In this lecture I will ask: is morale poor among doctors? If it is (and let us for a moment assume that it might be), why is it that? If it is worse recently then is the deterioration an inevitable part of the process of rapid change in the National Health Service (NHS)? Is it, on the other hand, remediable?

Climate change is already having unequal effects on the mental health of individuals and communities and will increasingly compound pre-existing mental health inequalities globally. Psychiatrists have a vital part to play in improving both awareness and scientific understanding of structural mechanisms that perpetuate these inequalities, and in responding to global calls for action to promote climate justice and resilience, which are central foundations for good mental and physical health.

The Report of the Social Services Committee of the House of Commons in 1981 (the ‘Short Report’) recommended the establishment of consultant posts without the support of trainee medical staff as part of a strategy to correct the situation where too many doctors occupied training posts for the number of consultant posts available.1 The Royal College of Psychiatrists has endorsed this policy,2 and the withdrawal of approval for training from an increasing number of hospitals around the country is leading rapidly to a situation where a large number of them need to look at alternative arrangements for providing medical cover. We would like to report the establishment and early development of such an arrangement based in a district general hospital.

We question whether adult attention-deficit hyperactivity disorder (ADHD) represents a discrete condition that is distinguishable from ordinary behaviour and other psychiatric disorders, and whether it is related to the childhood disorder, since adult and childhood ADHD are said to be characterised by a different range of symptoms. Although studies of stimulant drugs find marginal short-term effects, which can be explained by their known psychoactive properties, there is little evidence that there are any sustained long-term benefits of drug therapy. We suggest that adult ADHD represents one of the latest attempts to medicalise ordinary human difficulties, and that its popularity is partly dependent on marketing and the reinforcing effects of stimulants.

The lifetime prevalence of bipolar affective disorder is approximately 1% in both men and women (Reiger et al, 1998). In women the illness is most prevalent in the child-bearing years (Robins et al, 1984). While lithium for the treatment of bipolar disorder is a cornerstone of modern psychopharmacology (Llewellyn et al, 1998), there are inherent problems in treating this sizeable subgroup of patients, as lithium presents small, but significant, risks to a potential foetus. It is also becoming increasingly obvious that serious mental illness poses a risk to the unborn child. This paper reviews those risks, presents a protocol in algorithmic form for dealing with the prescription of lithium in pregnancy and discusses practical issues pertaining to dosage and lithium monitoring.

The development of ‘community care’ for the elderly, mentally ill, mentally handicapped and physically disabled has been Government policy in Britain since the 1950s. Problems with implementation of this policy led the Audit Commission (1986) to conclude that “the one option that is not tenable is to do nothing about present financial, organisational and staffing arrangements”. Sir Roy Griffiths was commissioned to review “the way funds are used to support community care policy …”. Radical solutions were proposed and subsequently incorporated in the Government White Paper Caring for People (Department of Health, 1989a). However, two very significant measures were not accepted: the ‘ring-fencing’ of community care monies and the creation of a ministerial post within the Department of Health with specific responsibility for community care.

Aggression directed towards health care workers has been widely discussed (Health Services Advisory Committee, 1987), but information relating to British psychiatry has been anecdotal. The Collegiate Trainees' Committee (CTC) has recently expressed concern about the apparent dearth of training opportunities in the recognition and management of aggression, and the difficulty in obtaining post-incident counselling (1991).

The European Court of Human Rights found that the care and treatment of HL in the ‘Bournewood case’ constituted infringement, in the form of deprivation of liberty, of his rights under Articles 5 (1) and 5 (4) of the European Convention on Human Rights. To prevent the infringement, the Deprivation of Liberty Safeguards were introduced into the Mental Capacity Act 2005 via the Mental Health Act 2007. The recent implementation of the Deprivation of Liberty Safeguards on 1 April 2009 has exposed some anomalies and higlighted some difficulties in its implemention and application, and these are described in the paper.

The number of reports of political activists falling victim to the political abuse of psychiatry is increasing. When the USSR first disintegrated, this practice virtually ceased to occur. What came in its place, however, was a disturbing collection of other forms of abuses, including human rights abuses, caused by a lack of resources, outdated treatment methods, a lack of understanding of individual human rights and a growing lack of tolerance in society. The number of cases of political abuse of psychiatry has increased since the 21st century began, particularly over the past few years in Russia, Belarus and Kazakhstan.

In the past decade there has been a rapid increase in gender diversity, particularly in children and young people, with referrals to specialist gender clinics rising. In this article, the evolving terminology around transgender health is considered and the role of psychiatry is explored now that this condition is no longer classified as a mental illness. The concept of conversion therapy with reference to alternative gender identities is examined critically and with reference to psychiatry's historical relationship with conversion therapy for homosexuality. The authors consider the uncertainties that clinicians face when dealing with something that is no longer a disorder nor a mental condition and yet for which medical interventions are frequently sought and in which mental health comorbidities are common.

In the form of economic evaluation known as cost-utility analysis, the consequences of health programmes are measured in time units adjusted by health utility weights (i.e., states of health valued relative to one another in terms of notional quality). The outcome of health programmes can then be expressed in terms of increased (or decreased) life expectancy and increased (or decreased) quality-of-life. This provides a device for evaluating health programmes that extend life at the expense of undesirable effects, or, that produce reduced morbidity rather than reduced mortality.