The UK's services for adult attention-deficit hyperactivity disorder (ADHD) are in crisis, with demand outstripping capacity and waiting times reaching unprecedented lengths. Recognition of and treatments for ADHD have expanded over the past two decades, increasing clinical demand. This issue has been exacerbated by the COVID-19 pandemic. Despite an increase in specialist services, resource allocation has not kept pace, leading to extended waiting times. Underfunding has encouraged growth in independent providers, leading to fragmentation of service provision. Treatment delays carry a human and financial cost, imposing a burden on health, social care and the criminal justice system. A rethink of service procurement and delivery is needed, with multiple solutions on the table, including increasing funding, improving system efficiency, altering the service provision model and clinical prioritisation. However, the success of these solutions hinges on fiscal capacity and workforce issues.

The theoretical notion of risk is sweeping all before it. Politicians, government planners, scientists and doctors, including psychiatrists, are having to confront a more formalised concept of risk. This is not to say that our awareness, as human beings, of notions of risk has hitherto been largely negligible. However, there is an evident contemporary preoccupation with risk, its assessment and management, which signals society's unwillingness to tolerate or bear anything but the most minimal possibility of adverse outcomes. There are competing definitions and concepts of risk which complicate discussions between experts and the lay public. For example, Thompson (1990) distinguishes between ‘real’ risk, ‘observed’ risk, and ‘perceived’ risk. Real risk is thought to reflect how things stand in the real world. That is, it is a term which refers to actual risk, the actual negative consequences which exist, be they random or otherwise. Whereas observed risk is our evaluation of negative consequences based upon a theoretical model of the physical world. This is further distinguished from perceived risk which is conceived of as being the estimate of real risk in the absence of a theoretical model of the world. The distinction which is being drawn is a subtle one but it is an attempt to capture the idea that our perception of risk is judgmental in nature and does not necessarily correspond with objective reality. The underlying assumption, that our subjective evaluation of risk may not coincide with the true nature of things, is one that psychiatrists are familiar with. The lay perception of the risk that psychiatric patients pose to the public is, at the least, an exaggeration of the objective facts. However, the observed risk, that is the risk calculated by experts that psychiatric patients pose to the public may not be an accurate reflection of the actual risk posed by psychiatric patients.

‘Drug induced psychosis' is a commonly used clinical label but lacks a universally accepted definition. Psychiatrists' understanding of the term was examined using a specifically designed questionnaire. Knowledge about the effects of drugs of abuse and their relationship with psychosis was also examined. A substantial proportion of clinicians did not have a logical and coherent scheme for understanding ‘drug-induced psychosis' and there was no consensus as to which reactions to drug taking should be included within the rubric. Diagnostic errors have potentially serious consequences, so lack of knowledge in this area needs attention and a proposed classification is given.

In successfully recruiting patients for drug trials in dementia the Therapeutic Research Unit for the Elderly (TRUE) had referrals from various sources. The local Memory Clinic (MC) provided 38 patients for screening of which 31 (81%) were recruited, 75% of the overall number recruited. This number was small (n=41) despite various efforts and does not reflect the time invested and amount of contact work with GPs, out-patient departments and other psychiatric services.

The memory clinic provides a source of recruitment of patients for drug trials as well as services for those who do not qualify for such trials. But recruiting without the aid of a memory clinic is difficult and time-consuming and new approaches must be found.

The climate crisis is a health crisis; it demands the urgent attention and action of healthcare professionals and organisations. In this issue of the BJPsych Bulletin, we consider what the destructive effects of the climate and ecological crisis entail for the mental health of populations, and what the response of psychiatrists, both individual and collective, must be. We also highlight the opportunities and benefits a more sustainable and preventative approach could offer individuals, communities and the planet.

It is known that in most traditional psychiatric hospitals a significant minority of patients can have a better quality of life in hospital-hostels. With ample hospital-hostel places it was decided to interview and/or review the notes of all the non-demented Gloucestershire patients under 75 years whose stay in psychiatric hospitals exceeded one year on a census date of 26 September 1990. The characteristics of these long stay or residual patients are described.

The title seems chosen to catch the eye. This it does, but as being perjorative. In contemporary writing about sexual variations only psychoanalysts and a few psychotherapists retain the term ‘perversion’; others have abandoned it as stigmatising.

This study explores the outcome and longer-term sequelae of suffering chronic fatigue syndrome in childhood. Ten such children, ranging from 10 to 16 years of age at diagnosis, were followed up into adulthood, an average of seven years. Most were completely well or markedly improved (seven of nine). Only children fully engaged in therapy made a total recovery. However, respondents felt medical staff did not believe their symptoms and that rehabilitative strategies were unhelpful. No physical or mental illness was subsequently diagnosed to account for the original symptom presentation. Childhood sufferers maintained the same pattern of symptoms as adults. Depressive symptomatology was present in two cases. The overall longer-term prognosis for children suffering chronic fatigue syndrome is good. A successful doctor-patient relationship is essential to improve compliance with management plans.

Referral rates to three groups of mental health professionals working In primary care were compared. All patients referred over an 18-month period at two health centres in an outer London borough were assessed by case-note review and data were collected on 181 consecutive referrals. In general, younger, more socially-stable patients were referred to the psychologist and older patients were seen by the CPN. The psychologist saw most new patients; patients previously seen by a psychiatrist were most likely to be referred again to a psychiatrist. Patients requesting referral to a mental health professional were most likely to be referred to the psychologist. Patients with a diagnosis of psychosis were seen mainly by the psychiatrist and the CPN; the psychiatrist saw most patients with a personality disorder. A high proportion of patients were seen for assessment only. In general, all interventions were brief. There was evidence of selection by GPs in the referral of patients to each mental health professional.

Substantial changes are taking place to undergraduate psychiatric curricula, in response to recent General Medical Council recommendations. The overall aim is to provide a training in core knowledge and skills that enables students to become competent junior house officers. These developments will inevitably affect clinicians' involvement in undergraduate teaching. How change is being implemented in Nottingham –and the success and challenges so far – is discussed.

The epidemic of formarrhoea blighting adult mental health services is spreading to child and adolescent mental health. Threatening to arrive all about the same time are forms to do with risk assessment, care programme approach, outcome and activity recording, Commission for Health Improvement, child protection, assessment of trainees … and more. They will likely cause an avalanche when added to the mountain of existing forms and Government circulars already piled up on my desk. Forms are increasingly governing all aspects of clinical practice. They threaten to get in the way of doing the job.

The importance of establishing registers for non-fatal deliberate self-harm is discussed along with their potential uses. Deliberate self-harm (DSH) data for a single hospital can be derived from the Accident and Emergency (A&E) casualty cards, A&E on-line registers, mental health assessments or general hospital in-patient data. The relative merits of these different data sources are discussed and local methods described. Some data derived from the DSH register are shown.

The depot clinic has long been part of the traditional British psychiatric service. With moves towards care in the community many of the traditional, particularly hospital based, methods of service delivery are becoming unfashionable. The depot clinic has been criticised (Beveridge, 1987) for being out of date, not geared to the needs of the patient, inaccessible and unable to provide personalised care, especially regarding the family factors recognised to be important in the management of chronic psychosis, and is portrayed as a facility designed for the convenience of the staff not the patient. This has led to suggestions for alternative methods of administering treatment to these patients, e.g. at home, from GP, health centre based.

The Union Européenne des Médicins Spécialistes, through its sections and boards, has responsibility for European aspects of training, qualifications, continuing professional development and accreditation. Many specialties have recognised the necessity for a Europe-wide assessment of training schemes and examination of individual practitioner abilities. As a result, several specialties (notably those in surgery) have established accreditation and examination procedures that are recognised throughout the European Union. The processes will have wider influence as the number of countries in the Union expands.

A psychosis workshop and its clinical role are presented. The workshop's mode of operation utilising basic psychodynamic concepts is described with related clinical illustrations. The value of the workshop in implementing College guideliness for general professional psychiatric training and the integration of psychotherapeutic skills into psychiatric practice is discussed.

Discussion of the need to reform psychiatric services in former West Germany started relatively late. It was only in the late 1960s, when the government changed from the conservative Christian Democrats to a coalition of the Social Democratic and Liberal Parties, that psychiatry became a public issue for the first time since World War II. Parliament appointed an expert commission, which after four years gave a comprehensive report in which the inadequate care of mentally ill patients was criticised.