The MARSIPAN (MAnagement of Really SIck Patients with Anorexia Nervosa) project was established in response to reports of patients admitted to medical wards and proving refractory to treatment, sometimes dying on the ward. Psychiatrists, physicians and other clinicians in nutrition and eating disorders were brought together to discuss key issues in the assessment and management of such patients. The resulting guidance report, which applies to adult patients over 18, addresses: assessment of risk, where to treat the patient, specialist support for medical teams, key elements of treatment, namely (a) safe refeeding to avoid refeeding syndrome and underfeeding syndrome, (b) management of problematic behaviours, (c) support for the family, and (d) transfer to a specialist eating disorder unit when appropriate and possible.

A group of interested people met for two days last year in order to attempt to reach a consensus on good practice in the management of patients with generalised anxiety. The result of their efforts is published below.

Most patients presenting with anxiety, whether acute or chronic, mild or severe, were until recently treated with tranquillisers. Recognition that these drugs can cause dependence in some patients has prompted a re-evaluation of the pharmacological management of anxiety and the value of non-pharmacological treatments is now recognised. Uncertainty remains among many doctors about the efficacy of the whole range of current therapies and the place of the new classes of drugs for anxiety. However, research findings are now accruing which indicate the relative merits of these various therapies, and clarify the principles on which they are based.

The Royal College of Psychiatrists has established a Working Group on Choice in Mental Health and held a conference to include service users in formulating a challenging view of the choice agenda for mental health. This is set out here to stimulate wider interest. Choice-based practice develops in a climate of trust and information, and goes beyond simple variety or individual consumerism. For some service users, limited initial areas of choice can be of great importance, but a true culture of choice requires the widespread participation of service users and carers in service improvement. It is important that psychiatrists champion the empowerment of their patients through choice, in policy and training, and in clinical practice.

Quality improvement (QI) approaches are becoming increasingly important in the delivery of mental healthcare internationally. They were originally developed in the manufacturing industry, but the principle of having a systematic approach to improvement has spread to many other industries, not least to healthcare. Quality improvement approaches in healthcare were pioneered in the USA at organisations such as Virginia Mason and the Institute for Healthcare Improvement. In recent years, they have become firmly established in mental health services in the UK's National Health Service (NHS). There are a number of different approaches to quality improvement, but two leading models have taken root: ‘lean thinking’ (also known as ‘lean methodology’ or simply ‘lean’), which arose out of Virginia Mason, and the ‘Model for Improvement’, which came out of the Institute of Healthcare Improvement. This article describes these two quality improvement approaches, critiques their philosophy and explores how they can apply in the provision of mental healthcare, particularly with reference to the use of data, evidence and metrics.

Sexual harassment and assault on psychiatric wards is an ongoing concern. A number of incidents have been reported in the media. This paper focuses on a policy drafted to deal with allegations of sexual assault or rape on an in-patient psychiatric ward. We aimed to produce a practical, easy-to-follow guide for junior doctors and ward staff who may face complex and possibly contentious issues surrounding consent, capacity to consent and police involvement.

This article summarises the findings of a National Health Service Executive, Royal College of Psychiatrists', National Association of Health Authorities and Trusts, and Trust Federation working group on medical staffing in mental health, which reported to ministers in summer 1996 and was launched at a conference in November 1996 jointly with the College. Although primarily focused on England and Wales, it is clear that similar problems exist in other parts of the United Kingdom and the Republic of Ireland.

In recent years, there has been increasing interest in the development of psychiatry in the Arab countries. Several reports have dealt with psychiatric problems in Iraq, Kuwait and Saudi Arabia (Al-Issa & Al-Issa, 1970; Kline, 1963; Dubovsky, 1983). Two general reviews have also dealt with major psychiatric research in the Arab Middle East (El-Islam, 1982; Racy, 1970). However, the countries surveyed have been under British and American influence and tend to follow the Anglo-Saxon psychiatric model. Little attention has been given to North African Arab countries which follow the French and franco-phone approach to psychiatry.

Despite anti-stigma campaigns in the UK in recent years, the experiences of people with mental health problems indicate that stigma is still a major problem. The stigma of being a member of a socially excluded group, based on socioeconomic, personal or cultural/ethnic characteristics, should be considered alongside the stigma of mental illness. Membership of a stigmatised group (not based on mental illness) is often itself a risk factor for developing mental health problems. This article discusses the experiences of people from Black and minority ethnic and lesbian, gay and bisexual groups to explore how stigma can create more stigma.

Comorbidity of severe mental illness and substance misuse is now common in general psychiatry (Regier et al, 1990), and perhaps almost standard in forensic psychiatry (Snowden, 2001). It is also reflected in child and adolescent psychiatry (Boys et al, 2003) and even in old age psychiatry (Jolley et al, 2004). The range of hazards associated with substance misuse in people with mental illnesses includes elevated risk of relapse of psychosis (Cantwell & Harrison, 1996), increased frequency of hospitalisation (Bartels et al, 1993), poorer compliance with treatment (Jablensky et al, 1992), higher levels of treatment-resistance (Bowers et al, 1990), impairment of the integrity of therapeutic regimes in hospital settings and in hostels in the community (Sandford, 1995), stress in the community (Drake & Wallach, 1989), higher rates of homelessness (Scheller-Gilkey et al, 1999), increased suicidality (Drake & Wallach, 1989), and increased potential for antisocial behaviour and crime of both an acquisitive and a violent nature (Stewart et al, 2000; Sinha & Easton, 1999). The misuse of substances is therefore a significant obstruction to the effective use of psychiatric treatment, and the financial cost associated with such clinical adversity must run into millions of pounds.

Traditionally, general practitioners and psychiatrists relate to one another through a system of cross referrals, from primary care to secondary care and back again, the referral being initiated by the GP through a request for a domiciliary visit or more usually for an out-patient assessment of the clinical problem. However, in the mid-1960s, individual psychiatrists began to report a new way of working, which consisted of the psychiatrist going by invitation into GPs' surgeries or health centres to work directly with the general practitioners and with other members of the primary health care team. A survey undertaken by Strathdee & Williams of the General Practice Research Unit of the Institute of Psychiatry, showed that by 1984 in England and Wales, one psychiatric consultant in five, sometimes with, sometimes without, junior staff, spent some time in a general practice setting. At the College meeting in Cambridge (April 1988), Pullen reported that in Scotland a similar survey showed that as many as 40 to 50% of psychiatric consultants spent some time in primary care settings.

Liaison with the various agencies which deal with mentally abnormal offenders is one of the prime roles of the forensic psychiatrist (Royal College of Psychiatrists, 1988). The probation service is a key agency in this regard. The importance of such collaboration has once again been highlighted with the clear message that the care of the mentally abnormal offender is improved as a result (DOH/Home Office, 1991). However, the provision of a satisfactory psychiatric consultation service to probation clients who have been remanded on bail can be problematic. Much of the work of forensic psychiatrists is institutionally based. Non-attendance rates at hospital based out-patient clinics are high (Bowden, 1978). However, general psychiatrists have found that psychiatric clinics based in general practitioners' surgeries are more acceptable to patients than hospital clinics (Tyrer, 1984). The probation office as a community base for forensic psychiatrists is a valid equivalent.