We have subjected the current structure of the psychiatric consultation to critical examination, and We propose that the concepts of ‘history’, ‘mental state’ and formulation’ should be abandoned. In their place we propose the more carefully defined concepts of ‘narrative’, ‘interaction’, ‘examination’ and ‘inferences'. The clinician should make a dear distinction between information that is reported, observed or inferred, as these sources of knowledge are qualitatively different, and subject to psychodynamic, systemic and cultural influences. We propose that this approach would facilitate a clearer and more comprehensive understanding of the patient, and lead to a more creative therapeutic relationship.

Referral rates to three groups of mental health professionals working In primary care were compared. All patients referred over an 18-month period at two health centres in an outer London borough were assessed by case-note review and data were collected on 181 consecutive referrals. In general, younger, more socially-stable patients were referred to the psychologist and older patients were seen by the CPN. The psychologist saw most new patients; patients previously seen by a psychiatrist were most likely to be referred again to a psychiatrist. Patients requesting referral to a mental health professional were most likely to be referred to the psychologist. Patients with a diagnosis of psychosis were seen mainly by the psychiatrist and the CPN; the psychiatrist saw most patients with a personality disorder. A high proportion of patients were seen for assessment only. In general, all interventions were brief. There was evidence of selection by GPs in the referral of patients to each mental health professional.

The study examines the knowledge and views among district social workers of a local child psychiatric service and determines whether their views influence decisions to refer to the service. The results are compared with similar studies of general practitioners (GPs) and paediatricians and discussed with reference to recent national reviews of child psychiatry in the UK.

The Urgent Assessment Service (UAS) was set up to provide community based urgent psychiatric assessment to a range of referrers. The work of the service was assessed over a six month period. Results show that it was popular with a broad range of medical and non-medical professionals. Patients generally presented with depression or psychotic illnesses and those referred from non-medical sources were more likely to be suffering from schizophrenia and assessed as being at least as unwell as those referred by GPs and hospital based doctors. Rates or referral to hospital services were low with the vast majority of patients being referred back to their general practitioner after initial assessment and treatment.

Psychiatrists in learning disabilities in the South-East Thames Region were asked to fill in questionnaires on the last five patients they had sectioned in an attempt to describe current practice in their usage of the Mental Health Act (1983). Clients tended to be sectioned under the category of mental impairment and were mainly young males with violent behaviour. Treatment of mental illness was less of a problem.

The alcohol withdrawal syndrome is characterised by symptoms such as anxiety, insomnia, anorexia, nausea, tremor, sweating and disturbances in coordination. These symptoms tend to occur within 6 to 12 hours of alcohol-dependent patients stopping or reducing their alcohol intake. Less frequently, convulsions, hallucinosis and delirium tremens can occur. Delirium tremens (disturbed orientation, visual and auditory hallucinations, paranoid ideation and tremulousness) is the most serious complication of alcohol withdrawal and occurs in up to 5% of patients withdrawing from alcohol. If it is severe or poorly treated, death can occur. In the UK some clinicians use chlormethiazole while others favour chlordiazepoxide. This article will examine and compare the use of these two drugs.

Rapid cycling (RC) occurs in up to 20% of patients with bipolar affective disorder and is particularly common in women. It is generally defined as a condition where four or more episodes of (hypo-) mania or depression occur in any year. Frequently, patients with RC switch rapidly between episodes without passing through a euthymic stage. RC is notoriously difficult to treat and the refractoriness of the condition has led to a number of drugs and combinations being put forward as potential therapeutic interventions. This article reviews current treatments and suggests a treatment strategy based on available evidence of efficacy and tolerability.

We conducted a survey of the psychotherapy training of a national sample of successful MRCPsych candidates to discover the extent of their psychotherapy training and their opinion about its adequacy. Ninety doctors answered the survey. Overall 71% of trainees had clinical experience in behavioural–cognitive psychotherapy and 78% in psychodynamic psychotherapy with fewer gaining experience in group and family psychotherapies. The majority of trainees were dissatisfied with the extent of their behavioural-cognitive psychotherapy training (82%) and psychodynamic training (50%). Trainees felt that their psychotherapy training was an important component of their psychiatric training.

We have seen many interesting accounts of people's training experiences on the part-time scheme published in this journal, and one or two interesting articles looking at broader related issues, for example looking at attitudes and awareness of part-time training among colleagues and the impact of these factors on recruitment to part-time training.

Clinical supervision of counselling and psychotherapeutic work performed in a district general adult psychiatric service is examined. Most staff received regular supervision, usually having more than one source of supervision. Paired peer supervision, within a discipline, was the commonest structure. Supervision was mainly focused in two areas, on interventions made by the therapist, and examining the therapeutic relationship. Most staff had confidence in their supervision, but those who had not discussed a supervision contract were significantly less likely to be satisfied with their supervision.

Most doctors are probably uncomfortably aware of the old joke that an alcoholic is someone who drinks more than his doctor. But how would one define a drug addict? Because of the taboo and illegal nature of drug misuse, if a similar doctor-based definition were coined, even in jest, it would cause a degree of consternation and indignation among the profession. However, the evidence that doctors abuse certain substances, in particular opiates and tranquillisers (Hughes et al, 1992), more commonly than the general population is well established.

Hyper and hypo-parathyroidism both lead to psychiatric disorder. In the former the hypercal-caemia is responsible for an acute or chronic organic reaction, depending on the speed with which the calcium has risen. The hypocalcaemia of the latter is more likely to present as tetany, and enters into the differential diagnosis of hysterical over-breathing (Hill et al, 1987). Hypo-parathyroidism most commonly follows inadvertent parathyroidectomy during thyroiddectomy when an abrupt fall in serum calcium can precipitate psychiatric disturbance. The mental state is closely related to the serum calcium level. If this is borderline there may only be symptoms such as anxiety, depression and tension, but with lower levels acute confusion may result. More chronic symptoms occur in long standing hypo-parathyroidism, such as poor concentration, emotional lability and impaired intelligence (Kendall & Zealley, 1983).

Between the 15 and 17 of June 1995, Liberty and other organisations concerned with human rights coordinated the Human Rights Convention. This gathering examined the meaning of human rights, why they matter, and how they could be strengthened. In the full programme there was a workshop on mental health. This workshop examined how mental health legislation and practices affect the human rights of psychiatric service users.

It has been demonstrated that images of madness in the media powerfully influence the general public and serve to perpetuate popular stereotypes of mental illness (Philo et al, 1993). While the cinema's treatment of psychiatric issues has received critical attention (Gabard & Gabard, 1987), there is one area of film-making that has, so far, been neglected: the work of Walt Disney. Perhaps, because it has been primarily regarded as entertainment for children, Disney's work has not been subjected to serious examination. This neglect, however, is surprising in view of the current debate about the influence of the media on children. When one also considers that Disney films are now available on video and are being seen by millions, it seems worthwhile to look at the images of madness they present.