The lifetime prevalence of bipolar affective disorder is approximately 1% in both men and women (Reiger et al, 1998). In women the illness is most prevalent in the child-bearing years (Robins et al, 1984). While lithium for the treatment of bipolar disorder is a cornerstone of modern psychopharmacology (Llewellyn et al, 1998), there are inherent problems in treating this sizeable subgroup of patients, as lithium presents small, but significant, risks to a potential foetus. It is also becoming increasingly obvious that serious mental illness poses a risk to the unborn child. This paper reviews those risks, presents a protocol in algorithmic form for dealing with the prescription of lithium in pregnancy and discusses practical issues pertaining to dosage and lithium monitoring.

The 11th International Congress of the World Psychiatric Association (WPA) was held in Hamburg during August 1999. The most memorable feature of the successful event was not the presence of 10 000 psychiatrists from 96 countries, nor their 6000 papers, nor the elegance of the rebuilt city, but a poignant exhibition prepared by the German Society for Psychiatry, Psychotherapy and Neurology. The presentation, titled ‘In Memoriam‘, described the wartime extermination within Germany of 180 000 psychiatric patients. The killers were their psychiatrists.

In October, 1996, an expatriate team commenced working at the Kuwait Hospital for Psychological Medicine on a three-year government contract to develop quality improvements in the mental health service in Kuwait. The team comprised of administrative, medical and nursing staff, including nurse trainers and an occupational therapist and social worker. I was privileged to work on the contract for 17 months as Medical Director - this paper gives an account of my work from a personal perspective.

Although considerable changes have taken place in Slovenia since it became independent in 1991, the psychiatric services face further challenges for their future. Among these, the two main priorities are a further development of the already proposed Patients Advocacy Act and Protection of Rights of Mental Patients Law, and a development of presently almost non-existent community psychiatric services (World Health Organization, Regional Office for Europe, 1999). The developing services should become needs-oriented as Slovenia is a country with extremely high suicide rate and has high rates of alcohol misuse and alcohol-related disorders, with both problems interacting significantly throughout the country.

With the increasing importance of evidence-based medicine in psychiatry, the recent inclusion of a critical analysis paper in the MRCPsych Part II Examination and the current emphasis on clinical governance, it is now necessary for all psychiatrists to have some degree of training in evidence-based practices.

The prospect of looking for a consultant post in child and adolescent psychiatry can be anxiety provoking. The ideal job should be balanced and fulfilling, with scope for personal and service development, and should minimise the likelihood of frustration and burn-out. It is not uncommon for newly appointed consultants to become dispirited by the discrepancy between the job description and the reality of the post.

Y is a 55-year-old woman who was brought to the accident and emergency department, following an epileptic fit on the street. She had a known history of severe alcohol dependency and epilepsy. She had numerous past admissions, which were always terminated prematurely by her. She has not been adhering to the anti-epileptic treatment. Five days prior to admission her daughter found her in a grossly self-neglected state. There was evidence of recent heavy drinking and she had been incontinent of urine and faeces. Despite this the daughter had not requested help. At interview Y presented as a small unkempt lady, seemingly undernourished and frail. She had recently undergone a hip replacement and was found to have an infected suture wound on physical examination. There were no signs of acute confusion or intoxication. She was neither depressed, nor deluded. There were early signs of cognitive decline (short-term memory impairment). She refused voluntary psychiatric treatment and denied her self-neglect, in spite of her bad personal hygiene and infected wound.

Argentina is the second largest country in Latin America. The country extends for about 2360 miles (3800 km) from north to south and is about 884 miles (1423 km) at its widest extension from east to west. Its population is around 35 million. Ninety-five per cent of the habitants are of European origin, more than 50% Italian, followed closely by Spanish and the rest Germans, Russians, Irish, English and other minorities from Eastern European and Arab countries.

The civilian population of southern Lebanon has endured military conflict, civil war, and two invasions since the foundation of the State of Israel in 1948. Currently part of the south is under Israeli occupation forming a buffer zone between Israel and the hostile forces of the Hizbollah and Amal militias. The Israeli Defence Forces are aided by the South Lebanese Army which is the remnants of a Christian militia. The Hizbollah is supported by Iran and Syria and is the dominant force outside the occupation zone. In the south of Lebanon there is a United Nations mandate force which is attempting to return Lebanese government control over the south, decrease hostilities, protect the civilian population and provide humanitarian aid. This is part of the humanitarian mandate of the United Nations Interim Force in Lebanon (UNIFIL) that I had the opportunity to observe and to treat the mental health problems of the civilian population who were living under long-term artillery bombardment and living with continuous fluctuating conflict. Under such circumstances, rigorous scientific methodology in assessing the mental health of the population is extremely difficult. In order to operate effectively, as well as my own rudimentary Arabic, a translator was required. A translator does more than just translate language they also translate custom, culture and provide a valuable source of local information. Utilising my own observations and those of my valued translator, Basima, I did my best to assess how the civilian population coped with what was difficult circumstances. These assessments are value laden and I suppose are in many ways personal. My position as a military psychiatrist in the United Nations allowed me access to both the occupation zone and unoccupied Lebanon.

Akathisia is a distressing movement disorder associated with neuroleptic medication. Patients complain of a feeling of inner restlessness (Barnes, 1989). The characteristic signs include constant moving when seated, rocking from foot to foot and pacing (Adler et al, 1989). Neuroleptic-induced akathisia (NIA) is usually an acute reaction, but a chronic akathisia can occur after prolonged treatment with neuroleptics (Fleischhacker et al, 1990). It has been suggested that chronic NIA is related to tardive dyskinesia, and that like tardive dyskinesia it is difficult to treat (Blaisdell, 1994). Reducing the neuroleptic dose may ease the symptoms (Barnes, 1989). Other options include using an atypical neuroleptic, which may cause lower rates of akathisia (Poyurovsky et al, 1999). Biochemical and pharmacological evidence has indicated the importance of serotonin in controlling movement (Bersani et al, 1986). Serotonin antagonists, particularly mianserin, ritanserin and cyproheptadine, have been used to treat NIA. This article reviews the published trials and case reports retrieved by a Medline search from January 1985 to August 1999.