An unstructured observation concerning low rates of observed psychological disturbance was explored by estimating rates of suicide, and psychotropic drug use. Recorded suicide, overdose, and ‘minor’ tranquilliser and antidepressant use were strikingly low on Tobago, when compared with the United Kingdom. Tobagonians were unlikely to medicalise distress by presenting with overt psychological symptoms. Most local doctors felt that patients preferred spiritual support, e.g. from charismatic religious groups and traditional healers (some using obeah). A rich network of social and recreational groups may also give important support, as may ‘liming’ (a local conversational pastime). Tabanka (a local culture specific syndrome) may also be a non-medical outlet.

The Joint winners of the second Merck Essay Prize for 1994 were Drs Andrew Smith and Swaran Singh. Their essays are published below. The number of entries was 15.

We describe the operation of a psychotherapy clinic where a one-way screen is used in the assessment of adults for a range of dynamic therapies. While observation of psychotherapeutic encounters remains contentious as an activity in its own right, we attempt to illustrate how such a way of working can be helpful to patients and staff. The potential drawbacks of this approach are discussed and ways of minimising these are explored.

Forty of 46 consecutive admissions to a psychiatric inpatient unit were encouraged to read their admission notes and discuss them with the Junior doctor. The offer was withheld for two patients with organic impairment. Twenty-eight patients (including 12 on compulsory admissions) accepted the offer. The 12 who refused were characterised by overall lower educational attainment. Diagnosis raised only a few problems, prognosis and maintenance treatment being the focus of most discussions. There was no evidence of a deterioration in the quality of notes or therapeutic relationships as a consequence of access. Only in one case was the exercise judged ‘harmful’, but ‘useful or essential’ in 22. Possible benefits for both patients and doctor are explored.

An experience by two senior registrars of a social skills group for five 9 to 11-year-old children with peer relationship difficulties at school is reported.

As postpartum depression can occur in up to 10% of mothers, antidepressants will often be required in mothers who are breast-feeding. The judicious use of antidepressants is important since all psychotropic drugs cross into the breast milk. Drug excretion into breast milk occurs primarily by passive diffusion. Small, highly lipid soluble, unionised drugs diffuse more rapidly than other drugs. It must be remembered, however, that for those drugs with a high volume of distribution, such as the highly lipid soluble drugs, most of the drug is outside the plasma compartment, leaving only a small proportion free to transport from plasma to milk. Also, most lipophilic drugs are concentrated in hind milk which is richer in fat than fore milk. All of the antidepressants are highly lipid soluble with large volumes of distribution.

This paper charts the progress of a continuing audit cycle of prescribing of hypnotics in a psychiatric hospital. First we reviewed some possible standards from the literature, then educated the prescribing doctors, and fed back to them their own patterns of prescribing. We present the results of this exercise repeated over 18 months; these show a change and general improvement in prescribing patterns. Finally we discuss some of the motivations and possible mechanisms behind these changes, and the implications for the audit process in general.

Complaints made against doctors are increasingly important given the current emphasis on consumerism in the National Health Service and the publication of the report of the Wilson Committee which reviews complaints procedures. There have also been recent changes in medical indemnity and increased litigation. The origins of complaints made against psychiatrists were studied. Most complaints were made by relatives and advocates rather than the patients themselves and half were made after the patient was discharged from hospital. It was found that most complaints arose out of a breakdown of communication between psychiatrist and patient.

Questionnaires were sent to 92 doctors asking them about aspects of their antidepressant prescribing; 72 returned them. Sixty had prescribed selective serotonin reuptake inhibitors (SSRIs) in the previous year. The ratio of SSRIs to all antidepressants prescribed in the previous year exceeded 40% in only eight doctors. Inability to tolerate and failure to respond to established antidepressants were the most common indications for prescribing SSRIs. Side effects and cost were the most common reasons deterring doctors from prescribing SSRIs. SSRIs being new products and doubts regarding their efficacy were factors that were significantly more likely to deter ‘doctors of other grades' than consultants from prescribing them. Fluoxetine and paroxetine were the most frequently prescribed SSRIs.

The adult psychotherapist model of staffing is considerably strengthened by a clinical directorate management structure with a specific local pay scale for psychotherapists. When such arrangements exist they are usually welcomed by clinicians and managers. One reason for this is that they make it possible to ensure that services maintain good clinical standards while meeting the managerial objectives of the unit or trust. Underlying the success of these arrangements is the fact that by promoting separation and individuation they give services a firm identity. This is good for the service itself and also for the unit or trust as a whole, because separation and individuation are the basis of co-operation and integration.

The recent review of mental health nursing recommended that nurses refocus their attention on people with serious mental illness. There are some encouraging trends in the training of nurses in problem-oriented case management. However, mental health nursing needs to face various problems. These include the need for the large-scale retraining of nurses currently working in traditional psychiatric hospitals and difficulties in the new Project 2000 programmes. In addition, there is a clear lack of leadership in the profession, largely because of the recent emphasis on management rather than clinical and academic attributes. Finally, nursing needs people who care what happens to the seriously mentally ill.

Seizures are a serious adverse effect of many antidepressants: most, if not all, tricyclics (TCAs) lower the seizure threshold, some atypicals (e.g. maprotiline) are known to cause convulsions and seizures have been reported to occur with all selective serotonin reuptake inhibitors (SSRIs). Opinions vary on which is the safest antidepressant to use in epilepsy.

Depression is the commonest psychiatric disorder in the industrialised world. Many patients are now diagnosed and treated with effective antidepressants by primary care physicians. A large proportion of depressed individuals fail to reach their premorbid level of functioning following a course of treatment; estimates vary from 10% to 30% (Nierenberg & Amsterdam, 1990). These individuals require a major input from the services and suffer prolonged distress, with many adverse personal, social and economic consequences.

Few would challenge the view that the contribution made by Cruse to the welfare of the bereaved is a very important one. Much effort is put into the training of Cruse counsellors but little is known about the impact of this training. An assessment of 30 prospective counsellors by means of questionnaires and ‘clinical’ vignettes to assess their knowledge of and attitudes to various matters pertaining to grief and bereavement is reported. While the results are encouraging In many respects, they also highlight areas of ignorance and bias which seem resistant to the influence of training.

The Job descriptions for five consecutively advertised consultant posts in psychiatry of old age were surveyed for the content and clarity of the information provided and for the adequacy of the resources described. Only one post provided a job description which came close to meeting our audit criteria. Employers may optimise the number and quality of applicants for consultant posts in psychiatry of old age by providing Job descriptions which contain both clearly written and comprehensively detailed information.

A review is made of the anti-psychiatric movement through its major protagonists, Lacan, Laing, Cooper and Szasz. The ideology was set to challenge the concept of mental illness and question the authority of the psychiatrist and the need for mental health institutions. The anti-psychiatric movement received a lot of attention in the 1970s but is now considered to be of the past and of likely interest to the psychiatric historian. However, the impact of the movement on current psychiatric practice requires further re-examination and appraisal.

The views of psychiatric day hospital patients on the helpfulness of components of their treatment programme were surveyed. Ratings given to social activities were significantly higher than those given to therapeutic activities. Patients rated having a bus pass and access to hairdressing services as the most helpful parts of day hospital attendance while community meetings and ward round attendance were regarded as the least helpful. Ratings were, however, generally favourable. No significant effect of patient age, gender, or duration of attendance was found. Possible explanations for these preferences are discussed. Patient preferences such as these are likely to influence purchasers of care, and thus the use of resources by providers.