In 2001 the National Institute for Clinical Excellence (NICE) produced guidance for the treatment of Alzheimer's disease. NICE encourages the withdrawal of medication when the Mini-Mental State Examination (MMSE) score reaches 12 and advises against the treatment of patients with cholinesterase inhibitors if the MMSE score is below 12. Most health authorities have rigorously enforced these guidelines, which has put old age psychiatrists in a difficult position. Our prospective 12 week audit of consecutive patients examines the response to treatment of patients treated both in accordance with and outside of NICE criteria. We also investigated the effect of stopping the medication according to NICE's recommendation.

Our results suggest that patients outside the NICE criteria respond better than those within the criteria. More disturbingly, when the medication was stopped owing to the MMSE score falling below 12, we found a very high mortality rate (5 out of 25, 20%) or acute deterioration (12 out of 25, 48%). This suggests that the medication is beneficial in the later stages and should not be stopped purely because of the stage of dementia.

If we are to prevent unnecessary suffering, greater freedom is needed by old age psychiatrists in the use of these antidementia drugs. Patients with severe dementia may benefit from acute treatment. The withdrawal of medication in line with NICE guidance is poor clinical practice and likely to have adverse outcomes in a large proportion of cases.

Greetings cards (wishing patients well) appear less abundant on psychiatric wards than other in-patient facilities. We tested this hypothesis in three cross-sectional surveys of teaching hospitals in Sheffield.

On each occasion, psychiatric wards contained significantly fewer card recipients (χ2 test, P<0.001). Individual recipients in psychiatric wards received significantly fewer cards than recipients in general hospitals (Kruskal–Wallis test, P<0.05).

Although receiving a card might seem a trivial matter, it nevertheless denotes the outcome of an altruistic act, which may be appreciated by its recipient. Psychiatric in-patients receive fewer such acts of kindness than other in-patients. These data concur with other recent reports suggesting that the stigma of mental illness extends to expressions of altruism.

The aim of the study was to examine the association between the assessment of need by staff and by severely mentally ill patients using the Camberwell Assessment of Need in a semi-rural setting (Maidstone, n=50) and an inner-city area (Camberwell, n=127). Staff and patients were interviewed separately. We specifically examined differences in the total number of needs between Camberwell and Maidstone, differences in the number of unmet needs and differences in the level of agreement between staff and service users.

Patients in Maidstone had fewer needs than those in Camberwell according to both staff (4.9 v. 5.8) and patients (4.2 v. 6.3), fewer unmet needs rated (staff, 1.1 v. 1.5; patients, 1.0 v. 1.9) and a greater level of concordance between staff and patients.

The needs of severely mentally ill patients were greater in the inner-city area compared with the semi-rural one. The fact that agreement between staff and service users was less in the inner-city area also suggests that more stable staff–patient relationships existed in the rural area.

In a cross-sectional survey, we assessed the attitudes of older patients and their carers towards receiving copies of letters about them and the effects upon outcomes of sharing letters. We also studied the opinions of consultants on letter-sharing.

Few old age psychiatrists shared letters with patients or carers, and many had concerns about this practice. In contrast, letters were considered ‘very welcome’ by 87% of patients and carers who received them, and 81% of those who did not would be ‘very pleased’ to receive them. Patients and carers who had received letters had significantly better knowledge of their care plan, whom to contact and ways of making contact with services.

Despite concerns expressed by psychiatrists, our findings support the sharing of letters with patients and carers of patients with dementia in old age psychiatry services.

The aim of this survey was to determine details recorded about the physical health of patients in rehabilitation and recovery. All medical and nursing notes from January 1998 to March 2003 were reviewed. Case notes from 63 patients were studied.

There was mention in less than 13 of the patients' notes (18%) of smoking, diet, exercise or prolactin levels; weight, blood pressure, electrocardiogram, erythrocyte sedimentation rate or lipids were mentioned in less than 20 (30%). A blood sugar test was performed in only 16 patients (25%) in the past year and 38 patients (59%) had a record of a test in the past 5 years. These results suggest that there is inadequate recording of the physical health parameters in patients in rehabilitation and recovery.

The physical healthcare of patients with schizophrenia is prioritised in the National Institute for Clinical Excellence (NICE) clinical guidelines, which specifically mention the monitoring of endocrine disorders such as diabetes and hyperprolactinaemia, cardiovascular risk factors, such as blood pressure and lipids, and lifestyle factors such as smoking. Routine recording of physical health indices should be mandatory and staff may need further training to enable them to do this.

To examine whether driving is discussed with patients attending a specialist day hospital for dementia and whether appropriate action is taken. Patients' notes were reviewed for evidence of such discussion. A questionnaire was implemented before the audit was repeated 6 months later.

During the first cycle 44 patients' notes were assessed and 38 were assessed on repeat audit. The documentation of discussions regarding driving increased from 23 to 95% of notes following implementation of the questionnaire.

By discussing driving status, important legal, insurance and safety issues can be addressed. Routine use of a simple questionnaire dramatically improved the likelihood of such discussion. These findings apply for all conditions requiring Driver and Vehicle Licensing Agency notification.

This is a descriptive study of the admissions of new long-stay patients and their outcome in a district with minimal access to longer-stay in-patient beds. Cases were identified through an ongoing in-patient census and information was gathered by retrospective case-note review.

Thirty-nine new long-stay admissions were identified. High rates of living alone, early readmission following previous discharge and use of the Mental Health Act 1983 were noted. The 39 admissions occupied 12% of the unit's capacity. Four patients returned to a family residence but 27 went into residential or in-patient care. Of those discharged to settings not providing patient care, 48% were readmitted in the year after discharge.

New long-stay admissions continue to absorb a high proportion of the bed resources of an in-patient unit for their numbers and these patients are at risk of unsuccessful discharge.

We aimed to establish current practice in the risk assessment of harm to others within general adult psychiatry and review risk assessment documentation in use. Consultants working across 66 randomly selected trusts across England were surveyed. A qualitative analysis of risk assessment documentation was carried out.

Data were obtained from 45 trusts (68%). Consultants reported that 30 (67%) of the trusts had standardised forms for risk assessment. Forty-one forms were subjected to content analysis. Wide variation was found in the methods used to identify risk factors and in approaches to quantifying risk.

Current risk assessment practice is highly variable, indicating a lack of consensus about suitable methods.

To evaluate the physical health and health risk factors in long-stay psychiatric patients in a high secure psychiatric hospital. A cross-sectional survey of consenting patients was undertaken using a semi-structured questionnaire, a brief physical examination and review of patient case notes. A comparison was made with data collected on admission and held on the Special Hospitals' Case Register.

Main findings were: a mean increase in weight since admission, in men of 10.62 kg and in women of 12.74 kg; high rates of smoking, obesity and large waist size; 54% of patients had one or more health problems.

The study's profile of the physical health of psychiatric in-patients indicates the need for health promotion initiatives in such hospitals and the need for primary care services.

Through a postal survey we sought to determine the current retirement intentions of consultant psychiatrists working in Scotland. Consultants were asked their likely date of retirement, whether they might return as a locum and what might induce them to retire later.

Full data were returned by 180 consultants. The mean planned age at retirement was 58.0 years. Women intended to retire significantly earlier than men. Most respondents could be persuaded to retire later through changes in services, conditions or job content; only 7% regarded their proposed retirement date as immutable.

Early retirement among consultants is likely to contribute to an even more seriously understaffed service. It is necessary to seek national and individual changes to the factors that give rise to early retirement in psychiatry.

A postal questionnaire survey was conducted of the directors of nursing of all mental health NHS trusts in England, in order to examine current activities and attitudes regarding nurse supplementary prescribing (NSP) in psychiatric settings.

Fifty-four per cent of nurse directors returned the questionnaire. They perceived that NSP was an important means for improving patient care and treatment, particularly in community settings. In their opinion, psychiatrists were generally not opposed to its introduction. To date, relatively few mental health nurses have received training in NSP.

Directors of nursing have positive views and experiences of NSP. Widespread implementation of NSP is likely to occur over the next few years and psychiatrists will need to consider how this will impact on their role.

To develop and evaluate a screening tool based on the observational skills of prison officers to identify adult male prisoners with severe mental illness. The tool was developed from open-ended interviews with officers and diagnostic interviews with prisoners. A case–comparison study was used to evaluate the tool. Fifty prisoners identified using the tool and 50 randomly selected prisoners underwent diagnostic interviews to determine the proportion in each group with severe mental illness.

Five behavioural indicators of severe mental illness were identified and incorporated into the tool. In the evaluation, 19 out of 50 (38%) of the cases identified were found to have severe mental illness compared with none in the comparison group.

The simple tool shows promise for the identification of prisoners with severe mental illness by prison officers. It does require further evaluation in other prison settings.

There are no data or guidelines on who should be referred to community mental health teams (CMHTs), resulting in enormous variability in referral patterns. General practitioners (GPs) and psychiatrists were surveyed using a purpose-designed questionnaire to assess their attitudes regarding referral of individuals with different psychiatric disorders.

There was consensus among GPs and psychiatrists that individuals with psychotic disorders, mania, severe depression and phobias should be referred to CMHTs. GPs were more likely to refer personality disorder, whereas the reverse was true for moderate depression and anxiety/ panic disorders. There was disagreement within groups about referral for acute stress reaction, mild depression and adjustment disorders.

Uncertainty about appropriate referral causes variability in referral patterns and service provisions. This needs resolution through the Royal Colleges of Psychiatrists and General Practitioners, to provide guidance leading to equality of care for all.

A new fast-track assessment (FTA) clinic was established by a community mental health team (CHMT) in SouthEast London. Previously, those who responded to an opt-in letter were offered an appointment with a duty worker or at an out-patient clinic. In the new system, all routine referrals are booked into a single fortnightly clinic staffed by two doctors and two to three other CMHT staff with post-clinic discussion of all cases (2–6 min per case). A total of 100 consecutive referrals before the introduction of the FTA clinic were compared with 100 following the introduction.

The interval between receipt of referral to first appointment offered was reduced from 55 to 18 days and to actual assessment from 71 to 26 days. Eighty-four referrals to the FTA were offered a first appointment date that was within 21 days of receipt of a referral, compared with four before the introduction of the FTA. These differences were highly significant. There was a trend for more patients to attend for assessment after the FTA clinic was introduced (79 compared with 68).

This simple re-engineering of the assessment process within a CMHT has achieved its objective of reducing waiting times to first assessment appointment. It also appears to have reduced the number of referrals that do not result in an assessment.

Despite good evidence for their effectiveness in the treatment of schizophrenia, family interventions are difficult to implement. Prior to a local trust-wide programme to encourage their use, we carried out a case note review of family contact with clients and staff of community mental health teams (CMHTs). A 10% sample of CMHT clients was included.

The majority (81%) of clients had been in contact with family or carers in the preceding year. In 88% of case files the carers were relatives. In 37% of cases care coordinators were in recent contact with carers, primarily by telephone. Evidence of any family intervention was recorded in 5% of case files and carers' assessments in 7%.

The majority of CMHT clients have some form of contact with their families, and care coordinators make informal links with these families. This contact could be reframed to encourage more formal family interventions.

A survey of 58 patients with alcohol dependence was carried out to ascertain how much knowledge such patients have about the Driver and Vehicle Licensing Agency (DVLA) regulations. Patients completed a questionnaire about whether they follow DVLA regulations, what information health professionals had given to them and whether they would still seek treatment if they knew doctors might inform the DVLA.

The majority of patients surveyed were continuing to drive. Very few had any knowledge of DVLA regulations regarding alcohol dependence. With the knowledge that doctors have a duty to notify the DVLA in certain circumstances, a significant proportion said they would be less likely to seek treatment or would stop attending for treatment.

Health professionals may be avoiding discussions of the DVLA regulations with patients suffering from alcohol dependence in an attempt to preserve the doctor–patient relationship.