This article outlines a problem in the referral pattern for mental health workers on the Isle of Wight, when they require psychiatric or psychological help. The authors are concerned that treatments are offered by colleagues. A survey undertaken of 12 community mental health units in Wessex seems to indicate that there are no dear policies or financial arrangements for referrals to other units. The authors agree that the treatment of mental health workers everywhere may be compromised in the market economy, if trusts start to function, because of economic pressures, as islands.

The bulk of transcultural research has concentrated on particular themes, which include parasuicides among British Asian women, schizophrenia among Afro-Carribeans, and clinical presentation of somatisation in different races (Littlewood & Lipsedge, 1989). The focus has largely been on clinical patterns of illness and the social determinant of distress as experienced by ethnic minorities in the community remains largely neglected. An attempt has been made, after two years experience of working in a Birmingham city catchment area with an Asian Muslim community, to highlight day to day cultural issues which directly or indirectly contribute to psychiatric morbidity.

An anonymous questionnaire was sent to 67 senior and junior psychiatrists enquiring about their perception of equivalent antipsychotic dosages of three commonly used neuroleptic drugs. Thirty-one questionnaires were returned and revealed a wide variation in perceived potencies for the specific drugs. Increased experience in psychiatry was not associated with a decreased variation. On average clinicians saw haloperidol and flupenthixol decanoate as substantially less potent, relative to chlorpromazine, than the available literature would suggest.

In a catchment area survey, 43 patients with cognitive impairment acquired in the presenium associated with behavioural or social dysfunction, or both, were identified. Twelve of 18 carers were also interviewed. The patients were mainly in their 50s, had a high prevalence of behavioural as opposed to cognitive disorder, were frequently taking psychotropic drugs and had disorders which were largely progressive. Those living at home were as disabled as those living in residential settings. Carers were stressed but uncomplaining. The findings suggest that psychiatrists, perhaps especially old age psychiatrists, have an important role in developing services for this neglected group of people.

The use of the term client, rather than patient, has become frequent in psychiatric hospitals. There is little evidence to justify this change, so this study surveyed the views of the in-patients in a community based psychiatric hospital to establish the term they prefer. It concludes that a dear majority of people admitted to a psychiatric hospital think of themselves as patients, not clients.

Attempts to deliver quality service outside the traditional mental hospital to those with chronic mental illness have resulted in several new models of care. We describe one such model of alternative care and asylum. Considerable improvements in quality of life, quality of care and clinical state occurred.

This paper discusses the theoretical foundation of QALY and examines the assumptions which underlie these theories. It argues that there are methodological flaws in the construction of QALY and that there are inherent risks in its possible application to psychiatry. It also draws attention to fundamental ethical problems with the concept of QALY as a tool for valuing the quality of life or well-being of persons.

The extrication of seriously mentally disordered offenders from all stages in the criminal justice system from arrest to imprisonment is a major role for both general and forensic psychiatry. A survey of inmates in Cardiff Prison referred to an ‘out-patient’ forensic psychiatric service held weekly is presented. An alarming number of referrals were patients with schizophrenia.

The aim of this study was to determine the extent to which general practitioners are informed of and involved in their psychiatric patients' discharge plans, their satisfaction with the present level and methods for improvement. Postal questionnaires were sent to 100 GPs from different practices in England. They reported a high level of dissatisfaction with the present frequency with which they are informed of and involved in discharge plans before the event. They report being informed and involved too infrequently or randomly, or both. This dissatisfaction could generally be resolved by pre-discharge telephone discussion with a member (preferably medical) of the multidisciplinary team.

The adolescents (n=57, age 13–19 years) attending the special schools for moderate and severe learning disabilities in a South East London health district and their families were assessed. The mothers of adolescents with severe learning disabilities in the transitional stage to adult services and development reported greater behaviour problems in their offspring, greater stress, more negative psycho-social family effects and more negative attitudes. Implications of the results for interventions, needs assessment and future research in family and adolescent functioning and the origins of psychiatric morbidity in young people with learning disabilities were discussed.

The care programme approach was developed to ensure that patients in the community receive the health and social care they need. It pre-empted the philosophy and practice of care management and can form the core. There are several strengths to this approach in that it permits a response to individual needs that may change over a period of time, and co-ordinates the contribution of all care agencies to make effective use of the available resources.

Patients and their relatives sometimes make what to others appear to be unfortunate decisions. In this paper the ethical dilemmas raised by such decisions in the context of old age psychiatry are examined. The case also raises questions about financial responsibility for the care of the elderly and suggests that the health needs of patients can no longer be separated from their financial interests.

The Royal College of Psychiatrists (1991) has recommended that all local mental health services should include specialist psychotherapy departments. At present these are uncommon outside major teaching centres, although a considerable amount of simple psychotherapy is provided on an ad hoc basis by mental health professionals of various disciplines. This paper describes the structure, functioning and costs of a specialist department in a non-teaching district in the south west of England.

This paper examines the ethical principles of justice and autonomy in psychotherapy. A case history is presented which illustrates how ethical dilemmas concerning the type of psychotherapy to be offered are powerfully influenced by often unconscious counter-transference feelings in the resource allocators. The question of how autonomous a psychotherapy patient can be, when unconscious motivations could be affecting rational choice, is also explored and possible answers provided.

Mental Health Review Tribunals (MHRTs) are intended to protect the liberty of the detained patient. In practice, however, they have been said to fall short of providing this safeguard. This is frequently for administrative reasons. We report a systematic examination of the pattern of delays in holding MHRTs. Our main finding is that delay cannot be attributed to a single factor but rather reflects the inherent complexity of some cases.

Activity and outcome data for two ‘ward-in-a-house’ projects for new long-stay in-patients are described. The results confirm that up to a third may be successfully resettled providing that good quality sheltered housing is available. However, a similar proportion appear to find such environments too demanding and may be transferred after an acute exacerbation of symptoms or a violent incident. The remainder need high quality, ongoing care.

There has been a substantial increase in the number of Mental Health Review Tribunals (MHRTs) and hence the cost of administering the tribunal system. We report an estimate of the cost of MHRTs taking account, for the first time, of both direct and indirect costs to the various government departments. We estimate that the total cost is currently £12,274,380 per annum.

General audit of psychotherapy services is slowly becoming a more regular part of practice in psychotherapy departments. Parry (1992) in her key review article states that “unmonitored practice is no longer defensible”. Audit specifically targeted at the quality of psychotherapy performed has been recommended (Fonogy ft Higgitt, 1989) but it is not often reported in psychotherapy (although a notable exception is Feldman, 1992). The beneficial effects of an ad hoc audit of the quality of psychotherapy using tape recorded sessions are reported.