A review of the drug treatment of 163 patients attending two old age psychiatric day hospitals showed that 29 received medication from the day hospital, 44 from general practitioners and 60 from both sources. Many of the patients' knowledge of their drug treatment was incomplete. Of those individuals interviewed, approximately equal numbers expressed a preference for day hospital and general practitioner prescriptions. The origin of the prescription did not bear any obvious relationship to subsequent admission to hospital or continued attendance at the day hospital.

Three hundred and fifty-six patients admitted under sections of the Mental Health Act (1983) were studied. One hundred and twenty-six (35%) patients appealed against their detentions and 52 of these appeals were heard. Only 18 patients were discharged from their detentions by the Tribunal in the study period. Younger patients were more likely to appeal and no patient whose first language was not English appealed in the study period. The tribunals appear to be a fair system once the opportunity to appeal is taken up.

This paper explores the extent of known child sexual and physical abuse in child psychiatric out-patient services in Leeds. We surveyed a one-month period, looking at all out-patient contacts, and found that at least 17.9% of patients had been physically or sexually abused and these patients took up 25.8% of out-patient time. When the 70 abused children were compared to a group matched for age group, clinical team and diagnosis It was found that they were more likely to be followed-up for longer and they received more therapeutic time over a given period than non-abused children. The implications for resources are discussed.

Health services are now commissioned at a local rather than a regional level. It is essential for local consultants to have an input to the planning and commissioning process. For the child and adolescent psychiatrist this task is complicated by an absence of nationally agreed guidelines on the level of resourcing required for a district child and adolescent mental health service. This paper describes an approach to advising purchasers which offers them a choice of service models that differ in their levels of resourcing. Each of the service models is described briefly. The advantages and flexibility of this approach are discussed.

The psychiatric intensive care unit (PICU) is now at the cutting edge of acute psychiatric care. Very little guidance has been produced to ensure that the PICU structure and design is able to meet the complex demands put upon it. The creation, development and relocation of a PICU has taken place within the Severn NHS Trust. We describe the experience gained from a recently commissioned unit together with a review of the relevant literature. Recommendations are offered for core features and design.

The pharmacological management of acute behavioural disturbance in psychosis is not straightforward. The real, or perceived, dose:effect relationship of the various neuroleptics in common use has an important influence on prescribing patterns leading, in certain situations, to very high doses of neuroleptic medication being prescribed. Data from a study of the use of neuroleptic medication in two psychiatric intensive therapy units illustrate the potential extent of the problem. Over half of the cases were not amenable to accurate dosage monitoring due to the use of depot neuroleptics, Clopixol Acuphase or polypharmacy. The majority received doses exceeding the limit suggested by the British National Formulary. Efforts to standardise the use of such drugs would help to optimise the clinical management of this challenging group of patients.

Psychiatric distress is commonly found in general hospital patients and is associated with a poorer outcome and increased complexity of care. It is important for non-psychiatric hospital doctors to possess skills of assessment and treatment of common psychiatric problems. This survey of all house officers in their first pre-registration posts in three large teaching hospitals found that Junior doctors rarely ask about or consider the presence of psychiatric problems in their patients. Where psychiatric problems are found, house officers often feel they lack the appropriate skills of assessment and management. This has important implications for medical school course content and emphasis.

Lay involvement in clinical audit has been advocated but rarely reported. Since early 1994 in the mental health unit at Airedale, Yorkshire, lay representatives have participated in all stages of clinical audit, Including selection of topics and methods, data collection and standard setting. After 8 months of lay involvement, all respondents to a brief questionnaire saw lay involvement as important, although none identified specific benefits that had already occurred. The paper outlines themes in respondents' perceptions of the benefits and problems of lay involvement and in their suggestions for minimising difficulties.

Recent questions have been raised regarding the development of policies by Trusts for the treatment of their locally resident staff outside the hospitals in which they work. A questionnaire was developed to elicit views of mental health care workers on this issue. Overwhelming agreement was found among a wide variety of staff groups on the need for provision of treatment options outside the local service. Considerable thought and planning are needed in the development of formal operational policies to ensure such a service is provided by all hospitals/Trusts.

A postal survey was conducted within four regional Health Authorities to ascertain how widely the supervision register had been applied in its first year of operation in adult mental health. A 72% response rate was achieved. The results showed that the register has been absorbed organisationally but is less accepted professionally. One hundred and nineteen of the 367 consultants in the sample (32%) had no entries on the register at 31st March 1995. The provision of training on its use had a significant effect on compliance, although London-based services had marginally less registrations per consultant than their colleagues elsewhere. Very few outside agencies had required access to the register.

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.

This case demonstrates some of the complex practical and legal difficulties in managing patients suffering from comorbidity of substance misuse and psychosis. A discussion of the ethical issues includes references to absolutist and utilitarian ethical models. Ethical dilemmas in such cases often impinge directly on clinical management, and the paper argues that the success or otherwise of treatment is partly dependent on awareness of such factors.

Quality of life scores were measured In a new hospital hostel in a rural community. These scores were compared to scores on patients in a similar hospital hostel in an inner city area in the United Kingdom and also scores on patients living in a range of different facilities in the community In the United States.

The importance of establishing case registers for suicide is discussed along with their potential uses. Suicide data can be derived from the coroner, the District Health Authority or the Office of Population Censuses and Surveys (OPCS). The relative merits of these different data sources are discussed and local methods described. Some data derived from the suicide register are shown.

A cross-sectional study of 74 consecutive alcoholic patients admitted to a subregional alcohol treatment unit examines the socio-demographic and clinical differences between those who had/had not attempted suicide, and investigates their relationships to current suicidal ideation. The suicide attempters were significantly younger, separated and unemployed. They began regular drinking earlier, were more severely dependent and had a higher proportion of major depression, antisocial personality disorder and another drug abuse. The results suggest a high incidence of suicidal behaviour in alcoholics and high psychiatric comorbidity in alcoholics who attempt suicide.

Increasing involvement of users in health service planning has led to a movement towards patients having more information about their care. Some have advocated patients having access to their medical records and this is now a statutory right. There has been concern as to whether this is suitable in mental health. An addition or alternative to access to medical notes is a client held record which might increase the patient's feeling of autonomy while also improving communication and compliance. In studies on access most patients and staff have found this beneficial. Client held records have also been positively received in the few studies reported but more evaluation in routine practice Is needed.

Learning medicine and psychiatry is a moral as well as an intellectual challenge. Successful training in psychiatry can lead to significant personality maturation. Using poetic examples, the paper explores aspects of emotional development relevant to the traditional values of dynamic psychiatry. Such values are contrasted with those of the prevailing bureaucracy.

The Internet, a military creation, is a collection of services shaped by its users, and offers the rapid transfer of vast quantities of information. Already there is concern that Developing World countries may be left behind by this revolution in information availability. Psychiatrists need to be aware of the type of facility the information in the superhighway provides, so that the useful aspects can be refined and directed. The type of facilities in use now by psychiatrists around the world is briefly described.

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.

Our moral conception of suicide is examined. It is argued that a neutral definition of suicide is difficult to achieve and that how we treat the Question of suicide shows what value we place on the sanctity of Me or on life as a means to other ends. The case is made that autonomy, the principle of self-governance, has acquired special importance in the modem world to me detriment of other ethical principles such as beneficence.