The ‘brain drain’, resulting from the recruitment by the UK of highly qualified mental health professionals from middle- and low-income countries, has been described as a serious problem effecting the service provision, training and research capacity of these countries (Doku & Mallett, 2003; Thara et al, 2004). Although this issue is important, the benefits of such migration are seldom highlighted. Professionals who migrate often invest in families and businesses in their home country and are a source of valuable foreign income. Many professionals undergo specialised training and gain experience not available in their home countries and then return to provide an enhanced level of service (Tareen, 2000). Such movement may also serve a catalytic purpose. An example of a sector that has gained enormously from the so-called brain drain is information technology in India, which is built largely around expatriates in the USA and their networks back home. The high profile of Indian information technology experts has encouraged a whole new generation to pursue excellence in this field.

The main source of topical information in most parts of the world is through the mass media – principally newspapers and television. Television news and current affairs have a duty to remain impartial, as they provide a service for the whole population. Newspapers, on the other hand, have a greater journalistic and editorial freedom as they target subgroups. British newspapers are currently being scrutinised as to how they report both factual and speculative information of a general kind. At the same time there seems to be an increase in their interest in psychological matters. However, work on newspaper reporting of psychiatric disorders (Day & Page, 1986; Matas et al, 1986) has shown that the mentally ill are usually portrayed in a rather negative light with few positive images.

Fifty-three female in-patients of a psychiatric hospital were interviewed to obtain their views on their own safety and security, and what improvements they would recommend. Most had experienced sexual harassment and a few had been victims of sexual assault. There was a reluctance to report incidents to staff. The majority felt that female-only wards would improve safety. Other recommendations included higher staffing levels, more staff awareness and vigilance, and single rooms with curtains on the doors.

Evidence-based medicine is an approach to clinical training and practice that is increasing in popularity. When introduced into the journal club format, it provides an opportunity to integrate real clinical problems with critical evaluation of the psychiatric research literature. The principles of evidence-based medicine and the practicalities of its introduction into the Journal club format are described.

Advances in neuroscience in recent years have blurred the boundaries between psychiatry and neurology. They now have more in common than what divides them and this signals a return to their origins. Many have called for a merger of the two disciplines, which would offer a more holistic approach, whereas others vigorously reject such a move. Limiting neurology to the study of the nervous system and psychiatry to the social brain or affect and its disorders is no longer sustainable. The ongoing separation of the disciplines has had an impact on diagnosis and treatment, on professional isolation and on funding psychiatric research.

A review is made of the anti-psychiatric movement through its major protagonists, Lacan, Laing, Cooper and Szasz. The ideology was set to challenge the concept of mental illness and question the authority of the psychiatrist and the need for mental health institutions. The anti-psychiatric movement received a lot of attention in the 1970s but is now considered to be of the past and of likely interest to the psychiatric historian. However, the impact of the movement on current psychiatric practice requires further re-examination and appraisal.

An incapacity to make decisions can crucially affect quality of life. Those who lack capacity are vulnerable to abuse from others, ranging from overpaternalism to exploitation, neglect and violence. Historically, those lacking capacity have not been served well by statutory services, with institutionalisation being commonplace. Community care has had its successes and failures; although care provided is often well intentioned and of good quality, abuses of power and trust continue to occur.

Absconding constitutes a significant clinical problem, leading to high levels of anxiety among staff. Ninety-five psychiatric in-patients who absconded from an Irish hospital over a period of 12 months were reviewed retrospectively. Absconders were significantly more likely to be single and compulsorily detained with a diagnosis of schizophrenia or personality disorder when compared to the remaining hospital population for that year. Common destinations included the public house and home, with most returning of their own volition within 24 hours. The rates of self-harm and violence against others are recorded.

Although antidepressants are regarded as effective and specific treatments, they are barely superior to placebo in randomised trials, and differences are unlikely to be clinically relevant. The conventional disease-centred understanding of drug action regards antidepressants as targeting an underlying brain process, but an alternative ‘drug-centred’ view suggests they are psychoactive substances that modify normal mental states and behaviour. These alterations, such as numbing of emotions, may reduce feelings of depression, and also create amplified placebo effects in randomised trials. Patients should be informed that there is no evidence that antidepressants work by correcting a chemical imbalance, that antidepressants have mind-altering effects, and that evidence suggests they produce no noticeable benefit compared with placebo.

Concerns about the use of high doses of neuroleptic medication prompted an audit of prescriptions of these drugs in a large psychiatric hospital. Following an initial audit in 1991 of 196 patients, a follow-up of 192 patients was undertaken in 1993. A significant reduction in levels of neuroleptic medication was found, although doses still tended to remain high.

We audited the use of high-dose antipsychotic drugs in patients admitted to a special (intensive) care unit over two periods. Five out of 57 patients in the first sample and three out of 62 in the second were treated with a single antipsychotic drug above the British National Formulary maximum dose. The proportion of patients treated with antipsychotic drugs such that the total dose in chlorpromazine equivalents was greater than 1000 mg, fed. The audit showed improvements in clinical practice, particularly with respect to the onset of, indication for and outcome of high-dose treatment and in monitoring the patients' physical status.

There has been considerable debate in the UK in recent years about the propriety of using various forms of ‘involuntary out-patient treatment’ for some individuals with serious mental illness (Eastman, 1995; Dyre, 1998; Burns, 1999; Moncrieff & Smyth, 1999; Sugarman, 1999). While most jurisdictions in the US have statutes that support involuntary out-patient treatment (Torrey & Kaplan, 1995), its use remains controversial (Slobogin, 1994; Diamond, 1995; Torrey, 1997). Involuntary outpatient treatment was originally proposed as a solution to the ‘revolving door syndrome’ (Geller, 1996). It has also been recognised, however, that it may provide a solution to the clinical and ethical dilemmas of allowing individuals who are incapable of making treatment decisions to discontinue treatment, with predictable deterioration to the point where they may harm themselves or others (Geller, 1990). This paper provides a review of controlled studies that have examined whether involuntary treatment in the community is effective.

The placebo effect is a fascinating phenomenon in clinical practice. Studies have shown that there is a significant placebo effect in a wide range of medical conditions including psychiatric disorders. This article looks at the background of the placebo effect, defines the common terms used, describes the various hypotheses that have been put forward to explain this seemingly inexplicable phenomenon and also covers the issue of using placebos in research trials, highlighting the important ethical dilemmas involved. Throughout, specific emphasis is given to psychiatry.