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.

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.

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 main principle of the Children Act 1989 is that the welfare of a child at risk of abuse or neglect takes precedence over all other considerations. In complying with the Act, these considerations may include the principle of medical confidentiality and the health and safety of some adult patients. Nowhere is this more poignantly illustrated than in the case of childhood sexual abuse disclosure by a distressed psychiatric patient who may be unprepared or unwilling to cooperate with the immediate reporting and ensuing investigation of their abuse as required by the Act.

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.

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.

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.

‘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.

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.

Psychogeriatrics began to develop as a specialty within general psychiatry in the 1950's, but few pychiatrists became involved in establishing clinical services until a decade later. An ad hoc enquiry carried out by the DHSS in 1972 of Regional Hospital Boards revealed that 18 consultants then had a substantial (defined as five or more sessions) commitment to psychogeriatrics. At the same time a survey of psychogeriatric service provision revealed 31 units containing a total of 1,123 beds. Presumably, a number of units were being managed by general psychiatrists with less than a substantial commitment to old age psychiatry.

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.

Over the past 2 years the Global Initiative on Psychiatry has developed a wide range of initiatives in the fields of prison mental health and forensic psychiatry in Eastern Europe and the former Soviet Union. Both areas, until recently, were either ignored or deliberately avoided. This is not coincidental. The prison systems in the former Eastern bloc are in essence military organisations with a strict hierarchy and a rather tarnished past. Although some reform programmes in this field were implemented or started during the past decade (e.g. by Prison Reform International and the London Institute for Prison Studies), none of these projects has involved mental health services within the penitentiary system. A society that often limits itself to locking away those who have committed crimes or are suspected of having committed them, and pays only little attention to the physical and emotional well-being of those imprisoned, does not see the mental health of these persons as a priority. Equally unimportant seems to be the mental health of those who guard the prisoners and who are under constant stress.

The past 20 years have seen the disappearance and degradation of biodiversity on earth at unprecedented rates. This phenomenon shares similar drivers to those behind climate change yet requires its own solutions. The twin catastrophes of climate change and biodiversity loss demonstrate how our health is bound up in the vitality of this planet. There has been an increasing effort on the part of healthcare professionals to appreciate this relationship, as evidenced by the growing influence of planetary health as a discipline. However, the health impacts of biodiversity loss have been less focused on than those brought on by climate change. Psychiatry's appreciation of the interface between environments and our health, alongside the evidence for the connection between nature and mental health specifically, prompt psychiatrists to ensure that the institution of healthcare throws its influence equally behind solutions to climate change as well as biodiversity loss.