In recent years, there has been growing recognition of the significant incidence of child abuse and neglect in the population, and of its adverse effect on the development of children and their mental and physical health. This awareness has led, especially following the implementation of the Children Act 1989, to an increased demand for psychiatric assessments of children for the courts by social services, solicitors, guardians adlitem and the courts themselves. There has been some reluctance to take up this work, for two main reasons. First, there has been concern that these time-consuming assessments will result in a shift of resources away from treatment, thus having an adverse impact on the balance of child mental health services. In some areas, the need has been recognised within the commissioning and contracting processes. Provision has been increased accordingly, acknowledging that it is part of the responsibility of the health authorities to assist the local authorities in this way.

There is a widespread concern that the medical profession is itself sick. This is represented in professional disillusionment and demoralisation, an increasing inclination to consider leaving the profession, and the ill-health of its practitioners in terms of their mental health, marriages and use of drugs and alcohol (British Medical Association, 1992). These trends have been attributed, at least in part, to protracted job stress and dissatisfaction, which may in turn be a major determinant in the quality of health care (Caplan, 1994). Although these issues have been cautiously acknowledged for some time, the concept of ‘burn-out’ has provided an opportunity for more open acceptance and creative debate.

Rapid-cycling bipolar affective disorder presents a unique spectrum of therapeutic difficulties. This article outlines some practical guidelines on the assessment and management of the disorder in the light of current research and clinical practice.

During the research interviews for Isobel Allen's prospective studies of medical careers (Allen, 1994), many young doctors voiced concerns about their working conditions. Although a relationship between doctors' health impairment and their arduous working conditions has only recently been empirically established (Baldwin et al, 1997a), concern about sick doctors, at all stages of their careers, has been growing for many years. There are very few empirical data on sick doctors' help-seeking, but the enlightened self-interest of trusts and health boards may become an important new driving force, because of the more clearly defined responsibilities of National Health Service (NHS) senior staff for the well-being of their colleagues and possible liability for colleagues' impaired clinical practice (General Medical Council, 1995; British Medical Journal, 1997). The anticipated UK shortage of doctors may also act as a stimulus for measures designed to encourage the retention of a healthy medical workforce.

Different cultures vary in their perceptions of mental illness (Karno & Edgerton, 1969), which can affect their utilisation of orthodox psychiatric facilities (Padilla et al, 1975; Sue, 1977). Mental health services may be seen by ethnic minorities as challenging the value of traditional support systems, reflecting dominant Western cultural values and harbouring implicitly racist psychological formulations. The clinician-patient interaction may become fraught with misunderstandings if the two parties come from different cultural backgrounds and bring distinct cultural expectations to the encounter.

In 1979 Archie Cochrane, a British epidemiologist, stated that:

Mental health professionals regard the assessment of suicide risk as part of normal clinical practice, but most shy away from assessment of risk of interpersonal violence, either doubting that such predictions are possible, or, if possible, are part of their role. In part, this fastidiousness reflects the influence of a consensus which emerged in the 1970s to the effect that there was no substantial relationship between mental illness and violent behaviour. The only basis for risk assessments which remained were those factors in the general population known to be associated with criminality. Even here, however, the accuracy of predictions made by clinicians had been subject to considerable critical scrutiny, which undermined any claims the profession may have had to expertise (Monahan, 1981; Brizer, 1989). There seems to have been wide acceptance that psychiatrists were doubly disabled in the business of predicting violence by having no relevant specialist knowledge and by being poor at applying knowledge gleaned from other disciplines such as criminology.

In a 17- to 19-year follow-up study it was shown that patients admitted to the Maudsley Hospital, London (whose index episode marked their first psychiatric contact) had a 50% chance of readmission during their lifetime; those with previous admissions had a similar chance of readmission within three years. Less than one-fifth of the patients had remained well, and over one-third suffered severe chronic distress and handicap or had died unnaturally (Lee & Murray, 1988). Similar gloomy pictures were reported in a 15-year follow-up study of patients in London and Sydney (Kiloh et al, 1988) and an 11-year follow-up study of patients in Montreal (Lehmann et al, 1988). As a result of such findings, much emphasis is now put on the importance of continuation and maintenance treatment of depression.

The prime duty of specialist mental health services is to provide effective care to often non-compliant and unstable severely mentally ill (SMI) patients. Society expects such care to be humane and effective, but also demands that the severely ill are closely supervised to minimise risk to the public. Sadly, specialist services all too often fail on both counts. In part, this is due to the sheer complexity of care that is needed, going far beyond purely medical or therapeutic interventions. SMI patients have profound difficulties accessing and using everyday services and opportunities. Negative symptoms of apathy, self-neglect and low motivation, coupled with irrational beliefs and compounded by inadequately resourced and tightly rationed provision of social care, require mental health care services to be constantly active across areas of both medical and social provision. Services that ignore the importance of long-term, integrated care do so at their peril. A steady stream of disasters has been blamed on a lack of communication and coordination between agencies (Spokes, 1988; Ritchie et al, 1994), and follow-up studies of SMI patients managed by traditional hospital out-patient services repeatedly note a mismatch between levels of need and service uptake, with the least needy consuming the greater amount of service (Goering et al, 1984; Melzer et al, 1991).

The General Medical Council (GMC) relies upon consultant psychiatrists throughout the UK to assist in carrying out its twin tasks under the health procedures of protecting patients and guiding doctors. One of the reasons for the fitness of a doctor to be seriously impaired is the illness, usually mental illness, of that doctor, and frequently doctors do not realise the extent to which their ability to carry out their work has been affected.

The problems associated with alcohol and drug misuse are diverse and make a major impact on the health of the nation (Anderson, 1991; Royal College of Psychiatrists, 1992). A recent survey showed that the prevalence of alcohol dependence in the population (aged 16–64 years) was 47 in 1000 and of drug dependence 22 in 1000. (This compares with a prevalence for functional psychosis of 4 in 1000) (Office of Population Censuses and Surveys, 1994).

Meta-analysis is the use of statistical techniques to analyse the findings of many individual analyses (Glass, 1977). It covers all aspects of the review process involving formulating relevant research questions, searching the literature, assessing the quality of studies and choosing relevant ones, extracting and combining the data (for review see Henry & Wilson, 1992; Wilson & Henry, 1992). Meta-analysis as part of a systematic review has advantages over a narrative review but there are problems in applying it in practice (Box 1).

This half-joking remark from the Specialist Adviser to a national mental health charity, sums up the dilemma every consultant faces from time to time: how to be all things to all people. What is more, it tunes in to our own sense of omnipotence. A recent review of ethics in psychiatry (Adshead, 1995) urged consultants to follow the four principles in practice: respect for the autonomy of the patient; beneficence (actively doing good); non-maleficence (avoiding doing harm); and the pursuit of justice – an incontestable but formidable remit.

A recent working party report published by the Nuffield Provincial Hospitals Trust (1996) made a series of recommendations for the improvement and better coordination of existing services. This comes at a time when new and expensive counselling services are springing up everywhere, the most ambitious being the British Medical Association's 24-hour counselling service for doctors and their relatives.

The importance of personality is recognised tacitly by the development of the multiaxial classifications of ICD–10 (World Health Organization, 1992) and DSM–IV (American Psychiatric Association, 1993). The separation of axis 1 or current mental state diagnosis from axis 2, on which personality is described, is a recognition that personality is separate from other aspects of the patient's diagnostic status. Nevertheless, many clinicians are sceptical that personality can be assessed reliably and some hold that the diagnosis should be abandoned as being merely judgemental and pejorative (Lewis & Appleby, 1988). There is some basis for scepticism in respect of reliability in view of the evidence that even with operational criteria the clinical assessment of personality is not transportable, and the level of agreement between practising clinicians is much less than that achieved during field trials (Mellsop et al, 1982).