found in North American and Australian literature.

The majority of people with learning disabilities in the UK live at home with their families, usually with their parents (Mental Health Foundation, 1996) or – more commonly in later life – with one parent, usually their mother. Nowadays, people with learning disabilities live much longer than they did in the past, with the result that there is also an expanding population of elderly parents who are continuing to care for a son or daughter well into old age.

Depression in old age is a pathological process, not a normal reaction to growing older. The majority of people cope with ageing, and many feel happy and fulfilled. However, there is a bias among health professionals and the community in general to accept lower functioning and more symptoms in older people (Alexopoulos, 1992). Depression tends to be denied by the current generation of elderly people, many of whom were raised in an atmosphere where showing feelings was discouraged, and this adds to diagnostic difficulties. Comorbid medical conditions, the tendency of patients to somatise, cognitive deterioration, and multiple life events, often of loss (e.g. bereavement, retirement, moving to smaller housing), all further complicate the diagnostic process.

“The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself” George Bernard Shaw, Maxims for Revolutionists.

Stigma is defined as a sign of disgrace or discredit, which sets a person apart from others. The stigma of mental illness, although more often related to context than to a person's appearance, remains a powerful negative attribute in all social relations. Sociological interest in psychiatric stigma was given added vigour with the publication of Stigma – Notes on the Management of Spoiled Identity (Goffman, 1963). More recently, psychiatrists have begun to re-examine the consequences of stigma for their patients. In 1989, the American Psychiatric Association's annual meeting's theme ‘overcoming stigma’ was subsequently published as a collection of articles (Fink & Tasman, 1992), and last year saw the launch of the Royal College of Psychiatrists' five-year Changing Minds anti-stigma campaign.

The current National Health Service (NHS) approach to commissioning health services is in flux. The purchasing of care from providers by general practitioner fundholders (GPFHs) and health authorities has changed with the new White Papers. GPFHs no longer exist and the commissioning role is being handed over from health authorities to primary care groups (PCGs). An understanding of the reasons for change and current arrangements will aid the consultant psychiatrist in influencing this process.