Non-attendance at new patient clinics is a well-known problem in psychiatry and particularly common in alcohol treatment units. Reported non-attendance rates in this field range from 12.3% (Addenbrooke & Rathod, 1990) to 52% (Wanberg & Jones, 1973). A number of factors may contribute to this failure to attend including a long waiting time, lack of consent to the referral (e.g. by the GP), postal and administrative problems and the nature of the disorder itself. Hyslop & Kershaw (1981) contacted patients who failed to attend an alcoholism referral clinic in an attempt to establish their reasons for non-attendance. Out of the 39 patients contacted 23 appeared to have good reasons for not attending while 16 gave poor reasons and refused the offer of a second appointment. Ways of increasing attendance at new patient clinics have included reduction of waiting time (Hyslop & Kershaw, 1981) and telephone and written prompts prior to the appointment (Bourgoyne et al, 1983; Grover et al, 1983).

Dose titration is the new colloquialism in ECT circles. The technique, as generally applied, assumes that current and the time for which it is passed, are equally important in the depolarisation of nerve cells. The units used to quantify its measurement, namely the milliCoulomb (mC) reflect this. We think this is misleading and suggest it ought not to be used as a parameter to describe a treatment regime. It is the aim of this communication to explain, in general terms, the physical parameters that control the current flowing in the patient's head, to suggest a more appropriate method to describe the treatment administered and outline the requirements of a good ECT machine.

Psychiatric patients have had the right to see their notes from 1 November 1991. The ‘Access to Health Records Act (1990)’ makes provision for certain parts of the record to be exempt, including information which may cause serious mental or physical harm to the patient or anyone else. In addition, patients should not have access to information given by third party informants unless appropriate consent has been obtained. The legislation only applies to records made after 1 November 1991. It does not cover informal arrangements where written application for access is not made.

Despite a good deal of argument to the contrary (Maughs, 1941; Hunter and Macalpine, 1963; Walk, 1954; Walk and Walker, 1961; Craft, 1965; Whitlock, 1967) it is still commonly believed that Prichard's ‘moral insanity’ (1835) was the forerunner of our present-day concept of psychopathic (sociopathic) personality; the most recent example of this appearing in the paper by Davies and Feldman (1981), who write: ‘In 1801 Pinel described a condition termed by him manie sans délire, the notable feature of which was that the sufferer showed bouts of extreme violence but with no signs of psychosis … Prichard confirmed Pinel's observation and coined the term “moral insanity” which led to “a marked perversion of the natural impulses”.’ A number of modern textbooks (Sim, 1974; Friedman et al, 1975; Slater and Roth, 1977; Trethowan, 1979) also appear to regard moral insanity as the precursor of psychopathic disorder, although Trethowan correctly noted how the word ‘moral’ denoted ‘affective’ and was not being used in the usual ethical sense. He went on, however, to write that Prichard described cases showing antisocial or even criminal behaviour.

In November 1980, two men, Mackenny and Pinfold, were convicted at the Old Bailey on several counts of murder which were of a particularly callous and brutal nature. They were sentenced to life imprisonment. In the preceding December (1979) another man, Childs, had pleaded guilty to all the murders with which Mackenny and Pinfold had been charged, and which he alleged had been carried out with them together. He turned Queen's evidence, and it was his testimony that was crucial and central to the Prosecution's case against Mackenny and Pinfold.

Although there are some well recognised physical disorders such as intracranial lesions that can present with mental illness, many psychiatric conditions do not appear to be associated with underlying somatic complaints. However, a number of recent studies have shown that there are often high rates of concurrent medical conditions among acute psychiatric in-patients that were previously undiagnosed or unsuspected. The author illustrates this point by presenting two case studies in which a significant medical condition was only identified after physical examination on a psychiatric unit.

The practice of modern high quality psychiatry would be well served by the abandonment of the expression ‘community psychiatry’ and a moratorium on its further use for at least a decade.

In setting out a health strategy for England the White Paper, The Health of the Nation includes mental illness as one of its five key areas for action. Within mental health three targets are set out.

It is well recognised that there is an increased psychiatric morbidity, in particular psychosis, personality disorder and substance abuse, among the single homeless (Lodge Patch et al, 1971). The reasons for this are complex. There is evidence that these people are mentally ill before becoming homeless and that their illness may be a cause of their homelessness. In a study of newly presenting patients at the DHSS Reception Centre in Camberwell, London, Tidmarsh & Wood found that 87% of those with mental illness had been staying recently with their families just before their first hospital admission, suggesting that mental illness may have led to homelessness in these patients (Tidmarsh & Wood, 1972). Although direct evidence is scant in the UK, it is felt that the closure of long-stay psychiatric hospitals could lead to some of their in-patients becoming homeless.

Mental health services in general are at present receiving a bad press. Recent complaints focus on two main areas: the widespread prescription of tranquillising drugs, and the social consequences of the policy of community care. There is now serious concern, both among the public and in the profession, about the over-prescription of tranquillisers. The legal implications are serious. An article in the Journal of the Medical Defence Union was recently quoted in the Bulletin: “Dr Ashton's article is a timely reminder that the prescription of benzodiazepines is now a high profile activity for the psychiatrist that has been scrutinised much more closely than many of our other functions. It is well to be aware that one of the potential onlookers is a lawyer” (Tyrer, 1988).

In February 1984 at the Quarterly Meeting of the Royal College of Psychiatrists, Professor A. Guz from the Department of Medicine, Charing Cross Hospital, presented a paper with the above title. In this paper he raised a number of points regarding the role of liaison psychiatry and of the psychiatrists involved in practising it. The paper collated the views of himself and other professors of medicine, and obviously it is important that we as psychiatrists take note of the opinions expressed by people with such an extensive knowledge of medicine. Many of the points which Professor Guz raised I found myself to be in total agreement with; however, there were one or two issues which I think perhaps deserve a reply and I would like to attempt to do this through the Bulletin. As many of the Bulletin readers will know, there is an increasing interest in liaison psychiatry and this has been recognized by the College in the recent establishment of a special interest group. I should perhaps point out, however, that the views expressed in this article are mine alone and do not necessarily represent those of any other liaison psychiatrist, or of the special interest group.

Concern is increasingly being expressed about the lack of provision for mentally disordered offenders, who by default end up within the penal system. Gunn et al (1991) in a study of sentenced prisoners identified a significant number who were mentally disordered to be in need of psychiatric treatment. Among these, 0.4% were considered to be mentally handicapped. Recent reports have emphasised the importance of diverting these individuals from the criminal justice system (Woolf & Tumin, 1991; Home Office, 1990; British Medical Association, 1990). However, the majority of such offenders do not fulfil the criteria for admission to hospital under the Mental Health Act 1983. Most are not overtly mentally ill and do not require treatment in conditions of medium security such as exist in regional secure units. However, it is not clear what provision there should be for such individuals. Smith (1988) described an open forensic unit for mildly mentally handicapped offenders (the Leander Unit). She concluded that there was a need for a specialised service to cater for these patients, who were neither appropriately nor adequately provided for by the general psychiatric services, the mentally handicapped services, regional secure units or special hospitals. Unfortunately, in practice there are very few facilities for this group of patients.

Although psychiatry's future looks less and less likely to be in large psychiatric hospitals, trainees at SHO/registrar level still spend nearly all their time in them. Although the White Paper looks set to dismember comprehensive provision as we know it, few psychiatrists have experienced self-employment, and most are untrained in practical management skills. Although our consumers – as we must now view them – are getting more discerning about what services we offer, psychiatrists only see them after they become ill, and less able to decide for themselves.