The Prime Minister's challenge on dementia called for improved dementia diagnosis rates, based on assumptions of benefit to individuals and those who care for them. Subsequent policies have led to increased target drives for clinical practice to achieve early diagnosis of dementia through intense case identification. However, the current evidence base and treatment options do not support screening for dementia, and there is little empirical evidence that such intensive case identification and early diagnosis for dementia is justified without a better understanding of the benefits, costs and potential harms to individuals and services.

This editorial offers an overview of mental health service provision across different languages and cultures in the UK. It is increasingly recognised that mental health service users with limited English proficiency are rendered doubly vulnerable by the combination of their illness and their language difficulties. Only recently has the importance of safe, coherent, nationally available interpreting, translation and language support (ITALS) been recognised by healthcare providers. We review the challenges within the interpreted interaction, some reasons for the scarcity of qualified and accredited ITALS suppliers, and some solutions to the ITALS problem.

Psychiatric disorder is a common complication of mental handicap. Whilst there are few detailed studies of psychiatric morbidity in mentally handicapped people, recent epidemiological surveys indicate that approximately 50% of mentally handicapped people in hospital and in contact with services in the community have suffered from psychiatric symptoms or behavioural problems sufficient to require specialist advice. All forms of psychiatric disorder are seen although the pattern differs somewhat from that in the general population and there is a high frequency of behaviour disorders.

Since the 1960s, Western society has adopted a more liberal attitude to sexuality. Choice of sexual partners, sexual preferences, attitudes and practices are increasingly a matter of individual choice and freedom. These changes, however, have had little impact on the lives of psychiatric in-patients (Eiguer et al, 1974; Akhtar et al, 1977; Taylor & Swan, 1999). ‘Mental illness,’ it has been suggested, ‘is one of the few disabilities where people run the risk of losing their freedom in order to receive in-patient treatment’ (Cook, 2000). This loss of liberty and rights becomes more pronounced in secure settings where mentally disordered offenders can spend a substantial part of their adult (sexual/reproductive) lives. Prisoners in some US state prisons (of medium and low security) are afforded conjugal visits from their married partners, in view of the rights of the latter. Paradoxically, detention in secure units, which we consider a therapeutic and not a punitive measure, places constraints on the formation of new relationships and the maintenance of previously existing ones. New relationships are, in our experience, viewed with more concern than previously existing ones.

The development of psychiatric care in Ghana since the colonial era in the 19th century, up to the present, is described. Distorted planning and limited accessibility to psychiatric services in many parts of the country, coupled with shortage of trained staff of all grades (including psychiatrists and nurses) plus inadequate funding, have adversely affected the establishment of a fully comprehensive psychiatric service. Suggestions for improving services into the 21st century are briefly discussed.

Mental health legislation in Northern Ireland has always been separate from legislation in the rest of the UK; the Mental Health (Northern Ireland) Order (MHO) had been in place since 1986. In common with other jurisdictions, this legislation utilises the presence of mental disorder and risk as criteria for detention and involuntary treatment. The MHO has been replaced by the Mental Capacity Act (Northern Ireland) 2016 (MCA), an example of ‘fusion’ legislation in which impairment of decision-making capacity and best interests are the only criteria to be used when making decisions across health and social care. In this paper, we outline the development of the MCA to date, and discuss its potential to improve mental healthcare by placing the treatment of mental illness within the same legislative framework as physical illnesses.

The Department of Health publication Building a Safer NHS for Patients sets out the Government's plans for promoting patient safety (Department of Health, 2001). This follows growing international recognition that health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events occurring in health care settings. These plans include a commitment to replace the procedures set out in the Department of Health circular HSG(94)27. This guidance details the methods for investigating every homicide (and some suicides) by patients in current or recent contact with specialist mental health services. Part of the process to modernise HSG(94)27 includes a plan to build expertise within the National Health Service (NHS) in the technique of root cause analysis. This investigative process was developed in industry to identify causal or systems factors in serious adverse events.

Lithium is an established treatment for bipolar disorder and an augmenting agent for treatment-resistant depression. Despite awareness of renal adverse effects, including chronic kidney disease, for the past five decades, there has been a lack of research evidence. This has led to debates around the existence and magnitude of the risk. This article discusses the current evidence base regarding the link between lithium and chronic kidney disease, monitoring of renal functions and its clinical implications.

This is the final contribution to a five part series on risk in psychiatry. Bowden (1997) has cast a bleak eye on the realities of making risk decisions about difficult and dangerous patients, identifying the essential subjectivity of these decisions and the cognitive distortions that psychiatrists can undergo to make them apparently easier; distortions that can blind the clinician to impending disaster. Morgan (1997) emphasised the limitations of a simplistic ‘risk factor’ approach to the management of potentially suicidal patients, concluding that the priority is the refinement of our basic clinical skills (and by implication deployment of successful treatments for our patients' illnesses). Prins (1997) analysed the particular difficulties faced by mental health review tribunals hearing the cases of Restricted patients. The perhaps unsurprising conclusion is that tribunals make bad decisions when presented with inadequate information (which begs the question why not adjourn and seek the information required before proceeding?). Roy (1997) has addressed a range of risks faced by Trusts and the clinicians who work for them. There is a clear demand that Trusts develop risk management strategies: of necessity these strategies will discourage inherently risky behaviour such as inadequate staffing of in-patient units and the devolution of inappropriate levels of responsibility to staff who are inadequately trained or supported.

The growing realisation that health care resources are limited has led to increasing concern about the wastage caused by the failure of patients to keep their psychiatric appointments. Generally, non-attendance following psychiatric referral is particularly high (e.g. Baekland & Lundwall, 1975), although in the north-east of Scotland the rate is roughly similar to those reported by other specialties (Alexander & Hillis, 1989). However, little effort has been made to elicit the views of non-attenders themselves or to consider what aspects of the referral system may contribute to this failure to attend.

Ambulatory deep brain stimulation (DBS) became possible in the late 1980s and was initially used to treat people with movement disorders. Trials of DBS in people with treatment-resistant psychiatric disorder began in the late 1990s, initially focusing on obsessive-compulsive disorder, major depressive disorder and Tourette syndrome. Despite methodological issues, including small participant numbers and lack of consensus over brain targets, DBS is now being trialled in a wide range of psychiatric conditions. There has also been more modest increase in ablative procedures. This paper reviews these developments in the light of contemporary brain science, considers future directions and discusses why the approach has not been adopted more widely within psychiatry.

I have recently taken up a post as Senior Registrar in Psychotherapy in Leicester where about 20% of the citizens are Asian or Afro-Caribbean. For the rest of this article I shall use the term ‘black’ as synonymous with Asian and Afro-Caribbean. While realising this may offend some readers, I use it in a political sense and know that many prefer it to the equally inaccurate use of the term ‘ethnic minority’. Before being promoted, I was on the general psychiatry registrar rotation in the same city and not surprisingly had a large number of black patients. Now I have none; there are very few referred to the Department, and I gather this is typical of psychotherapy units across the country. I want to consider why this is so, and what, if anything, should be done about it.