With the implementation of community care and resettlement programmes, the extent, frequency and the management of emergencies in the mentally handicapped population have attracted a good deal of attention. Among the issues of importance are crisis in the community and unnecessary and repeated hospital admission; inappropriate emergency referrals leading to abuse of services; the need for emergency services and the importance of short term admission facilities (Nolan et al, 1992). While the number of psychiatric emergencies in people with mental handicap is not large, the trend towards living in the community has brought the need to monitor such referrals.

A previously unknown Spanish-language mutual aid resource for substance use and mental health concerns is available in Latino communities across the USA and much of Latin America. This kind of ‘4th and 5th step’ group is a ‘culturally adapted’ version of the 12-step programme and provides empirical grounds on which to re-theorise the importance of spirituality and culture in mutual aid recovery groups. This article presents ethnographic data on this organisation.

The Commission for Health Improvement (CHI) ceased to function at the end of March 2004. This provides the opportunity to review its contribution and achievements as a new body, the Commission for Healthcare Audit and Inspection (CHAI), takes over its functions∗. CHI recently published its assessment of mental health services (http://www.chi.nhs.uk/eng/news/2003/dec/11.shtml). The report is based on the 35 clinical governance reviews, in England and Wales, published between July 2001 and October 2003; two investigations into serious service failures; and a report on safeguarding arrangements for children in England and a self-audit of child protection arrangements. CHI concluded that mental health services lag behind acute health services in developing clinical governance systems and processes that promote high-quality care and continuous improvement. It specifically highlighted the shortages of psychiatrists and in-patient nurses, and the reliance on agency nurses and locum staff; the unsuitability of buildings and facilities; the pressures on in-patient beds; the lack of management capacity and poor information systems; and the low priority given to services for children and older people.

There has been much debate about effective treatments, service configurations and costs within Britain's mental health care system, but it has largely taken place in academic and management circles. We were interested in the views of those providing care. We organised a meeting of community psychiatric nurses, general practitioners and consultant psychiatrists (funded with an educational grant from Zeneca Pharmaceuticals). Participants worked in various parts of Great Britain, including rural and inner city areas. The authors facilitated the discussion, the emphasis of which was on participants' clinical experience.

In 1973 a survey was carried out of male schizophrenic patients who had become long-stay residents in Leverndale Hospital, Glasgow, ‘long-stay’ being defined as having been continuously in hospital for more than three years (Todd et al, 1976). The patients were recruited from a four year cohort of admissions in the years 1967 to 1970 inclusive. In the following years there have been many changes in the provision of facilities and in clinical practice. In some countries, such as Italy, the USA and England, there has been a strong drive to reduce long-stay populations along with the closure of some mental hospitals. In Scotland the process has been much more gradual, possibly reflecting the differences in preexisting provisions and patterns of care.

Service user memoirs are frequently reviewed in The Psychiatrist and other related journals. Some academic publications include first-hand accounts of mental ill health, and there is a lively market for autobiographical books and articles about mental illness. But clinicians already have extensive contact with service users and it might seem unlikely that they have much to gain from reading memoirs. In this article I suggest that the greater depth of reflection in published memoirs means clinicians do in fact have something to learn. I illustrate my argument by showing how memoirs cast a light on the world of information and conclude by suggesting reasons why memoirs raise issues that are of increasing clinical importance.

Conventional antipsychotics, historically the mainstay of schizophrenia treatment, were ineffective in many patients, at least 30% fitting treatment-resistance criteria (Kane & Lieberman, 1987). All had the same mechanism of action: none was any more effective in the individual than any other. Therapeutic nihilism accepted poorly controlled positive symptoms and disabling negative symptoms: nearly all patients suffered side-effects (Barnes & Edwards, 1993), particularly extrapyramidal side-effects (EPS) and hyperprolactinaemia. Conventional antipsychotics raise prolactin to a range associated with sexual dysfunction or even macroprolactinoma: effects in men include erectile dysfunction and hypospermatogenesis; in women, galactorrhoea, oligo- or amenorrhoea, hirsutism and increased risk of osteoporosis. In both men and women there is loss of libido, and a link between hyperprolactinaemia and weight gain.

Sir James Crichton-Browne (1840–1938) held a uniquely distinguished position in the British psychiatry of his time. Unburdened by false modesty, he called himself ‘the doyen of British medical psychology’ and, in the narrow sense, he was indeed its most senior practitioner. At the time of his death, he could reflect on almost half a century's service as Lord Chancellor's Visitor and a similar span as a Fellow of the Royal Society.