An audit was undertaken to assess the efficacy and efficiency of a community-based mental health service which attempts to prioritise the care of those with severe and enduring disorders. Referral patterns over a three month period and change in case-load over the subsequent 12 months were recorded. Seventy-five per cent of new referrals met the priority group criteria, allaying anxieties that community services unceasingly get drawn to the care of those with less severe disorders. Furthermore, at 12 months the service had maintained contact with all patients previously admitted to hospital and all those presenting with psychotic disorders (27% referrals). Some changes in service structure are also suggested as a result of this evaluation.

People with the dual diagnosis of mental illness and mental retardation have proved difficult to resettle from hospital. Yet there is considerable evidence that, if diagnosed correctly, treatment for such patients can be effective (e.g. Matson, 1981; Welch ft Sigman, 1980). This paper describes the outcome of treatment at a specialist unit for patients with dual diagnosis.

As hospitals close and relocate, our patients are increasingly being moved between different sites and out into the community. A move back to a large institution, however, is rare. This article describes the move of an in-patient facility located in a general hospital to an old psychiatric hospital with which, historically, it did not have very strong links.

The contribution of the chaplain to patient care is rarely discussed and is sometimes forgotten. This paper discusses the role of the chaplain in a regional secure unit.

All staff based in a newly built acute psychiatric unit for more than six months were asked about the difficulties they encountered in the implementation of their duties and what changes they recommended. The problem areas identified included poor design and location of nursing observation station, lack of proper seclusion facilities, insufficient ventilation, unsafe position of the roof garden, exposed beams and supports, proximity to the lake and inadequate interview facilities for all staff. The urgent recommendations included alteration in the design and positioning of observation station, improving ventilation, making the roof garden safe, and covering all exposed beams and supports. The desirable changes included extra interviewing facilities and a spacious observable television room. Consultation by mental health professionals during the initial stage of designing of psychiatric units is essential.

This paper describes a supervision group for senior house officers which focused on the psychodynamics of their working relationships with patients. The SHOs worked in a variety of hospital specialties as well as general practice. The description includes details of how such a group was set up and some of the practical difficulties in maintaining the SHOs' attendance. Brief details are given of the types of cases the SHOs were most eager to discuss, and the nature of the leading anxieties connected with the cases. The SHOs found this type of supervision supportive and enlightening as they developed and improved their clinical skills.

Questionnaires exploring the attitudes of psychiatrists to philosophy were distributed at two meetings of the Royal College of Psychiatrists. Out of a possible 240, 126 questionnaires were returned (53%). The results showed a surprisingly high level of interest in and support for philosophy. Over 50% of respondents indicated that they considered conceptual analysis, ethics, jurisprudence, the philosophy of science and the philosophy of mind to be practically important in psychiatry. Similarly, 89% believed that ethics, and 72% that other areas of philosophy, should be included in the MRCPsych syllabus. The significance of the study is reviewed briefly.

A one day census of patients on the acute wards at a psychiatric hospital revealed that approximately 40% of in-patients were holders of driving licences and that the majority of them would be affected by the current regulations regarding fitness for driving. Despite this, few patients could recall being given medical advice regarding their driving. In only one case was any advice documented in the case-notes. Psychiatrists' responsibility for ensuring that patients are given appropriate information regarding the effects of their illness or medication on their driving performance is discussed.

One hundred and fourteen psychiatric trainees in the South Western region were canvassed by questionnaire concerning their knowledge of and attitudes towards the recommendations of Caiman Report, (DOH, 1993). Of the 78% of senior registrars and 80% of registrars who replied, the majority knew of the major recommendations mainly from reading articles and talking to colleagues. The 50% response rate from the senior house officers perhaps reflected a lack of knowledge and an erroneous perception that the report was of less relevance to them. The article reports responses to both structured questions concerning the facts, and comments received on more controversial aspects.

I previously reported (O'Shea, 1989, 1992) on the experience of national voluntary Huntington's disease (HD) and Alzheimer's disease (AD) organisations. This series of enquiries stemmed from an observation of Black (1988) that the medical profession in general offered little support to voluntary groups, a statement which has been largely supported for both HD and AD organisations in the first two parts of this trilogy. This final paper examines the experiences and attitudes of (mostly national) schizophrenia organisations.

Much of psychiatric practice involves understanding a patient's perception of reality and the influences that may affect this perception, including those of the environment. In organisations, such as the National Health Service, the need for consensus and approval within the organisational culture and environment may influence the publicly expressed views of employees, a process encouraged by short-term contracts and performance related pay. This article briefly describes some diverse experiences relevant to interpreting the real and the apparent.

A survey of the medical management of 75 mentally handicapped in-patients with epilepsy was carried out between June and December 1991. The study focused on the number and type of anti-epileptic drugs used, the frequency of monitoring of serum anti-epileptic drug levels and the nature and frequency of other blood tests carried out. Quality standards were then agreed and the survey repeated a year later. The results show that the agreed standards were generally achieved, although a large number of patients continued to receive more than one type of anti-epileptic drug.

We describe a survey examining the use of clozapine in South Manchester since 1990. The aims were to determine the patient characteristics, type of illness, response to treatment and recording of this information. The case-notes of the first 25 patients to receive clozapine between 1990 and 1992 were audited. Guidelines about who should receive this drug and what objective assessments should be performed were agreed by the consultant group. The audit demonstrated that 24 patients suffered from chronic schizophrenia which had failed to respond to conventional neuroleptics. Routine mental state examinations were regularly performed but objective assessments using standardised rating scales were employed infrequently. Sixteen out of 25 improved on clozapine but at the end of 1992 only ten subjects were still receiving this drug. The majority had been discontinued because of side effects.

A reason sometimes given for not applying a section off the Mental Health Act 1983 to patients for the first time is that this may stigmatise them in some way. A practical example off stigmatisation is that patients who have previously been ‘sectioned’ may be refused tourist or immigration visas to other countries. Since no information on this subject is available in the psychiatric literature this paper attempts to clarify the policy of diplomatic missions in the UK in relation to visa applicants who report a history of mental illness and compulsory hospital treatment.

Circumstances surrounding emergency detention under the Mental Health (Scotland) Act were examined, with particular regard to whether consent was obtained from a third party. Twenty-eight ot 100 consecutive detentions occurred without consent. These patients were more likely to exhibit aggressive behaviour and be detained by a psychiatric registrar or senior registrar. Mental disorder was doubted more often and detention was less often continued. Reasons given for failing to obtain consent were frequently inadequate and possible explanations are discussed. Increased education and supervision of trainees resulted in a substantial fall in cases of non-consent in a follow-up sample.

A brief description of the place of psychodynamic psychotherapy in the treatment of offenders is followed by an account of a forensic psychotherapy course run under the auspices of the British Postgraduate Medical Federation. The first year of a second year course leading to the diploma in Forensic Psychotherapy of the University of London is also described.

This paper examines the experience and motivation of junior doctors who successfully published in the Psychiatric Bulletin and The British Journal of Psychiatry, over a four month period. Most articles took over a year from first involvement to successful publication, although this varied according to the type of article. While having published is recognised to increase the likelihood of appointment to registrar and senior registrar posts, interest in the subject is frequently cited as a more important reason to publish among authors than enhancement of their curriculum vitae.

The Royal College of Psychiatrists specifies that supervision of trainees is the single most important ingredient of training. This paper reports the results of a pre-audit survey about trainee supervision. Eighty-three per cent of consultants (n=52) and 67% of trainees (n=51) responded to a 21-item Likert questionnaire. There was unanimous agreement for seven items. A significant number of consultants and trainees were dissatisfied with the existing arrangements despite the majority being involved in weekly supervision. The minimum standards proposed served as the basis for providing guidelines against which practice may be audited.