A leading article in the British Medical Journal (Miller, 1992) comprehensively criticised the Joint Planning Advisory Committee (JPAC) for failing to implement the changes in manning levels needed for Achieving a Balance. This leader came as no surprise to psychiatric trainees, and nor did it offer much comfort. The ‘bottleneck’ between registrar and senior registrar has become a ‘log-jam’ and although prospects for trainee psychiatrists are not as bleak as for the unfortunate would-be thoracic physicians cited in the leader, they are bad enough. For example, when a single SR post in adult psychiatry was recently advertised for the NW Thames region, there were over 60 enquiries, 45 of which transformed into definite applications, even though the post offered was in a less than popular sub-speciality. Local selection committee members for NW Thames in other psychiatric specialities have also been surprised by the number of applicants. JPAC may not be entirely to blame: the economic recession may be a disincentive for consultants wishing to retire early, thus slowing-up career progression throughout the profession.

More than any other area of medicine, psychiatry is influenced greatly by the cultural setting in which it is practised. Iran and the UK have similar-sized populations, but are very different in many other respects. The opportunity arose to compare psychiatric practice in these two countries when one of us (N.H.) spent 3 months visiting mental health services at a UK centre.

This study investigated the links between aspects of cultural life and response to ethnic monitoring questions, and compared parental and adolescents' responses. Questionnaires were given to consecutive attenders at a child and adolescent psychiatry department situated in central London. Forty-seven parents participated, and 24 adolescents (aged 12–16 years) also completed questionnaires. Parents came from many parts of the world and their offspring were mostly born in the UK, but had varied cultural life with respect to language, peer group and diet. Just over half of the offspring were regarded as ‘White British’ by parents but the second largest group was that marked ‘other’, who all had mixed identity. There were differences in how parents described adolescents, especially in relation to peer culture. Since ethnic categories have limitations the data should be used carefully, and for many aspects of health planning and delivery other cultural variables would be useful. Consideration should be given to the need for specifying whether adolescents or their parents should respond to ethnic monitoring questions.

The objects and purposes of the constitution of the Royal College of Psychiatrists in 1971 included to “advance the science and practice of psychiatry” and “to promote study and research” (Supplemental Charter and Bye-Laws, 1989).

Working for Patients (1989) demonstrates the Government's intention to “encourage all Royal Colleges to make participation in medical audit a condition of a hospital unit being allowed to train doctors”, suggesting this may also become a requirement for psychiatric trainees. The Psychiatry Department at Fazakerley Hospital moved into the rather uncharted territory of clinical audit with monthly unit audit meetings in 1989. At each meeting randomly selected cases are reviewed and data presented which are relevant to clinical practice on the unit. The majority of topic audits have been presented by trainees with support from consultants. Most Colleges agree that casenotes should be available for scrutiny (Warden, 1988). Consequently I undertook a casenote audit.

The Scottish Liver Transplantation Unit (SLTU) opened in the Edinburgh Royal Infirmary in November 1992. We describe the liaison psychiatric input during its first 23 months. Sixty-five patients were seen from 69 referrals and their case notes were studied retrospectively to obtain information on patient demographics and details of each psychiatric involvement. A high level of psychiatric morbidity was found and psychiatric opinion contributed to the transplant assessment procedure. Our results indicate the need for good liaison psychiatric input with subsequent resource implications.

Increasing referrals to psychiatric clinics, combined with restricted medical manpower, require innovative ways of meeting the demands. We appointed a nurse to help in an out-patient clinic. The nurse recorded new patients' case histories and presented them to the consultant, who could then see the patients in less time. In the first 15 months the clinic saw 260 new patients, compared with 190 in the previous period. The median waiting time for appointments came down from 32.5 to 22.5 days (P=0.018). Patients reported a high level of satisfaction with seeing a nurse and a doctor.

Patients seen in psychiatric settings may, for a variety of reasons, be incapable of informed consent. The Mental Health Act allows for their treatment, but research into their pathologies is practically impaired (while their consent is a criterion for inclusion). Is it ethically unacceptable to perform research upon these patients? If so, then the prospects for therapeutic and conceptual advance seem remote. In this paper the competing ethical claims are examined. An approach is proposed which is humane yet permissive of research in this heterogeneous group of patients.

Mental disorders may seriously impair insight and therefore cause some patients to refuse potentially life-saving treatment which they would otherwise accept. Opinion on the ethics of current legislation regarding compulsory admission and treatment varies with open debates leading to heated and emotive exchanges. During the reading of the 1982 Mental Health Amendment Bill intense lobbying of MPs took place (Bluglass, 1984). Some argued against compulsory detention because of its infringement on personal liberty while others argued that it was necessary for the adequate treatment of mental disorders which impair insight. They pointed out one's right to receive appropriate treatment whether or not insight is impaired.

Help-seeking is important for patients with suicidal ideation. Currently, a risk management paradigm is used with patients who express suicidality; however, this may limit support and increase stigma, reducing future help-seeking. Coping planning is proposed as a paradigm shift that overcomes these problems by focusing on patient needs and strengths.

We describe the problems encountered in dealing with a ‘discharge refuser’ in the context of recent government guidelines on good practice in the discharge of mentally disordered people.