Since their introduction in the 1960s, benzodiazepine drugs have been widely prescribed for anxiety states and insomnia. Despite the initial hopes for these drugs being non-addictive and not producing tolerance, recent work has shown that there is a well defined withdrawal syndrome (Hallstrom & Lader, 1981; Petursson & Lader, 1981; Tyrer et al, 1981; Tyrer et al, 1983) and that tolerance has also been shown to occur (Aranko et al, 1983; Aranko et al, 1985). There has been widespread concern about these effects. The British National Formulary advocates that “used as hypnotics routine prescribing especially in hospitals is undesirable, and ideally they should be reserved for short courses of treatment in the acutely distressed” and that they should be discontinued as soon as possible. Indeed the Royal College of Psychiatrists' statement on benzodiazepine prescribing and the Committee on Safety of Medicines have recommended that their use as hypnotics should be considered only when the condition is severe, disabling or subjecting the individual to extreme distress. Tyrer & Murphy (1987) have recommended that these drugs are best used for no longer than two weeks in regular dosage.

Electroconvulsive therapy (ECT) involves the close collaboration of psychiatrists and anaesthetists (Freeman et al, 1987). The Royal College of Psychiatrists' audits of ECT in 1980 (Pippard & Ellam, 1981) and 1991 (Pippard, 1992a, 1992b) relied on psychiatrists rating the facilities and performance of staff in ECT clinics. In contrast we are unaware of any research assessing anaesthetists' views of ECT clinics. Considering their different roles and expectations, opinions may well differ. To investigate this possibility we conducted a survey between November 1990 and February 1991.

As postpartum depression can occur in up to 10% of mothers, antidepressants will often be required in mothers who are breast-feeding. The judicious use of antidepressants is important since all psychotropic drugs cross into the breast milk. Drug excretion into breast milk occurs primarily by passive diffusion. Small, highly lipid soluble, unionised drugs diffuse more rapidly than other drugs. It must be remembered, however, that for those drugs with a high volume of distribution, such as the highly lipid soluble drugs, most of the drug is outside the plasma compartment, leaving only a small proportion free to transport from plasma to milk. Also, most lipophilic drugs are concentrated in hind milk which is richer in fat than fore milk. All of the antidepressants are highly lipid soluble with large volumes of distribution.

Mental health morbidity is perceived as being predominantly urban based. Little is known about the health of the UK's rural residents. This paper summarises existing knowledge of rural health and social indicators. There is a relative dearth of information in this area making the application of urban-based (and biased) factors perhaps unreliable. Some rural areas have levels of deprivation similar to urban areas, even using urban-biased factors, though they encounter specific problems of service provision and accessibility. Currently, there seems to be no valid method of measuring rural deprivation and comparing it with urban deprivation. We highlight this inequality by describing discrepancies in day care provision between urban and rural areas.

If many patients having multiple difficulties are to receive the integral and efficient psychotherapies they require, they need attention from psychiatrists who have specialised training in psychotherapy. This paper sets out the roles to which existing holders of the Certificate of Completion of Training have already moved to, as they work with patients, families, teams and organisations. The General Medical Council has recognised that the understanding of medical psychotherapists is also vital to the future clinical teaching of all psychiatric trainees. This paper summarises key components of the knowledge and roles of future specialists in medical psychotherapy. It recommends that the term ‘medical psychotherapy’ be used widely to clearly differentiate psychiatrists with this training and these responsibilities from non-medical psychotherapists.

Privatisation of psychiatric care is an increasing phenomenon in the USA. This is a relatively new trend and has followed on the heels of other trends like the deinstitutionalisation of the 1960s and 70s. Until recently the majority of in-patient population was in public hospitals, with some in psychiatric units of general hospitals. In the 1980s, the private hospital corporations seem to have discovered that there is money to be made in the business of psychiatric care and started building and marketing psychiatric hospitals on a wide scale.

We reviewed all 112 suicides and self-harm open verdicts in Central Nottinghamshire between 1987 and 1991. The rate of consultation with general practitioners of completed suicides was similar to control patients a year before death. It then increased during the succeeding months, particularly in the month before death, when 41% consulted their general practitioner. A further 12% saw another doctor in their last month. Those who did not consult were more likely to be middle-aged, male, divorced or separated, to have experienced a recent broken relationship, and to show evidence of planning the suicide. Better awareness may have detected and possibly prevented some suicides in consulters. Those who did not consult a doctor had different characteristics. Additional strategies would be needed to prevent these deaths.