“Chronic fatigue syndrome” (Sharpe et al, 1991) is an operational definition for conditions of disabling physical fatigue, of over six months duration, unexplained by primary physical or psychiatric causes. It encompasses nomenclature such as “myalgic encephalomyelitis” (Acheson, 1959), “post-viral fatigue syndrome” (Behan et al, 1985) and “chronic mononucleosis syndrome” (Straus, 1988).

Happy New Year, and welcome to what some are predicting will be the year of continuing professional development/ continuing medical education!

The role of pharmacotherapy in the management of depressive disorders is well-established and frequently reviewed. This paper focuses on the prospects for reducing the incidence, prevalence and morbidity of depression through psychosocial interventions. A central requirement in prevention is a knowledge of the epidemiology of the disorder being investigated. This data can be used to identify high-risk groups. By comparing the number of known cases with population levels of morbidity, it allows comment on help-seeking behaviour and accessibility of services. Also, differences in incidence and prevalence rates give some indication of the chronicity of the disorder.

It has been known for some time that the majority of adult mental health problems within any community are seen within general practice, making up a fifth to a quarter of the general practitioner's workload (Shepherd & Clare, 1981). Most patients are not referred to specialist services. It is therefore the primary care team and not the psychiatric specialist who assumes the major burden of responsibility for the care of mental disorder. Hence, more attempts are now being made to improve the quality of psychiatric care within general practice. Most of the research on mental health morbidity within primary care has been in the field of adult mental health and it is only relatively recently that equivalent information on child mental health morbidity has become available. In parallel, an increasing number of studies examining the effectiveness of interventions in primary care have been undertaken and different models of mental health service provision within this context have been described (Strathdee & Williams, 1984). There are few evaluated studies of interventions in primary care focused on child mental health. Most guidance for the development of such services has to be obtained from the adult mental health literature, or from work with other types of childhood disorder, often in non-general practice settings.

There is no direct coherence between medical and legal concepts or between medical and legal ways of thinking (Eastman, 1992). As a result, there are often substantial difficulties in translating the findings of one (medicine) into the decisions of the other (law). In order to minimise interdisciplinary confusion, it is necessary for each to have an understanding of the approach of the other. This paper attempts to elucidate the relationship between law and psychiatry as it is played out specifically in personal injury litigation and in relation to civil legal claims for (legal) ‘nervous shock’. It is not confined solely to claims arising out of the development of post-traumatic stress disorder (PTSD) (Eastman, 1995; Napier, 1995), but is applicable to any psychiatric sequelae of events for which legal liability of a defendant can be established. It also offers general comments about the provision of civil psycho-legal assessments, advice and opinion writing (Carson et al, 1993) as a backcloth to its more specific purpose.

Deliberate self-harm remains a common problem in the United Kingdom, with rates in the order of 250–300 per 100 000 per year (Hawton & Fagg, 1992). Since the suicide rate in the 12 months after hospital attendance for deliberate self-harm is around 1% (Hawton & Fagg, 1988), each year approximately 2–3 per 100 000 of the population die by suicide within a year of attending hospital with a non-fatal episode of deliberate self-harm. This is about a quarter of the overall suicide rate of 11 per 100 000. There is therefore an easily definable group at risk of suicide who should be the focus of a suicide prevention strategy.

Since the introduction of lithium therapy 30 years ago it has become a major weapon in psychiatrists' armamentarium. It is the drug of first choice for the prevention of recurrent mood disorders, and it is estimated that about one person in every thousand people in Britain receives lithium at any one time. It therefore behoves doctors to be familiar with its use. This article is not a comprehensive account of the pharmacology of lithium (for this the reader is referred to Johnson (1987) and Peet & Pratt (1993)) but concentrates on its clinical use in practice and some less well known, but important, phenomena.

It is hard to disagree with the principles of the care programme approach (SPCR, 1993; Kingdon, 1994) but it has been much harder to agree how to put them into practice. What should be ‘just good practice’ becomes more complex the more it is discussed by clinical teams.

Much attention has focused on prompt, accurate identification and treatment of depression and anxiety in primary care settings. Less is known about what to do when treatment is unsuccessful or the initial opportunity to intervene is missed. The long-term prognosis of depression and anxiety in primary care settings is not good: half of sufferers experience a relapsing remitting course and a quarter become chronic. There is also a relationship between chronicity and high service utilisation. The label “heartsink” has sometimes been applied to these patients, often pejoratively.

The psychiatric sequelae of trauma have been most often discussed in relation to disasters, both natural and man-made, and military conflict. This may sometimes lead psychiatrists to think of posttraumatic stress disorder (PTSD) and other posttraumatic mental illnesses as being somewhat exotic and unusual in general psychiatric practice. In this paper, I propose that PTSD and related disorders are actually common psychiatric problems which require treatment.

The preparation of medico-legal reports is an increasingly important responsibility for the psychiatrist as legislation and administrative regulations become more complex and litigation increases.

One of the most valuable commodities in the NHS is the individual consultant's time. This is what patients, their relatives, and other staff want most, and they complain that it is not sufficiently available. We increasingly examine the use of our resources and the quality of our service but do not pay sufficient attention to this variable. This article aims to highlight the importance of the clinician's time and suggests that it should be subjected to periodic audit, along with other aspects of the service, and that the duration of face-to-face contact with patients should be introduced as one of a series of quality measures.

Most professions have recently realised that basic undergraduate and postgraduate training is not enough to maintain high standards of practice throughout a long career. Continuing professional development (CPD) has become a feature therefore of the working life of these professions, and medicine, which was in the forefront for undergraduate and postgraduate education, has somewhat lagged behind in this. The failure of consultants to keep up to date in their professional knowledge and attitudes is clearly detrimental to patients, to the doctors themselves, and to the Health Service.

Medical and nursing staff in acute specialities spend up to 25% of their working lives collecting, analysing, using and communicating information (Audit Commission, 1995). It is likely that staff delivering mental health care, which often involves services and staff based in a number of locations and inter-agency collaboration, spend just as much of their time on these activities.

Advances in the understanding of the genetic causes of some neuropsychiatric disorders are having an impact on clinical practice as direct mutation analysis becomes possible. Mutation analysis is now available in UK Health Service diagnostic laboratories for Huntington's disease (HD) and the fragile X syndrome (FRAXA). Psychiatrists need to be familiar with issues surrounding presymptomatic and diagnostic testing in HD and diagnostic and carrier testing in FRAXA. They may be asked to assist clinical geneticists in the assessment of candidates for HD presymptomatic testing and a suggested mode of assessment is described here. The procedure for HD will provide the model for use with other familial neuropsychiatric disorders of late onset, notably familial Alzheimer's disease (FAD). Testing for FAD is already possible in conjunction with research laboratories in the few families where a mutation has been discovered and we shall have more tests for FAD within a few years.

Healthcare organisations are currently in the midst of a period of fundamental change. Mental health services in particular have moved away from institutional care towards a complex inter-related community health social and voluntary model of service delivery, involving a diverse range of care professionals and commissioners.

Community mental health teams (CMHTs) have their origin in the American Community Mental Health Centre programme of the 1960s. The teams were mandated to provide services with an emphasis on the needs of the severely mentally ill (SMI). However, over time the focus of work became ‘the worried well’, to the neglect of those with severe mental illness. CMHTs are now a firm feature of British psychiatry. A Sainsbury Centre study recently identified over three hundred CMHTs across England, defining themselves as comprising at least four members, from two or more disciplines, with a caseload of individuals with mental health disorders, largely residing in the community.

The first electroconvulsive treatment was administered by Cerletti and Bini in 1938. The event was essentially an experiment, carried out like a military operation (Endler, 1988). The patient was stimulated three times, each time increasing the intensity of the stimulus before a generalised seizure was induced. He had been suffering from an acute psychosis with a poor prognosis, but responded to a course of 11 treatments and was discharged free of symptoms two months later. The first paper on electroconvulsive therapy (ECT) in English was published in the Lancet (Kalinowski) in 1939. At that time, somatic treatment alternatives for the severely ill in large mental institutions included lobotomy and insulin coma therapy. In comparison, unmodified ECT (albeit associated with a significant risk of serious physical morbidity) was predictable, efficient, quick and effective. It is understandable why the treatment became widely and fairly indiscriminately adopted before systematic objective evidence of its efficacy was collected.