Guidelines are systematically developed statements designed to help practitioners and patients make decisions about appropriate health care for specific circumstances (Jackson & Feder, 1998). ‘Help’ is an important word. Guidelines/guides, in most instances, may suggest a road to take in order to travel from A to B, and make explicit why those suggestions have been made. Provision of this information respects the traveller's ability to assimilate the information, and make decisions on applicability. The traveller is then not constrained by information but helped by it. At the end of the day, for clear reasons, a different road may be chosen.

The German mental health care system differs significantly from the system in the UK. There is no central organisation with overall responsibility as in the National Health Service (NHS), and the government is not entitled to prescribe details of policy or set specific targets. It can only determine the legal framework, define general goals and, with difficulties, influence the spending level. Responsibilities for mental health care, as for other fields of health care, are shared between federal authorities, the 16 states (Lander), local authorities, and semi-statutory organisations, which govern out-patient health care provided by psychiatrists in office-based practices. Virtually every citizen is health-insured and there is free access to health care for those who have no insurance coverage, in which case social services usually cover the costs. Social services also directly fund various services in the community. The fragmented system can be difficult to comprehend. However, many of the challenges are similar to those in other countries, and policy makers and practitioners elsewhere might be interested to know some of the lessons learnt in the German system.

Prolactin, a protein hormone synthesised and released by the anterior pituitary, promotes mammary tissue development and lactation and suppresses gonadotrophin secretion. Dopamine is the natural inhibitor of prolactin release and so standard antipsychotics, which block dopamine receptors, will cause prolactin levels to rise. This hyperprolactinaemia can lead to gynaecomastia, galactorrhoea, menstrual disturbances, a reduction in sperm count, erectile dysfunction, failure of ejaculation and reduced libido. Prolactin-related adverse effects are frequently encountered in patients on antipsychotics and are a cause of substantial morbidity.

The weekly educational supervision sessions between consultant psychiatrists and their trainees have emerged as a central pillar of psychiatric training. The College has set out, in various Statements on Approval of Training Schemes for General Professional Training for the MRCPsych, what it expects of these sessions: they should happen weekly, be devoted entirely to the needs of the trainee, and be applied to the development of the trainee's clinical skills as opposed to academic knowledge.

A controlled study of community care in serious mental illness (SMI) was carried out. Patients with SMI were randomised to have hospital care or be looked after by a community psychiatric care team in a Daily Living Programme (DIP). The day-to-day work of a clinical team with the difficulties encountered in delivering community psychiatric care in an inner city is described. There were seven deaths from self-harm during the 45-month study. One DIP patient committed homicide. An ordeal by media following this and the suicides are described. Lessons learnt include the need for the community care team to be responsible for discharge from any in-patient phases and for attention to team morale, especially during adversity, and to time spent working under pressure.

Controlled trials show that about 80% of schizophrenic patients remain relapse free when given adequate neuroleptic maintenance therapy but this level of efficacy is not achieved in clinical practice. Guidelines for proper use of neuroleptics in relapse prevention were developed by a group of experienced psychiatrists – the ‘Consensus Group’ – in 1989. In this survey, the views of UK psychiatrists, GPs, CPNs and pharmacists involved in community care of schizophrenia were compared with the Guidelines.

What follows is concerned with the role of the consultant. To avoid stereotyping of gender or race, this consultant will henceforward be referred to as she and should be considered as of minority ethnic origin.

The British National Formulary (BNF) entry for clozapine clearly distinguishes the treatment dose (200–450 mg daily, maximum 900 mg) from the maintenance dose (150–300 mg daily). We looked at 44 patients maintained on clozapine locally and found that 36 (82%) received doses above the BNF guidelines. This has considerable cost implications. While it is always good practice to maintain patients on the lowest possible dose of antipsychotic, the BNF guidelines are not based on objective outcome data, and should be treated cautiously.

It is important to explore and interpret the dynamics of cultural differences and racism in clinical work. Race and culture often play a significant role in any psychotherapeutic relationship. Vignettes and clinical narratives are used to illustrate that they can be a useful vehicle for the expression of transferences, demonstrating how basic concepts of psychotherapy apply to cross-cultural interactions.

Patients waiting for psychotherapy show high levels of morbidity and distress from psychiatric symptoms and a high frequency of personality disorder diagnoses. They constitute a group at risk of completed suicide. Local NHS provision is less than half the minimum amount of treatment needed.

The role of carers is explored in the process beginning with the early detection of changes in cognitive function through to the diagnosis of dementia. Carers were not always aware of early cognitive decline before other family and friends. Forty-five per cent of initial diagnoses were made by GPs. In over 50% of cases, the sufferer had not been told their diagnosis by health professionals or carers. A quarter of carers wanted more information about dementia even after referral to specialist services. The importance of early referral and provision of sufficient comprehensive information about dementia are discussed.

A postal questionnaire concerning the management of cognitive impairment of vascular origin was completed by 88 psychogeriatricians and 100 geriatricians. Aspirin was considered an important part of management, and clinically indicated with: a history, or clinical signs of stroke; computerised tomography (CT) scan changes suggestive of cerebrovascular disease; and atrial fibrillation. Advanced dementia was seen as a contraindication for treatment. Eighty per cent of responders indicated they would institute antihypertensive therapy in an elderly patient with a history of raised blood pressure and cognitive impairment. The median lower limit of systolic blood pressure requiring treatment was 160 mmHg, with a treatment target blood pressure of 150 mmHg.

There is an increasing body of research literature investigating the effects of parental mental illness on children. This study investigates the views of psychiatric in-patients on consequences of their admission to hospital and their mental illness for their children. The results suggest that the parents do not readily acknowledge that their children have problems, and that interventional approaches require good liaison between adult mental health services and child-focused agencies.