To ascertain the competence of voluntary psychiatric patients to consent to neuroleptic medication and whether there is a hierarchy of tests of competence. A prospective, observational study of consecutive, voluntary admissions to an acute ward using a questionnaire designed to test four levels of competence, the Mini-Mental State Examination and the Brief Symptom Inventory.

All subjects (n=40) could communicate a choice; 5% were competent at all levels. Tests were arbitrary and not hierarchical. Symptom relief/trust in doctors motivated most decisions to accept treatment.

The number and identity of individuals identified as competent will vary with the test set, and tests limited to cognitive criteria will not cover the complexity of the task.

To assess the degree of psychological morbidity and burnout in 138 psychiatrists in three Manchester teaching hospitals.

The results for senior house officers (SHOs), registrars, senior registrars and consultants were compared. The overall response rate was 76.8%. There was no significant difference in psychological morbidity between the three training grades, but SHOs and registrars reported significantly higher levels of burnout than either senior registrars or consultants. Dealing with violent patients was stressful for all psychiatrists, no matter what the grade.

Factors related to job stress in psychiatry need to be addressed. In particular, the provision of safer working environments needs to be considered for psychiatrists at all levels of training.

Health of the Nation Outcome Scales (HoNOS) were piloted in 248 patients with serious persistent mental health problems. Staff were trained by a cascade approach and rated patient outcome after six months.

There was poor interrater reliability between nurses and psychiatrists/psychologists. Outcome measured by HoNOS often contrasted with clinical experience.

HoNOS were not a reliable or valid measure of outcome. The scales are now completed only under supervision.

To follow up homeless people with psychoses treated by a dedicated team; changes in accommodation, risk behaviour, mental state and psychiatric care were examined.

Service uptake improved as did symptomatology and residential stability. However, substance use and criminality continued to be prevalent and a minority remained homeless.

Specialist psychiatric teams are a valuable adjunct to mainstream services in areas with high levels of homelessness.

A small minority of treatment-refractory patients who could benefit from treatment with clozapine, refuse to comply with blood tests or oral treatment. Treatment with clozapine can be enforced under the Mental Health Act.

An aide memoire was developed locally to guide clinicians through the process of enforcing clozapine treatment.

It is possible to enforce treatment with clozapine under the Mental Health Act and so offer a valuable treatment option.

Leaflets are commonly used as a way of providing information to users. In this study, we use a simple index of ‘readability’ to compare a range of leaflets available to people with mental health problems.

The majority of the leaflets contained passages that are likely to be beyond the comprehension of people with mental health problems.

Leaflets are a cost-effective way of providing information, but only if the text can be understood by the target audience.

The aim of the study was to investigate changes in service utilisation following therapeutic community treatment for patients with severe personality disorder. The study examined service usage, in the form of acute psychiatric admissions, of a series of 52 admissions to a residential therapeutic community in the three years before and year after admission.

There was a reduction in the mean duration of acute psychiatric admissions after treatment, this was greater for extra-contractual referral patients than local district patients.

This study replicates results from previous studies. It also suggests that more accessible local services may be able to intervene earlier in patients' psychiatric careers preventing heavy use of acute services. We argue for greater provision of therapeutic community treatment for severe personality disorder.

To discuss the working of a new paediatric liaison service. To review paediatric referrals to a child and adolescent mental health service (CAMHS) 21 months before and 21 months after the establishment of this service.

One hundred and eighty-three children were discussed in the 21 months after the new service was set up. There was a rise in referral to CAMHS from 72 to 120. Non-attendance rates from paediatric referrals also rose. Likely reasons for these changes are discussed, and include an increase in referrals of children with somatisation.

Interdisciplinary liaison appears to carry many advantages, but is likely to increase referral rates to the CAMHS. This has both clinical and resource implications.

We aimed to update Information on the development of old age psychiatric services using a postal survey of consultants.

The response rate (51%) was lower than previous surveys in the 1980s. Senior academic appointments showed little increase and academic posts were largely National Health Service (NHS) funded. Services had smaller catchment areas and increased numbers of staff in medicine, nursing and social work, but not in occupational therapy, physiotherapy and psychology. Relative workload was increasing and most services included early-onset dementia. There was a decrease in provision of NHS long-stay beds with only marginal changes in other facilities.

Services were offering more to patients than previously. Weakness in academic development may cause problems for the future; the results suggested that recruitment in some disciplines may already be problematical. There is a need to develop the role of NHS long-stay facilities.

From March 1997, the acute day hospital in Central Manchester was extended to 24 hours, seven days a week, with patients treated entirely at home if preferred. The development and organisation of the new service are described. Preliminary evaluation data include service activity for the first 12 months and comparison with a consecutive series of in-patients during the first three months.

There was an increase in the number of patients treated in the first year (n=214). Sixty-two per cent of patients suffered from schizophrenia, psychotic depression or bipolar disorder. Patients treated by the new service in the first three months (n=43) were more likely than in-patients (n=37) to have problems eating or drinking and to present with suicide risk, whereas the inpatients were more likely to have had adverse past experiences of services and to show behavioural disturbances.

The findings support the continued development of 24–hour alternatives to inpatient care, while emphasising that those requiring inpatient care have different presentations and needs.

Inner London psychiatric services face particular pressures. One measure of this is over-occupancy of acute psychiatric beds. Seven census-based surveys were conducted between June 1994 and January 1999 to quantify and monitor problems of inner London acute psychiatric bed provision. The censuses involved 14 inner London mental health services with a combined catchment population of approximately three million. Measures included levels (and changes over time) of occupancy, detention under the Mental Health Act, prolonged hospital stays and ward violence.

‘Minimum’ occupancy levels for the combined services were above 100% at all census points. Occupancy level fell from 122% to 112% between the first and seventh census. This was associated with an increase in bed numbers of 2.5 per 100000. Levels of detention were consistently at around 50% and violent incidents were high at all census points.

Current provision of acute beds remains insufficient to meet service demand. To meet the 85% ward occupancy level recommended by the Royal College of Psychiatrists a further 14 beds or community alternatives per 100000 population would be required.

Within a mental health service for children and their families a range of treatment options should be offered. We discuss the organisation of family therapy as one mode of treatment within a generic child and adolescent mental health service. It is based upon a review of all referrals during a 12-month period (April 1997–March 1998).

This review showed a high rate of non-attendance for first appointments, that the family therapy offered an effective forum for assessment and that a brief focused model of intervention could be effective within a generic service.

This review has lead us to modify our deployment of family therapy as a treatment option: this modification has implications in terms of resource utilisation and of the clinical use of family therapy.

The government has proposed a ‘root and branch’ review of the Mental Health Act 1983 to be conducted by the end of 1999. The aim of the study was to establish the views of general and forensic psychiatrists as to the adequacy of present legislative provision for England and Wales. The study was carried out by postal survey.

The response rates were 82%, for forensic psychiatrists and 67%, for general psychiatrists. Most respondents considered most of present provision satisfactory. Areas considered in need of amendment were: the term ‘psychopathic disorder’; the requirement for an offence punishable by imprisonment before a hospital order can be made, provision for remands to hospital and the loss of clinical independence consequent upon the making of a restriction order.

Forensic psychiatrists seem more willing than general psychiatrists to see their clinical discretion limited by the courts. Most of the suggestions were for changes to individual aspects of the present legislation rather than radical reform.

This study presents an evaluation of an education programme for families whose relative has experienced a first episode of psychosis. Participants attended a five-week programme and were asked to rate their level of knowledge and confidence in managing the illness before and after the education sessions.

Two consecutive groups of relatives (n=9; n=11) attended the programme. Comparison of knowledge and confidence ratings before and after the education sessions demonstrated significant levels of change at the final session for both groups.

Education for relatives of people experiencing psychosis for the first time is an important component in community management. Such education improves the knowledge and confidence of relatives in coping with the illness, possibly leading to a more accepting and less stressful family environment reducing the risk of relapse and promoting the psychological health of the patient.

The aim was to provide effective time-limited management of acute episodes of mental illness in the community, thus reducing dependency on the psychiatric services. A multi-disciplinary team supplied intensive psychological and pharmacological interventions.

Fifty-nine per cent were discharged within 12 weeks to the care of their general practitioner. Twelve per cent were admitted to in-patient care.

A time limited multi-disciplinary approach will have benefits to patients and the service.

An audit was performed to look at how carefully anticholinergic medication was prescribed and monitored in a population of psychiatric patients on depot medication.

The mean duration of prescription was 47 months and 44% of patients' prescriptions went unaltered for over three years. Evidence was lacking for rational initial anticholinergic prescription.

Anticholinergic treatment needs to be prescribed more rationally with regular monitoring of extra-pyramidal symptoms.

To describe the characteristics of probationers assessed (n=83) and supported (n=31) by a mental health worker (MHW) attached to a probation service. A survey of cases and case descriptions.

Referrals were predominantly White, unemployed males on probation orders. Most had acquisitive/property and violent convictions along with substance misuse problems and personality disorder diagnoses. The MHW supported probationers already in contact with psychiatric services and provided a safety net and sometimes sole support, to those who were not.

The MHW helped to bridge the gap between criminal justice and mental health systems by facilitating contact between probationers and psychiatric services. The clinical effectiveness of the scheme should now be examined.

To test the impression of wide national differences in the use of deterrent medication in the treatment of alcohol dependence, data showing comparative sales of disulfiram in 13 countries were obtained.

Sales in Britain were lowest, and less than a tenth of those in Denmark. Rates bore no relation to alcohol sales or an index of alcohol-related problems in the 13 countries.

British doctors may apply a particularly cautious risk/benefit ratio for disulfiram. The disparity may also reflect the predominantly nonmedical approach to treating alcohol dependence in Britain.