As clinicians, we are used to making often fast and life-altering decisions. As professionals, the clinical decisions we make depend upon our training, knowledge base, supervision, expertise and experience. Sociodemographic factors such as age, gender, ethnicity and cultural background can also influence our views. However, rarely do we step back to think about the mental processes behind our decision-making. In cognitive–behavioural therapy and in our general dealings with patients, we aim to help them identify their cognitive schema and attribution errors as a way forward; but we rarely reflect on our own cognitive schema and possible misattribution in making decisions. Both patients and healthcare professionals are affected by cultural norms, mores and expectations.

Borrowing books was a privilege introduced for women by several academic institutions and libraries in England in the 19th century. Cambridge University accepted women on equal terms with men in 1948. Various objectors before that feared that higher education would have untoward effects on women's bodies and minds. The eminent 19th-century psychiatrist Henry Maudsley was convinced it would make them infertile (Robinson, 2009). Yet women played an important role in the founding of many Islamic educational institutions from the first millennium, and Christian religious orders fostered education for girls and women in Europe before the modern era.

We are living in significant and challenging times for mental health services across the world. On the one hand, many countries are in the middle of comprehensive reforms of their mental health systems, and these require funding (WHO Europe, 2008). On the other, they are affected by the global financial crisis as regional and national economic recessions threaten to herald a social crisis in many countries. Governments have had to come up with multi-billion-dollar rescue packages. At an individual level, debt status is already high in many countries, owing to falling house prices and high consumption levels, combined with rising commodity prices during the past few years, before the onset of the recession. At a public level, countries will be forced to make stringent cuts in public sector expenditure.

At the turn of a new decade how might the futures of psychiatrists look? Here we address issues of social inclusion and, also, the professional identity and relationships of psychiatrists.

As the median age of populations around the world increases, due to the provision of better diets and better medical care, the number of elderly persons vulnerable to mental illness will inevitably increase too. We are not good at providing high-quality geriatric care, even in high-income countries. For example, Age Concern (a UK-based charity) states on its website: ‘Health and social care services have made some progress in tackling age discrimination, but older people still report feeling that they have had second class treatment and care simply because of their age’ (www.ageconcern.org.uk/AgeConcern/ageism-in-healthcare.asp). How much worse these matters are in low- and middle-income countries is the subject of our theme in this issue. We have drawn articles from three distinct geographic regions: India, Africa and South-East Asia. We often assume that cultural factors in lower-income areas lead to greater respect for, and better care of, the elderly than we experience in many parts of the Western hemisphere. This appears to be a misapprehension, and attitudes towards the elderly are changing as the impact of industrialisation increases.

In the UK, only 13% of people with long-term mental health problems are in employment, compared with 35% generally of people with a disability (Royal College of General Practitioners, 2005). Nearly 2.6 million individuals receive incapacity benefit and/or severe disability allowance and, of these, close to 1 million are claiming incapacity benefit due to mental ill health. The management of this enormous number of people – providing support to them and helping them get back into employment – is an issue that cannot be addressed adequately by our specialist mental health services. Accordingly, other models of service delivery need to be considered. The three thematic papers in this issue look at this issue from the perspective of three highly contrasting societies.

Back in April 2006 (vol. 3, no. 2) we published papers on the theme of misuse of alcohol by young people, 3 years after the UK government had introduced the option of 24-hour drinking. The British Medical Association (BMA) subsequently recommended that there should be a programme of research to examine the consequences of this change to our drinking culture. In 2008, it reported on current trends in alcohol misuse (BMA Board of Science, 2008). An appendix to that report summarises the different alcohol control strategies pursued by the governments of England, Wales, Scotland and Northern Ireland in the past few years. These are outlined in the document Safe. Sensible. Social. The Next Steps in the National Alcohol Strategy (HM Government, 2007).

Over the past 20 years the number of children recruited into armed conflict, as combatants, spies, labourers and sex slaves, has increased substantially (Wessells, 2009). In this issue, we focus on the research that has been done in recent years to identify the extent of this problem and, in particular, the efforts that are being made to discover the most effective ways of rehabilitating former child soldiers into society.

Studies worldwide have reported alarming rates of alcohol misuse among medical students (Webb et al, 1996; Kuo et al, 2002; Akvadar et al, 2004). These reports are surprising as well as of extreme concern, as medical professionals are supposedly more educated on the harmful effects of excessive alcohol consumption. The majority of studies exploring the knowledge and attitudes of medical students regarding alcohol have been from the USA and the UK, with only few from lower-income countries and the Islamic world (Kumar & Basu, 2000; Akvadar et al, 2004).

In China, ‘community’ was an alien word. Many people used to live in dormitories (Danwei), to which they were assigned by government according to their work units. ‘Dormitory form’ community was closely linked to where people worked, and thus administration and supervision were simple, as was the provision of health services. In each Danwei, a clinic provided basic healthcare not only for its employees but also for the other residents of the dormitory. The old primary care service was based on this. In fact, the ‘golden age’ of community mental healthcare was at that time, when psychiatric hospitals extended their service to communities via the Danwei's clinics in the cities and via ‘barefoot doctors’ in the rural areas. Home beds, occupational therapy stations and shelter factories were set up in some cities and mobile mental health teams played important roles in the villages. Although this did not really represent the ‘integration’ of mental health into primary care, it was a good example of maximising the utilisation of the very limited mental health resources by stretching the psychiatric service, using administrative power, and mobilising family members (Shen et al, 1990; Zhang & Yan, 1990; Zhang, 1999).

Sixty per cent of the global elderly population live in low-and middle-income countries, and this proportion was expected to rise to 70% by 2010 (International Institute of Ageing, 2001; Ferri et al, 2005). The 2001 Indian census found over 70 million people aged 60 years or more (considered senior citizens according to the Indian National Policy on Older Persons). Most of those senior citizens live with younger family members and are dependent on them for financial and social support. Hence, any physiological and psychological changes in the older family members affect the younger supportive members as well.

Worldwide there are currently 300 000 child soldiers. Not only does the use of child soldiers lead to individual suffering but it also alters the dynamics of war and makes conflict and instability more likely. It is important both to prevent recruitment and to rehabilitate former child soldiers into their communities. For rehabilitation and reintegration programmes to be effective, it is necessary to understand the consequences of child soldiering. This paper reviews and summarises some of the key findings related to the mental health consequences of being a child soldier.

Mental health disorders account for about 14% of the global burden of disease. Neuropsychiatric disorders may be responsible for more than 1.2 million deaths annually (Prince et al, 2007). Around 80% of those affected live in low- and middle-income countries. Yet, despite the fact that older persons carry a disproportionate burden of non-communicable disease and mental disorder, they are not seen as priority issues for healthcare provision in these countries. Logically and ethically, older persons should be prioritised for targeted interventions, alongside the generic strengthening of primary and community health provision. African governments, spurred on by the specific agendas of non-governmental and parastatal organisations, continue with more urgent tasks; their healthcare provision is oriented towards the ‘younger generations’ (maternal and child healthcare, and infection). In most African countries, the expenditure specifically targeted for mental health is below 1% of the total healthcare budget, that is, effectively non-existent (Saxena et al, 2007).

Alcohol is widely consumed in many societies. It is estimated to be responsible for 4% of the global disease burden, and is third only to tobacco and hypertension as a leading cause of death in high-income countries. Ireland has one of the highest levels of alcohol use per capita in the world. According to Barnardos (a children's charity) there was a 48% increase in alcohol consumption per capita in Ireland between 1986 and 2006 (Barnardos, 2008). The Irish government endorsed the European Charter on Alcohol in 1995 but, in spite of this, the negative health consequences of alcohol consumption have increased (Mongan et al, 2002). About 28% of all injuries presenting to emergency departments in Ireland are alcohol related (Hope, 2008) and the number of hospital discharges related to alcohol increased by 92% between 1995 and 2002 (Mongan et al, 2002). Hope (2008) found that alcohol was implicated in 36.5% of road traffic fatalities in 2003 in Ireland, and was also a contributory factor in several cases of house fires and domestic abuse.

Child soldiers represent a challenging population for mental health and psychosocial support (MHPSS), as we have little evidence regarding their needs or the efficacy of interventions. Despite an increasing breadth of MHPSS interventions for children affected by war, very few are supported by evidence (Jordans et al, 2009). In a recent decade-long conflict, Maoists and the government of Nepal conscripted thousands of children to serve as soldiers, sentries, spies, cooks and porters. After the war ended in 2006, we began a project incorporating research into the development of interventions for former child soldiers. Through this work, conducted with Transcultural Psychosocial Organization (TPO) Nepal, we identified four key principles to guide research and intervention with child soldiers (Fig. 1). We present these principles as location- and context-specific examples of the growing effort to develop guidelines and recommendations for research and intervention in acute post-conflict settings (Inter-Agency Standing Committee, 2007; Allden et al, 2009).

Egypt has a population of roughly 80 million, served by about 9000 psychiatric beds, 1000 psychiatrists (one psychiatrist per 80 000 citizens), 1900 psychiatric nurses and about 200 clinical psychologists (Okasha, 2004). Service providers fall into three main sectors: public, private, and not-for-profit non-governmental organisations (NGOs). The public sector is managed essentially by the Ministry of Health and bears the brunt of service provision.

The report World Population Ageing 1950–2050 (United Nations, 2002) estimated that in 2005 there were 37.3 million elderly people (i.e. aged 65 years or more) in South-East Asia (a region incorporating Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand and Vietnam). There are only a few epidemiological studies on mental disorders among elderly people in this region and the published data are mainly from Singapore, Malaysia and Thailand. Using Singapore's prevalence rate of 3% for dementia and 5.7% for depression, the numbers of elderly people with dementia in this region would be 1.2 million and with depression 2.12 million (Kua, 1992; Kua & Ko, 1995). However, even in Singapore, we have identified only 10% of all potential cases of dementia and depression — meaning that the large majority of elderly people with mental disorders are not detected, although they may be known, for other reasons, to the health services.

The forceful conscription of children (both boys and girls) into armed forces has been documented in at least 86 countries (Coalition to Stop the Use of Child Soldiers, 2008). Research suggests that these children may be at heightened risk of psychological and social problems (Wessells, 2009; Blattman & Annan, 2010). However, there is little information on the long-term effects of child soldiers' wartime experiences.

Substance use has become a major threat to health and human development in many European countries. In 23 out of 28 countries participating in the European School Survey Project on Alcohol and Other Drugs (ESPAD), there was a constant and substantial increase in substance use among secondary-school students between the years 1995 and 2003 (Hibell et al, 2003). Iceland experienced a similar upward trend in substance use (Sigfusdottir et al, 2008). Throughout the 1990s, the use of alcohol, tobacco and other drugs increased steadily among 15- and 16-year-olds. In 1998, approximately 17% of 16-year-olds had tried hashish, which was the highest frequency to be measured in Iceland, and over 80% reported that they had used alcohol once or more in their lives (Thorlindsson et al, 1998).

Chile has two major national health systems, the public one, which serves nearly 80% of the country's close to 17 million population, and the private one, which serves the other 20%. The public primary healthcare system has been developing in Chile since before the Alma Ata Conference in 1978 (which produced the first international declaration on the importance of primary healthcare).