As we doctors are beginning to understand more and more about dementia, the public has become increasingly aware of the condition and in turn this has been reflected in the arts. This article discusses four books whose main focus is the experience of dementia, each written from an entirely different perspective: a novel giving a first-person account of dementia by the Dutch writer J. Bernlef; a biography of the famous novelist Iris Murdoch by her husband John Bayley; Linda Grant's account of her mother's multi-infarct dementia (which also describes Jewish migration to the UK two generations ago); and Michael Igniateff's autobiographical novel Scar Tissue. Such accounts, offering insights into how patients and carers feel, cannot but help make us better doctors.

The history and meaning of doctors' approval by the Secretary of State under Section 12(2) of the Mental Health Act 1983 is discussed. The definition for approval is examined with relevant rulings on interpretation. Training requisites of such doctors are examined, outlining a framework of educational aims and objectives, with suggestions for delivery. The aims must include direct factual content and also the skills, values and attitudes required for humane and consistent practice. The particular needs of some specific groups and individuals are highlighted. The continual learning for updating skills and knowledge, including event-based learning, audit and reflection, is placed in the context of clinical governance wherein doctors must ensure that they continue to be ‘fit for purpose’. The case is made for ‘nationalisation’ of the syllabus and standards.

Children with either normal or impaired cognitive abilities presenting to child and adolescent mental health services (CAMHS) with psychiatric or behavioural problems may have an underlying syndromic or neurological diagnosis. Diagnostic clues exist in the measurement of growth and head circumference, recognition of dysmorphism and in the full physical and, in particular, neurological examination of the individual. Recognition of these clues will allow referral, as necessary, for further investigation or surveillance. Prompt diagnosis of disorders is important for many reasons: the provision of an explanation for the child's current difficulties and the anticipation of further difficulties; the recognition of genetic, and therefore reproductive, implications for parents and siblings; the recognition of a grim prognosis; and access to any available treatments.

Those who possess expertise or experience of a scientific or technical nature are often called to give evidence as a witness in a court or tribunal (in Scotland, he or she is known as a ‘skilled witness’). In so far as the expert witness expresses an opinion, that evidence is, strictly speaking, an exception to the hearsay rule. However, since the 16th century, the courts have admitted opinion evidence from anyone, not just a ‘professional’, who can assist the court on a scientific or technical matter which is an issue in the case and is beyond the knowledge of the court or tribunal. Frequently, the expert witness will be giving evidence as to fact as well as opinion. For example, the forensic pathologist who conducts a post-mortem examination will be able to give a factual description of the condition of the body and, at the same time, give an expert opinion on the cause of death. The forensic psychiatrist will similarly describe what has been determined about the patient on examination of his or her symptoms and express an opinion on the patient's mental health. There will be cases where the expert is supplied with factual data on which to express an expert opinion.

Three main approaches are used to explore the neural correlates of mood disorder: neuropsychological studies, neuroimaging studies and post-mortem investigations. Lesion studies implicate disturbances in the frontal lobe, basal ganglia, striatum and anterior temporal cortex. Early neurocognitive and neuropathological investigations led to a ‘hypofrontality’ hypothesis of unipolar and bipolar depression, but functional neuroimaging has revealed a more complex picture. Thus, increased metabolism may occur in the subgenual anterior cingulate gyrus in resting-state studies of depression and sad-mood induction. Antidepressants may reduce this activity. Amygdala hyperactivation also is associated with affective disorders. Task-related studies reveal abnormal biases in memory, the experience of pleasure and the perception of emotional facial expressions. There is still little clarity whether the abnormalities in brain activation represent state or trait characteristics of affective disorders.

Now that training under Section 12 (Section 20 in Scotland) of the Mental Health Act 1983 is mandatory under the NHS Executive Guidelines HSG (96) 3 (1996) both prior to and while maintaining approval, discussion of the educational objectives and how to achieve them is overdue. The article by Brown & Humphreys (2003, this issue) is a welcome introduction to the debate. Given that psychiatrists may move between different legal jurisdictions and that there is a constant stream of new and relevant case law (not to mention that we may soon have a new Mental Health Act), it is clearly important that training is about principles, issues and asking questions rather than a didactic teaching of facts. One must consider what are the relevant issues.

Assertive outreach is a well-established method of managing patients with severe mental illness in the community. However, there is limited application and evidence of its efficacy in services for people with learning disabilities who also have mental illness. This paper elucidates current service provision for this group of patients and illustrates the pathways to mental health care available to them.

Doctors, like other health professionals, show increased rates of psychological morbidity, including anxiety, depression, suicide, drug and alcohol misuse and professional exhaustion (burnout). This might be due in part to the pressures of clinical work, but might also reflect Malan's ‘helping profession syndrome’, in which an individual chooses, usually unconsciously, to work as a carer as a response to personal vulnerability, or ‘the patient within’. This paper reviews the literature relating to the complex relationship that health professionals have with their work role, discusses the implications for the profession, and proposes areas of prophylactic or remedial action.

Treatment of illicit drug dependence typically involves a combination of pharmacotherapy and psychosocial interventions. Efficacy research supports methadone maintenance in opiate dependence. There is less evidence to support buprenorphine (an opiate receptor partial agonist), lofexidine (an α2-adrenoreceptor agonist) and naltrexone (an opiate receptor antagonist). Evidence for the effectiveness of detoxification, which one of the most widely used treatments, is poor. Of the psychosocial interventions, reasonable evidence exists for the effectiveness of motivational interviewing. Other psychosocial treatments have rarely been compared with no or minimal contact conditions in randomised trials, and their reported effectiveness is often weak. Residential treatments are not demonstrably more effective than community programmes.

Carers play a vital role in supporting family members who need help. Facts and figures on caregiving are set in the context of current UK policy. Research into the impact of caregiving shows that one-third to one-half of carers suffer significant psychological distress. Factors associated with carer stress are reviewed, including those related to the care-recipient, the caregiver, their relationship, and wider family and social support. The most well-known frameworks for understanding caregiving stress, including stress-process models, are introduced. Measures that may help in assessing psychological needs of carers are reviewed, emphasising the distinction between objective and subjective stress. The range of possible interventions leads to promising evidence of the effectiveness of individual psychosocial interventions, but further research is needed.

Mental health problems are the most significant cause of morbidity in prisons. Over 90% of prisoners have a mental disorder. The prison environment and the rules and regimes governing daily life inside prison can be seriously detrimental to mental health. Prisoners have received very poor health care and, until recently, the National Health Service (NHS) had no obligations to service this group, which was the Home Office's responsibility. The NHS is expected to take responsibility eventually, following a new health partnership with the Prison Service. NHS psychiatrists will have to be much more active in the development and delivery of health care to prisoners who now have the right to equal health care. There are positive developments but concerted and determined action is required to bring prison health care up to acceptable standards.

Aspects of print, broadcast, film and ‘new media’ are related to their interactions with psychiatry. Frequent representations of mental health issues are paralleled by the adoption of psychological theories into media studies. Key areas are covered where psychiatric items diverge from other medical specialities, such as the depiction of suicide, the dominance of ‘human interest’ stories and negative representation of people with mental illness. Although the language of mental disorders is important, the power of the image needs to be examined. Media items also have implications for public mental health (children as vulnerable viewers) and the clinical practice of psychiatry that are not uniformly negative. Television has limitations and clinicians are encouraged to participate in radio and other media. Resources and practical advice for media contact are provided.

The recruitment and retention crisis in UK nursing puts many reforms outlined in recent health policies at risk. Increasing bureaucratisation of health care, unattractive working conditions, poor pay and the emotionally exhausting nature of the work are associated with high rates of burnout and workplace violence. Some nurses prefer agency work, some leave because they cannot reconcile a caring role with working in the NHS. It seems that health care has become emotionally distant and the profession's longstanding attachment to caring through interpersonal relationships has been overridden by a high-technology, fast-track system of care management. To retain the principles and ethos of nursing at the centre of health developments, attention must be given to the micro-environments in which nurses work.

Catha edulis (khat) is a plant grown in the countries around the Red Sea and on the eastern coast of Africa. Its leaves are chewed by the local people for their stimulant action. Its principal active constituents are cathinone and cathine, which have sympathomimetic actions. Migration of Africans from these countries has spread the habit of khat chewing to the West. Chewing khat has a number of important psychological and physical sequelae. ‘Khat-related’ psychosis is very similar to that seen following use of amphetamines.

With new developments in image generation and transmission, researchers have studied the feasibility of using comunications technology for remote diagnosis and care delivery. The term ‘telepsychiatry’ has been used to describe the application of telemedicine and telecare to mental health. This article reviews the development of telepsychiatry and key research findings. Results suggest that service users are more comfortable with mediated services than are professsonals. Most work has been done in areas of low population density, where accessibility to conventional services is limited by economics and geography. In urban settings, with distributed community services, telepsychiatry can improve communication between primary and secondary sectors and within secondary services.

Intoxication with alcohol and drugs is commonly associated with criminal offending. The relationship between intoxication and criminal culpability is complex and may be of psychiatric relevance, especially if a mental condition legal defence is being considered. This article outlines the legal issues (such as they apply in England and Wales) of which psychiatrists should be aware when preparing medico-legal opinions about mentally disordered offenders.

Globalisation means crossing borders. It is a complex, large-scale social phenomenon that presents to mental health services both challenges and opportunities. These relate to the increased cultural diversity of service users and service providers; the effects of migration on mental health; and the implementation of international protocols in relation to training, policy and education. In the aftermath of 11 September 2001 in the USA, the relationship between large-scale social change and mental health has also focused attention on the concepts of anomie and social capital. An explicit return to the principles of biopsychosocial psychiatry and a positive engagement with globalisation will advance the development of effective, evidence-based models of care appropriate to the changing needs of patients.

The sustained study of literary texts and, to a lesser extent, of techniques of literary analysis offers a number of educational ‘goods' to the medical curriculum, to medical students and to the clinical practitioners they will one day become. In addition to the intrinsic goods of literature – the intense and direct experience of connecting with another's vision of the world – there are ‘instrumental’ goods augmenting the clinician's necessary physical understanding of patients' bodies with the equally necessary personal understanding of patients as individuals. These goods include (within the context of a medical curriculum genuinely located in higher education rather than in mere training) skills of communication, sensitive appreciation of the ethical dimensions of practice, the development of students' personal values and the stimulation of an enduring sense of wonder at embodied human nature.

Psychiatrists have always been concerned about the mental health of prisoners. If they did not devote much energy to their treatment, it was only because they had more-pressing problems, including how to squeeze ten patients into nine beds. In any case, it was someone else's job to look after prisoners. Luke Birmingham's article (Birmingham, 2003, this issue) could not be more timely, as this situation has now changed. With the publication of The Future Organisation of Prison Healthcare (Prison Service & NHS Executive Working Group, 1999), and the creation of a joint Department of Health and Home Office task force, the Government has made it clear that the problem of mentally disordered offenders belongs to the National Health Service (NHS). There is a plan, there is a partnership and there are targets. Can those of us who have been worrying about prisoners with mental illness sit back and relax, as the solution unfolds?