Clinical governance is defined by the government as:

“a framework through which [National Health Service (NHS)] organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish'’ (emphasis not in original) (Department of Health (DOH), 1998).

A 19-year-old student, wandering the streets of a Northern city, is picked up at 3am by a taxi driver. The student requests delivery to a fictitious destination. The student recounts to the driver a series of events including abandonment by parents at the age of six in a forest in the West Country, and subsequent adoption by an elderly couple who live in Birmingham. The taxi driver takes the student to the central police station, where, after a brief interview, sectioning under the Mental Health Act 1983 takes place.

Recognising the vast extent of psychiatric morbidity internationally and the burden of mental illness on people, communities and nations, the World Psychiatric Association and the World Federation for Medical Education have recently published global guidelines for developing core curricula in psychiatry for medical students (Walton & Gelder 1999). More locally, major changes are taking place in undergraduate medical education throughout the UK. These changes represent a response to the appreciation, both by medical schools and by the General Medical Council (GMC), of two major pressures in undergraduate education. The first is that students have been asked over the years to accumulate more and more factual knowledge while the knowledge base in medicine itself expands and changes more rapidly. The second is that both understanding of illness and delivery of care are developing an increasing focus on the role of the community and community support. These general pressures have led to a number of specific recommendations, initially put forward by the GMC in their document Tomorrow's Doctors (GMC, 1993). This document encourages the reduction of ‘core knowledge’ taught to medical students to 65% of what has previously been taught, together with the identification of special study modules (SSMs), which would fill the remaining time in the curriculum. These SSMs would allow students to explore areas of particular interest in greater depth than was previously possible.

Making effective use of psychotherapy can be difficult for patients and their doctors, for a number of reasons. First, the term ‘psychotherapy’ itself is unsatisfactory, used by some people to indicate a particular type of psychotherapy (usually psychodynamic), and by others to embrace all forms of psychological treatment. When we use the term ‘medication’ we usually add a qualifying adjective (e.g. antidepressant or antipsychotic medication) and it is helpful to do so in psychotherapy (e.g. dynamic therapy, cognitive therapy, etc.).

Treatment of people with drug problems requires a consideration of those inviduals in their personal and social context, while being mindful of the complex interaction of genetic and developmental influences. Approaches to treatment should reflect this often complex aetiology and phenomenology, and the totality of treatment will typically include social, psychological, educational and pharmacological therapies. Treatment should result in a health benefit; consequently the goals of treatment should be tailored to the health care needs of the individual. Thus, with many patients, treatment will include abstinence as an explicit objective, whereas with other patients, intermediate goals, such as reduction of harmful injecting, may be more realistic and achievable.

Depressive disorder has no single cause. Arguably, in old age it is a more heterogeneous condition than in earlier adult life, in both clinical presentation and causation. A broad distinction is often made between early- and late-onset depression in later life. The aetiology of these may differ and is currently the subject of new research.

The economically developing countries face a perpetual challenge to provide essential health care. The available health care delivery systems are primitive and lack organisation and resources. Mental health care suffers even more acutely for want of attention, widespread ignorance and prejudice. The services in this field are inadequate and often inappropriate. The urge for a qualitative change has led to a focus on higher training of specialist doctors.

The occurrence of depression in people with learning disability is not a late-20th century phenomenon. Reports were first published in the 1800s describing the existence of depression in individuals with intellectual impairment (Clouston, 1883). However, as we enter a new millennium, the appropriate diagnosis, assessment and treatment of depression, and indeed all forms of mental illness in people with learning disability, will become the focus of considerable concern for all professionals working in this field. With recent national trends towards de-institutionalisation, referral of individuals with learning disability to psychiatrists to ‘rule out a possible depressive illness' and to ‘advise about further treatment’ will increase. It remains essential for all psychiatrists in learning disability to continue to improve their diagnostic skills to better manage depressive episodes and, where possible, to learn how to prevent a future relapse. This review highlights the important presentation and management issues relating to depression in the field of learning disability. Depression in this review implies a single major depressive episode, irrespective of whether or not it conforms to any given classification system.

As psychiatrists, we are responsible for large numbers of patients who require follow-up over years, and often lifelong. Usually these patients suffer from chronic psychotic illnesses, and their psychiatrist may be their main point of contact with the medical profession. As a group they face a whole range of problems – not only from the psychiatric condition itself, with its associated stigma and psychosocial stresses, but also from unemployment, poverty, poor housing and worse physical health.

This review will look at the evidence that patients in continuing care have increased morbidity and mortality. The types of illness excess will be examined and explanations suggested as to why such an increase exists. Finally, we present practical steps that might usefully be taken to reduce physical illness and premature death in this vulnerable group.

The origins of the probation service can be traced back to the late-Victorian era and the introduction of the so-called police court missionaries who supervised offenders on conditional release from the court. The service grew slowly, but mushroomed in the 1970s and 1980s when several major acts widened the scope of the service by introducing parole, aftercare of discharged prisoners, community service by offenders, and extended the scope of probation and bail hostels. Since the beginning of this decade the probation service has been working in an ever-changing legal and philosophical context. Public protection and the prevention of crime are our primary aims. Legislation and ministerial directives have necessitated increasing involvement of probation offices in work with offenders with mental disorder, and have brought into greater focus the relationship of the probation service with psychiatry.

“These medications (antipsychotic drugs) were originally developed to treat not the mentally handicapped but the mentally ill; those, for example, with schizophrenia, paranoia and other specific conditions, but now the far wider use of these drugs has been challenged because there is evidence that they can produce serious side-effects in addition to the distress already suffered. Future changes in the use of antipsychotic drugs in the UK may come from the Royal College of Psychiatrists or from action in the Law Courts” (Public Eye, BBC2, 1.5.92).