For over three centuries we, in Western societies, have lived in an Age of Reason. The accepted wisdom is that decision-making must be a purely rational process devoid of emotion and underpinned by objective knowledge. This article draws attention to the invasion of human affairs by an ideology which makes deliberate use of one kind of rationality to the exclusion of all others. Changes in work and its organisation have been particularly driven by economic rationality which allows no thought for the effects on individuals. The clinical evidence centres around four specific cases which are presented against a background of the business practices current in the control of work. It is argued that these have a deleterious effect on mental health, especially for those psychologically disposed to respond faithfully to management calls for greater teamwork and commitment.

Most old age psychiatrists see long-stay care in good quality community hospitals as an essential component of a comprehensive service for older people suffering from mental illnesses (Jolley & Arie, 1992). Yet in recent years some Health Authorities have sought to reduce or close their long-stay beds and this has caused a great deal of controversy (Alzheimer's Disease Society, 1993; Benbow et al, 1994).

In a textbook of psychopharmacology published as recently as 1990, Hollister and Csernansky wrote about antipsychotics “It is most discouraging that more effective pharmacotherapy has not been developed. Present drugs have many deficiences: they are not curative; their ameliorative effects are often limited, many patients remain totally unresponsive; they are unpleasant to take so that many patients are less than fully compliant; they produce major side effects such as tardive dyskinesia whose full implications are still uncertain”.

Of 299 referrals to the Dundee general psychiatry liaison service over a six month period, deliberate self-harm (DSH) was the reason in 83%. An overdose was used in 94%, and alcohol misuse occurred in 56% of DSH episodes. Fifty-two per cent of referrals were followed up by the general psychiatry service; 31% of these were admitted directly to a psychiatric ward, 10% on a compulsory basis. At follow-up, 23% remained in contact with the Dundee psychiatric service. Twenty-three per cent of all patients referred to the Area Alcohol Service (AAS) were in contact with it six months later. Clearly, liaison psychiatry has a role in detection and management of significant mental disorder.

This paper presents the results of a survey of Junior doctors' opinions concerning the emergency tranquillisation of acutely disturbed, confused elderly patients. Although the majority of respondents gave recommendations within current guidelines, there were large variations In drug dose, and the choice of psychotropic agent may have been determined more by availability than rational prescribing practice.

The prevalence of smoking is higher among chronic psychiatric patients than the general population, in spite of their lower income. The purpose of this study was to calculate the percentage of income these patients spend on smoking and to discuss the relationship between smoking and chronic psychiatric disorders, in particular schizophrenia. Ninety-six smokers were included in the study. The mean percentage expenditure on smoking was 294% of income. We discuss why chronic psychiatric patients smoke so much, why they should not, and what factors may encourage them to quit.

The importance of establishing registers for non-fatal deliberate self-harm is discussed along with their potential uses. Deliberate self-harm (DSH) data for a single hospital can be derived from the Accident and Emergency (A&E) casualty cards, A&E on-line registers, mental health assessments or general hospital in-patient data. The relative merits of these different data sources are discussed and local methods described. Some data derived from the DSH register are shown.

Public sector psychotherapy differs from private practice in its explicit responsibility for a population. This has major implications, with the need to ration a scarce resource inevitably affecting clinical practice. De facto rationing has existed within the National Health Service (NHS) for years, and the ‘unconscious' processes involved must be made explicit if NHS psychotherapists are to deal with their broader responsibilities, and influence current changes in the Health Service. Resource issues and the related psychological conflicts shape clinical practice and thus theoretical concepts. The effects on practice could be seen as a series of unhappy compromises, or a stimulus to the creative development of a specific NHS psychotherapy, as envisaged by Sigmund Freud.

A postal survey of the drug treatment of behavioural emergencies by senior registrars and consultants in psychiatry revealed that 90% would initially use a non-depot antipsychotic (including 24% who would combine it with a benzodiazepine if the situation warranted), and 10% the short-acting depot, zuclopenthixol acetate, with another antipsychotic or a benzodiazepine, or both. The choice was made from a restricted range of drugs, with haloperidol being the most popular antipsychotic and diazepam the most popular benzodiazepine. Half of respondents did not consider British National Formulary maximum dose recommendations to be useful for rapid tranquillisation and many would exceed them. A substantial minority did not consider that adequate resuscitation was available at their unit and deficiencies were revealed in the training of junior doctors and in the audit of rapid tranquillisation. Very few psychiatrists reported that their units had written guidelines.

The outcome of 19 long-stay patients discharged from a large psychiatric hospital to staffed group homes managed by a voluntary organisation were compared with 11 patients discharged to a hostel ward managed by an NHS Trust. The former were found to have a higher rate of police involvement, readmission and threatened eviction. The study highlights the need for an integrated range of different residential facilities and the necessity for close monitoring of long stay patients discharged to more independent community settings.

Depot neuroleptic treatments can be compromised by side-effects unacceptable to users or, more seriously, by tardive dyskinesia (TD). Neuroleptic dosages can be lowered to increase acceptability and decrease the Incidence of TD, but with a greater likelihood of relapse. One argument proposes that many patients changing to lower dosages break down because withdrawal from a neuroleptic is stressful in itself. Research suggests that withdrawal regimes should be radically cautious. A computer tool is offered which can aid clinicians in calculating small reductions.

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.

Previous studies have looked of repeated admissions and failed discharges but none have followed up a group of patients requiring multiple admissions over several years. We found that of the 42 patients admitted three or more times to acute wards in 1990, half were having a bad year and did not require this level of inpatient care in succeeding years; one-quarter continued to use acute services heavily but none required three or more admissions in every year of follow-up; one-quarter did badly and required prolonged in-patient care or died.

This paper discusses ethical dilemmas that arise in parenting assessments on an in-patient Mother and Baby Unit with reference to one subject, a mother with schizophrenia who had been referred for a specialist opinion. The case raises ethical issues about the sometimes conflicting needs and wishes of mothers and their infants, and considers the requirements of the Children Act.

The effects of establishing a full multidisciplinary community psychiatric team in central London are described. The nature of referrals, and referrers' satisfaction with the service were examined during two comparable six-month periods, before and after the changes. The number and severity of referrals increased, and referrers were more satisfied with the new service. In contrast to the inter-agency model, the new multidisciplinary team was associated with more appropriate referral of those patients with the greatest need for specialist services. Clinical skill mix in the team and referrer education are the two factors most likely to have promoted these important changes. The key role of the psychiatrist in a full multidisciplinary team who can empower multi-professional case managers in their day-to-day management of severely ill patients is highlighted.

The prevalence of hepatitis B virus infection is thought to be higher in institutions for people with a learning disability than in the general population (Clarke et al, 1984). People with Down's syndrome are reported to be at higher risk than other learning disability groups. The prevalence of hepatitis B surface antigen (Hbs Ag) in Great Britain is in the order of 1 in 500 of the blood donor adult population (Department of Health, 1980). This rate is lower than those reported from countries in Europe, Africa and Asia. The present study was to identify those residents in an institution for people with a learning disability with a positive response to the test for Hbs Ag.

The characteristics of 452 patients referred over a two year period to a psychiatric service for the homeless population in inner London are described. The majority of patients were male and Caucasian, and tended to be referred through voluntary sector as opposed to statutory services. Fifty-nine per cent were sleeping rough at the time of first contact, 80% had a previous history of psychiatric treatment, but only 6% were currently in contact with psychiatric services. Serious psychiatric disorders predominated, with 52% suffering from schizophrenia or delusional disorders.

The pharmacological treatment of depression and the time elapsed since last seen by a doctor were investigated among 507 adults who subsequently killed themselves. The proportion of people consulting a general practitioner or psychiatrist prior to suicide was lower than reported by the British government in the Health of the Nation document. General practitioners prescribed relatively low doses of antidepressants. Nineteen out of the 115 people receiving antidepressants used the drugs to kill themselves. Our findings emphasise the importance of prescribing adequate doses of antidepressants and underline the need for safer prescribing.