This article is an extended consideration of a recent editorial (Parker, 1996), and seeks to argue the importance of studying both onset and trajectories of improvement in those with depressive disorders.

The treatment of acutely disturbed patients is a stressful area of psychiatric practice. Castle et al (1994) found that MRCPsych Part II trainees expressed a general dissatisfaction with training in the management of violence, and in our experience junior trainees are even less confident in the treatment of the disturbed patient. A survey by Cunnane (1994) found that no consensus exists among consultant psychiatrists on which drug treatment is most appropriate for the management of the aggressive, acutely disturbed psychotic patient. There was uncertainty as to optimal management, low expectation of quick results, unwillingness to express an opinion and the use of drug cocktails of dubious rationale.

There has long been considerable individual variation in the regimes for managing acutely disturbed patients, in terms of the drugs used, routes of administration and the dosages given. We all tend to learn from ‘accepted’ practice in the units in which we train, and the lack of good-quality controlled trials, published in leading and accessible journals, compounds the problem. Given the importance of this issue, when concerns about sudden death in the context of high dose regimes are generating considerable publicity (for example, MIND is calling for a blanket ban on dosages greater than those given in the BNF), the need for rigorous research has never been greater. Guidelines have, however, become established in a number of units, and this clear summary by Macpherson et al is therefore to be welcomed.

Ten per cent of the general adult population have a diagnosable personality disorder (Zimmerman & Coryell, 1990) and in 4% this is clinically severe (Tyrer, 1988). The clinical management of such patients may be difficult. However, much clinical difficulty is generated by interpersonal aspects deriving from the particular interaction of the patient and psychiatrist involved and the respective roles they play.

This article discusses the misuse of drugs which act as stimulants, an effect mainly produced by enhancement of the central transmission of catecholamines, particularly dopamine. Stimulant misuse is extremely widespread in the UK and elsewhere, but primary users of such drugs present relatively rarely for treatment at drug services. At present such services mainly see heroin users, not only because the greater addictiveness of heroin produces generally higher levels of problems, but because a substitute treatment can be used in that group in the form of methadone.

Most clinical psychologists and psychiatrists already work together constructively and cooperatively, although guerrilla warfare may descibe the situation in some areas. This outline of issues affecting work with clinical psychologists, looking not only at a mutual awareness of each others' profession-specific knowledge and clinical skills, but also at an understanding of mind-sets and value systems, is aimed at further improving working effectively together, while not glossing over actual and potential areas of role-confusion and conflict between the professions.

Over the past 10 years or so, management has gained greater significance as a career choice for doctors. They see enormous opportunities to improve clinical care by having a greater say in setting the agenda of their organisation and directing the deployment of the local healthcare budget. While doctors have always enjoyed a position of major influence over the direction of the health service, real opportunities to operate as managers only became available in the mid 1980s with the implementation of the Griffiths Report (Department of Health and Social Security, 1983). Although mental illness hospitals had Medical Superintendents until the 1970s, professional hierarchies and consensus decision making, combined with incremental planning and an administrative culture, resulted in few opportunities for meaningful involvement of doctors in management.