It is recognised that the consultants of the future will have a greater management role than those of the past. The Griffiths report (1983) regarded doctors as ‘natural managers’, although this has been challenged by some authors. They suggest that medical training, with its emphasis on the individual case and rapid decision-making (Higgins, 1989), leads to a very different perspective from the manager considering the often competing long-term needs of many individuals.

Treatment-resistant depression is a complex condition often requiring specialist psychiatric care. Many different psychiatric, physical and social factors can lead to a poor response to initial treatment of depression, and a careful assessment is required to determine the most appropriate management option. This can be particularly complex in the older population, who often have multiple physical and social comorbidities. We have used a fictional case to illustrate this, alongside an anonymised vignette of someone with personal experience of this condition. We have also provided an overview of the current evidence for treatment options, as well as a discussion of potential aetiological factors. By the end of this article, readers should understand the ambiguity of this diagnostic term, the aetiological factors that need to be assessed and the rationale for the treatment options available. They should be able to recognise how these ideas apply to the geriatric population.

The library of the Institute of Psychiatry is undoubtedly internationally oriented; it stocks writings in languages ranging from German to Chinese. As a foreigner one is bound to be on the look-out for texts in one's own language. In my case this search has until now been unsuccessful. After the librarian asked me whether the Dutch write about psychiatry at all, I have actually given up but at the same time I decided that it was my task to increase awareness of Dutch psychiatry among my colleagues. Although it is true that the Dutch have accepted English as the international scientific language more than any other members of the European Community, Flemish and Dutch psychiatrists do continue to publish in their native language by means of the Tijdschrift voor Psychiatrie, a journal which differs from, for example, its British counterpart by the emphasis it puts on case studies, psychotherapy and philosophical/historical issues rather than on research in the internationally accepted format.

Charles Taylor provides important philosophical accounts of what it means to be a ‘self’ in a secular age. Psychiatry has not traditionally concerned itself with other than limited accounts of the concept of the self but Taylor's work sheds a revealing light on the challenges to be met by aspirations to an holistic practice of psychiatry in our secular age.

With a view to stimulating discussion on the subject of trainee's attitudes towards, and experience of teaching, at an informal meeting of members of the Association of University Teachers of Psychiatry held in Leicester last year, a survey of Trent Region Psychiatric Senior Registrars, as well as delegates to the first College Trainees' Conference (held at Warwick University), was undertaken.

One hundred and fourteen psychiatric trainees in the South Western region were canvassed by questionnaire concerning their knowledge of and attitudes towards the recommendations of Caiman Report, (DOH, 1993). Of the 78% of senior registrars and 80% of registrars who replied, the majority knew of the major recommendations mainly from reading articles and talking to colleagues. The 50% response rate from the senior house officers perhaps reflected a lack of knowledge and an erroneous perception that the report was of less relevance to them. The article reports responses to both structured questions concerning the facts, and comments received on more controversial aspects.

British psychiatry has tended to hold itself aloof from social theory. Nonetheless, these ideas have influenced the development of mental health services. Alongside this, the biopsychosocial model cannot reconcile contradictions in the scientific evidence regarding mental illness. We need to develop a more constructive understanding of the implications of social theory.

Services for deliberate self-harm patients in the general hospital are unsatisfactory in many respects. A survey of activity and quality in a district general hospital confirmed recent trends observed elsewhere and highlights areas in which service provision can be improved.

High rates of deliberate self-harm (DSH) are a public health problem. A study in Oxford showed rising rates among young women during the late 1980s, and a threefold increase in the proportion due to paracetamol poisoning between 1976 and 1990 (Hawton & Fagg, 1992). A multicentre European study found a trend of increasing peak age, a declining female to male ratio, and unexplained differences between regions (Platt, 1992). In the year following DSH, 9% repeat (Hawton & Fagg, 1992); and suicide rates reach 1.1 to 1.3% of patients in the three years following an episode of DSH (Owens et al. 1991).

Substance misuse is widespread among individuals with early-phase psychotic disorders and is associated with a worse illness course. Thorough assessment of patterns of substance misuse at admission for psychiatric care is often lacking and can compromise the accuracy of a diagnostic assessment that distinguishes between a primary psychosis and one that is substance induced. Given the risk to recovery from psychosis posed by substance misuse, close monitoring of the course and treatment of early-phase psychosis that is accompanied by substance misuse is indicated and could inform the development of more effective dual-diagnosis treatments.

In May 1988, the greater part of an issue of Archives of General Psychiatry was given over to reports of the results of a clinical trial of alprazolam for panic disorder. More recently, in March 1991, supplement no 365, of Acta Psychiatrica Scandinavica (APS) was devoted to a further trial of alprazolam for panic disorder. Few other psychotropic compounds have received such concentrated coverage. What, if anything, emerges from the studies reported?