Clozapine is an effective antipsychotic medication but is associated with agranulocytosis, neutropenia and leucopenia. The reintroduction of clozapine improved management of treatment-resistant schizophrenia, yet resulted in a paradoxical situation whereby the risk of blood dyscrasias is rigorously managed but other adverse effects (e.g. seizures, cardiovascular complications) are less well monitored. Monitoring of weight, lipids, plasma glucose and other metabolic parameters is recommended. There is also a need to reconsider routine haematological monitoring with other medications associated with blood dyscrasia (e.g. phenothiazines, carbamazepine). In particular, individuals who develop clozapine-induced blood dyscrasia may require haematological monitoring during treatment with other antipsychotics.

The majority of patients respond to antipsychotic monotherapy at standard doses, but a subset of patients will require more heroic measures that include antipsychotic polypharmacy and high-dose monotherapy. Indeed, research has shown that roughly 30% of patients with psychosis are prescribed multiple antipsychotic medications. We discuss the potential benefits and challenges of these approaches and provide a rationale for why and when they should be utilised.

This paper outlines recent revisions to the psychotherapy elements of the core psychiatric training curriculum of the Royal College of Psychiatrists. The reasons why psychotherapy training is important as part of psychiatry training are developed and objections to the inclusion of this element are countered. The paper sets out the reasoning that led to the revisions in the training required and discusses the obstacles to the implementation of good-quality training in this area and suggests ways in which they can be overcome.

Few treatments are more controversial than the prescribing of injectable heroin (diamorphine) to heroin addicts. This practice is still banned in the USA and Australia, despite the serious drug problems in those countries. At present any UK doctor can prescribe injectable methadone for the treatment of heroin addiction; however, the prescribing of heroin requires a special licence from the Home Office. The National Treatment Agency for Substance Misuse is the statutory body currently responsible for advising purchasers (local drug action teams) in regard to specialist services for addictions. They have recently commissioned and published guidelines for the prescription of injectables in opiate addiction (National Treatment Agency for Substance Misuse, 2003). This follows the report of a Government committee, which stated:

‘If diamorphine treatment could be offered to all problematic users who do not successfully access other treatments, we believe it could play a useful part in managing the social problems generated by this group of people’ (House of Commons Home Affairs Committee, 2003).

As mental health care services move increasingly into the community with staff working in more isolated settings, violence against staff is becoming an increasing health and safety issue. Education and training of staff to cope with potentially violent situations is a priority, equally important is the design and physical layout of the room in which potentially violent patients are seen. This audit looked at the safety features present in consulting rooms used daily, for interviewing patients, by mental health professionals. The study identified rooms which were judged unsuitable for interviewing potentially aggressive patients in, and as a result, several recommendations for safety improvements to these rooms were made.

Treatment of the mentally ill by the Aboriginal Awaraks of Jamaica and the other Caribbean islands was first described by a Spanish monk in 1540: ‘Lunatics’ who were called ‘mind riven’ were treated in the community with salvent herbs, which were blended with food and left to hang on fruit trees for those who wandered, and by the administration of unguents and lavings while singing. This record indicates that the mentally ill were treated by the indigenous Indians without restraints, and with rudimentary attempts at pharmacology and cultural therapies. But this enlightened but primitive mental health system was destroyed with the advent of the Spanish conquerors who, according to Las Casas, “in about eight to forty years have unjustly put to death about twelve million Indians without distinction of quality, sex or age”.

This article gives an account of a 2-year project to establish the fate of the mental hospitals in three areas of the UK. There were two aims: to determine the proportion of mental hospitals that are currently open and to provide descriptive data on the fate of those that had closed.

Prolactin, a protein hormone synthesised and released by the anterior pituitary, promotes mammary tissue development and lactation and suppresses gonadotrophin secretion. Dopamine is the natural inhibitor of prolactin release and so standard antipsychotics, which block dopamine receptors, will cause prolactin levels to rise. This hyperprolactinaemia can lead to gynaecomastia, galactorrhoea, menstrual disturbances, a reduction in sperm count, erectile dysfunction, failure of ejaculation and reduced libido. Prolactin-related adverse effects are frequently encountered in patients on antipsychotics and are a cause of substantial morbidity.

Quality improvement (QI) projects have been shown to positively influence patient care. They provide opportunities for trainees to present and publish their work locally and nationally, and to gain valuable leadership and management experience. We describe a pilot project to engage in QI trainees across a National Health Service trust and a school of psychiatry. After the first year of this programme over half of psychiatry trainees in the school (58% of core trainees and 47% of advanced trainees) are participating in 28 individual QI projects and QI project methodology is to become embedded in the core psychiatry training course. Specialty doctors, consultants, foundation doctors, general practitioner trainees, medical students and the wider multidisciplinary team have all become engaged alongside trainees, working with patients and their families to identify problems to tackle and ideas to test.

Non-attendance rates are high in child psychiatry clinics. This potential waste of resources is coming under increasing scrutiny within the NHS. This study shows that therapists themselves are good at predicting who will attend and who will not. The family's previous attendance rate is the most reliable predictor. Why then is not more use made of this information when organising clinics? Ways are suggested how attendance rates might be improved.