Refugees are not a recent phenomenon. Since the time of the Roman Empire there have been many examples of people fleeing persecution and seeking refuge and protection in other countries. Refugees flee war, internal unrest and persecution by their own governments because of their ethnic origin or their political, religious or social activities. Estimates of the number of refugees and displaced people worldwide range from about 23 million to about 50 million, this latter figure including those who are not officially registered. It is perhaps pertinent to realise that this number is larger than the entire population of Australia and almost the same as the number of refugees resulting from the Second World War. Refugees represent a variety of cultures, races and nations from all over the world. Summerfield (2000) claims that nearly 1% of the people in the world are refugees or displaced persons resulting from about 40 current violent conflicts.

What prior assumptions might a psychiatrist bring into the room when the patient is an asylum-seeker? First, as a member of the public he or she is likely to have a view on asylum-seeking as a sociological phenomenon – up to 5 million have sought asylum in Western Europe in the past decade – and on how ‘deserving’ the average case is. After all, two adversarially opposed constructions of asylum-seeking have predominated. Governments, and the conservative social sectors, have stressed the prevalence of ‘bogus' applications by people who are essentially economic migrants, portraying them as wily, determined and tough rather than as having suffered. On the other side are the agencies and interests who support asylum-seekers, and the liberal and radical social sectors. They portray asylum-seekers as people who had no choice but to run from their countries, innocent of any thought but to escape further persecution and the risk of death. This portrayal invokes the image of suffering and vulnerability rather than resilience and agency. The reality is the muddied, uneven terrain that lies between these two entrenched positions. Many asylum-seekers do not have stories that easily fit the definition of a political refugee in the 1951 United Nations Convention. Even those with the clearest-cut cases – such as those with a credible history of torture – usually cannot prove it; few are vulnerable in any medically attestable sense and, however much they have suffered, they continue to make choices and actively engage with their situations. All asylum-seekers are looking for a better life for themselves and their children.

The Patron of the Royal College of Psychiatrists has pointed out the irony involved in recording patients' religion, without seeking to discover that all this means to them in terms of understanding and coping with their illness (HRH The Prince of Wales, 1991). One College past-President (Sims, 1994) firmly recommends evaluating the religious and spiritual experiences of our patients in assessing aetiology, diagnosis, prognosis and planning treatment. Across the water, an American Journal of Psychiatry editorial (Andreasen, 1996) has it that, ‘We must practice and preach the fact that psychiatrists are physicians to the soul as well as the body.’

Culliford (2002, this issue) has given us a valuable tour of what is involved in an appraisal of a patient's spirituality and its relevance to the assessment of mental state and prognosis. My task here is to provide some commentary from the perspective of a Buddhist. What immediately confronts me, therefore, is whether the teachings and practices of Buddhism do, in fact, find a place upon the map here set out. This is not a straightforward question, and this alone illustrates the fact that this is a subject within which one has to be willing to encompass, or at least allow for, differences of basic paradigm. However, what strikes me particularly is the fact that the Buddhist paradigm actually may be less at odds with the medical model than many might imagine.

I read Culliford's article (2002, this issue) with keen interest. I am pleased to comment on some of the aspects from the traditional view of my Islamic faith. Let me begin with the terminology. In Islam, the term spirituality is inseparable from the awareness of the One, of Allah (God), and a life lived according to His Will. This principle of Oneness (Al-tawheed –unity) must be taken into consideration in any study of Islamic spirituality. In the Qur'an, God has manifested that which is within the soul of man. He has ‘breathed into man’ His own spirit. The word that Muslims use for spirituality is ruhaniyyah. Ruh, which means spirit, is mentioned in the Qur'an; ‘The Spirit is from the command of my Lord’ (Chapter 17, verse 85).

There is widespread support for a positive and lasting relationship between participation in regular exercise and various indices of mental health, and several consensus documents and reviews (e.g. Biddle et al, 2000; Craft & Landers, 1998) have been published in this field. The evidence for psychological benefits, although impressive for mentally healthy individuals, is even stronger for psychiatric populations (Martinsen & Stephens, 1994). For example, a number of studies have demonstrated a positive relationship between exercise and mental health in people with alcohol misuse problems (Donaghy et al, 1991), people with schizophrenia (Chamove, 1986; Faulkner & Sparkes, 1999) and those with clinical depression (Mutrie, 1988; Martinsen, 1993; 1994; Martinsen et al, 1989a, b).

This article aims to provide a practical overview concentrating on civil legal aspects of psychiatric care for the elderly. We limit ourselves to English law (which also has jurisdiction in Wales; Scottish and Northern Irish law may be similar, but not identical). Civil law can, in turn, be divided into statute law (legislation provided by Parliament) and common law (the UK, unlike some European countries, has a strong tradition of law based on previous rulings by judges).

Murray & Jacoby (2002, this issue) emphasise the functional nature of capacity and draw attention to the dangers of adopting any other approach. The status approach (where determining whether someone is capable is dependent on diagnosis) makes assumptions about individual capacities and abilities that may be, and often will be, untrue. The outcome approach fails to realise that no one is expected always to make decisions with which others would agree. It is the process of decision-making that matters, and this must be determined in the case of an individual and in relation to a particular decision at a particular time.

It is not uncommon for people with mental illness to be convicted of a criminal offence. The relationship between the two is not necessarily simple. It may be diffuse and subtle, perhaps relating to the disinhibiting effect of severe mental illness or associated factors such as poor social integration, unemployment, lack of close and intimate relationships or substance misuse.

It is entirely possible that most readers will have been ignorant of community rehabilitation orders with or without requirements of psychiatric treatment until reading the article by Clark et al (2002, this issue). It is valuable as an educational article and is applicable to the work of both general adult and forensic psychiatrists.

‘Security holds the key’ was the title of a newspaper article concerned with e-commerce (D. Sumner-Smith, The Sunday Times, 6 February, 2000, p. 3.13). However, it applies just as readily to the health sector. The need to safeguard the confidentiality of information that patients share with clinicians is as fundamental as the principle of consent. This issue has come to the fore in the context of the rapid developments and applications of information and communication technologies within society in general and within the health sector in particular. There are also changing societal expectations regarding access to information, confidentiality and disclosure. The emerging scenarios present significant challenges in relation to the traditional methods used to deal with the privacy and confidentiality of personal information (Anderson, 1995). In addition to the impact of new technologies, consideration also needs to be given to the impact of changes in health care organisation and practice, for example multidisciplinary and multi-agency working. Mental health services are in many respects at the vanguard of these changes, where the ideals of community care, shared care and seamless care depend fundamentally on good communication and information sharing. Failures in communicating information, particularly across sectoral boundaries, have led to significant problems in patient care, as revealed in several recent enquiries into homicides (Northamptonshire Health Authority & Northamptonshire Social Services, 1999)

Depressive disorders are more common in patients with physical illness than in those without, with up to one-third of medical in-patients reporting mild to moderate symptoms of depression (Rodin & Voshart, 1986). Some medical conditions have a stronger association with psychiatric illness than others, for example the prevalence rates of depressive illness in patients with diabetes, cardiac or neurological disease is about 25%, but not much more than the general population in those with hypertension. Medical in-patients are more likely to have depression than are out-patients. There are a number of potential factors that may contribute to this increased risk of depression in people with physical illness, as outlined in Box 1.

As the arsenal of antidepressant drugs increases with time so, concurrently, does the list of caveats that must be considered when using these agents in patients with other physical illnesses and using other medications. MacHale's (2002, this issue) overview of the management of depression in physical illness serves as a crucial update for clinicians providing psychiatric services for patients with comorbid physical illnesses. Appropriate emphasis is placed on the usefulness of non-pharmacological treatments in such patients, although the reality of modern practice is that drug treatment is most often considered first-line owing to limited psychological service resources.

In the first article in this series (Williams & Garland, 2002) we encouraged readers to try out elements of the Five Areas model of cognitive–behavioural therapy (CBT) with some patients. Before we further discuss the model it might be of value to reflect on your experiences. If you did try, was it successful? Did it teach you anything about your clinical skills and the patients' problems? Can you build on this experience and use the Five Areas model more widely in your practice? If you did not try this out, why not? Were you prevented by internal factors (too busy, could not see the patient, thought you could not do it) or problems beyond your control (the patient failed to turn up)? How can you overcome these obstacles?