General audit of psychotherapy services is slowly becoming a more regular part of practice in psychotherapy departments. Parry (1992) in her key review article states that “unmonitored practice is no longer defensible”. Audit specifically targeted at the quality of psychotherapy performed has been recommended (Fonogy ft Higgitt, 1989) but it is not often reported in psychotherapy (although a notable exception is Feldman, 1992). The beneficial effects of an ad hoc audit of the quality of psychotherapy using tape recorded sessions are reported.

Clinical experience suggested that between one tenth and one fifth of new referrals to a county-wide child and family service were referrals of children who had mental handicap. The purpose of this project was to establish the proportion prospectively with the clinical assessment used routinely by the service.

Our objectives were to identify and assess the services provided by the Mental Illness Specific Grant in Scotland and to determine whether they meet government aims for the grant. Scottish Office information proved to be inaccurate on what projects are funded and currently running. Slippage was common with 39% of projects failing to start in Year 1 and 23% in Year 2. The grant appears to have funded easy option services, self-help, drop-in, which are less expensive and only require short-term planning. Despite being given priority by the Scottish Office, housing, supported accommodation and occupation remain unmet needs.

A retrospective investigation of case-notes compared 54 incidents of informal psychiatric in-patients being detained in hospital on an emergency basis with 66 incidents of discharge against medical advice (AMA). The characteristics of the two groups were compared. Detained patients were more likely to have been detained previously, to be suffering from a psychotic illness, and to have threats of violence or self-harm mentioned in their case-notes. AMA patients were more likely to have a history of substance abuse but were no more likely than the detained group to have been discharged AMA in the past. The results suggest that psychiatrists in this hospital are using current legislation on detention appropriately.

We describe the operation of a substance misuse clinic for adolescents as a Joint venture between a voluntary organisation ‘Streetwise’ and the Adult Substance Misuse Services and Child and Adolescent Psychiatry Services in Newcastle upon Tyne. A number of issues are discussed relevant to improving clinical services for adolescent substance misusers.

In 1992, 46 consultants in old age psychiatry were asked to list their five most frequently used antidepressants, with reasons for their choices, and to comment on an information set for evaluating an antidepressant for use in older people. Lofepramine tied with dothiepin as the most popular antidepressant. The relatively new selective serotonin reuptake inhibitors (SSRis) were also widely used. Cardiovascular safety, lack of anticholinergic side effects and safety in overdose were important factors in choice. Some antidepressants were preferred for particular symptoms or circumstances. A modified information set for evaluating an antidepressant for use in older people is presented.

A six year retrospective study was performed on the referrals to a fast stream rehabilitation unit in Plymouth (‘114’). In the wake of recent hospital closure, an historical perspective on the changes within the service and the model of our new rehabilitation service is presented. Clinical features, demographical details, outcomes and duration of stay were examined. New strains have been put on acute psychiatry resources and it was demonstrated that the rehabilitation process has had a beneficial effect on acute general psychiatric bed usage.

This paper contributes to a debate about the nature of religious belief and its relevance for the practice of psychiatry. The need for dialogue is recognised not only because of multi-faith UK society but also because mental health services are now more tailored to the expectation of patients. To understand the possible relevance of spiritual and existential dimensions to mental illness, even in a secular society, has become more necessary. Training, service delivery and research issues are briefly addressed.

The Health of the Nation asserts that the suicide rate in England and Wales can be reduced by the provision of better health care services. In a sample of suicides in one district health authority, 61% had had contact with health services during the year prior to death, suggesting that improvements in these services could have an impact on the overall suicide rate. However, the proportion who had had prior contact varied between different age and sex groups and individuals in groups with the higher suicide rates tended to have the least contact. Therefore, the impact of health service improvements on the overall suicide rate may be limited.

The Merck Essay Prize was inaugurated in 1993. All trainee psychiatrists (senior house officers, registrars or senior registrars) in the United Kingdom and Republic of Ireland were eligible to submit an essay on the topic: ‘Depression: Counting the Costs’. The winning essay by Dr Peter Haddad is printed here. The runners-up in Joint second place were Dr J. Bray, Lecturer, University of Leicester (Leicester General Hospital) and Dr R. Bullock, Senior Registrar, St Mary Abbots Hospital, London.

Depressive illness is the commonest form of mental disorder in the community. Its effects are far-reaching and include psychological suffering and social disruption for affected individuals and their families, increased mortality, and direct and indirect financial costs for society. Only about half of all cases of depression are recognised by doctors and not all of these receive effective treatment. The costs of depression could be reduced if detection and treatment were improved. Addressing this is a major challenge for psychiatric services.

Induction courses can offer trainees many benefits. These include a feeling of being welcome, a sense of belonging, reduced anxiety and increased confidence about the work ahead. The benefits to services include increased morale and efficiency brought about the trainees' quick orientation to their clinical roles and the organisation of services. This article considers induction to a hospital unit, to a hospital, and to regional services.

The use of electroencephalography over a three year period in a large mental handicap hospital was studied. There were no significant differences in its use according to sex or intelligence. The majority of requests were made following seizures and in the investigation of behavioural abnormality. In over a quarter of cases the EEG requests appeared to be inappropriate. It is suggested that a more cost-effective use would result if EEGs were requested only in those cases in which the result will lead to a change in the management of the patient.

There are advantages to be gained from a knowledge of the patient casemix that psychiatric hospitals, and community services, are likely to encounter. In particular the efficient allocation of resources would be better achieved if individuals could be ‘placed’ into groups. These groups would need to be clinically distinct and contain similar members. Previous methods of defining casemix have focused upon clinical diagnosis. However, the effectiveness of diagnosis in predicting resource utilisation is limited. A range of other factors could be used, including comorbidity, severity of illness, and previous hospital contact.

From April 1994, over 95% of health care services will be provided by NHS trusts. Mental Health services have a choice of remaining within the acute hospital trust or forming part or all of a community trust. Using data from trust directories, the distribution of mental health services within the first three trust waves is described. Forty per cent of acute hospital trusts currently do not include mental health services. Unlike other specialities, a significant proportion of mental health services are choosing to form specialist mental health trusts. The implications of the alternative trust arrangements for psychiatry are discussed.

The effects of losing a loved one through death on the physical and mental health of both adults and children are well documented in the literature. Children are likely to be referred to mental health professionals for various behaviour and emotional problems which may have a causative link with a bereavement within the family. In this paper I discuss the need for preventive work and, propose a role for child psychiatric services in preventive work for bereaved families with surviving children and adolescents. A ten-point plan is suggested as a guideline.

Residential child psychiatry units inevitably offer a form of temporary parenting to their patients. This paper explores various effects of this ‘parenting’ task on the treatment process itself and on a unit's relationship with parents. The potent therapeutic opportunities as well as potential unwanted effects deriving from this role are described. An awareness of the processes involved along with appropriate case management can maximise the benefits and minimise the unwanted effects of this factor within in-patient treatment.

In the new style NHS an annual report is essential for all services. Senior registrars have the necessary skills and are ideally placed to co-ordinate such an enterprise as part of their management training. The typical structure for such a report is described and suggestions are made on content and format. Pitfalls are outlined from the authors' experience.

This paper documents the rate of referral to an eating disorders service for adults which predominantly serves a large defined catchment area. It also defines the proportion of all new patients which presented with such disorders. People with eating disorders amounted to about one in ten of young women and one in 30 of all patients presenting to psychiatric services for the first time.

Doctors working in psychiatry have been shown to lack practical skills in basic cardiac life support (BCLS), but these have not been regarded as priorities for training. This study assessed levels of experience, confidence and skill in BCLS, in psychiatrists, and examined the effect of a single training session on practical skills. Levels of skill were generally poor but significant improvement was seen following training. It is recommended that all psychiatrists undergo brief regular practical training in BCLS.

As the care of people with learning disability has shifted from large Victorian hospitals to the community, provision for in-patient psychiatric treatment has, in many districts, also moved. Purpose built district or supra-district admission services represent the most common model. An alternative is the use of existing general psychiatric beds. In this article we describe the first 18 months of the Hillingdon district service where this latter model has been adopted.