The complex socio-cultural features of Latin peoples throughout the Americas represent a potent challenge to health care planning. Attempting to meet this challenge requires consideration of the suitability of diagnostic systems as key clinical and public health tools, as well as exploration of promising ways for improving them.

Two cases of agranulocytosis occurring after addition of a butyrophenone to a course of phenothiazine treatment are reported and possible mechanisms for this interaction are discussed. Agranulocytosis is a well-documented adverse effect of phenothiazine administration (Vincent, 1986). Important factors are the total amount of drug given and the duration of administration. Agranulocytosis usually occurs within the first three months of therapy (Pisciotta, 1971; Marcus & Mulvihill, 1978) and the relationship with the cumulative dose has been emphasised (Ananth et al, 1973). Agranulocytosis following prolonged administration has been rarely reported (Denber, 1970, Pisciotta, 1978). We report two cases where agranulocytosis developed in patients with a long previous exposure to phenothiazines, treated for the first time with a combination of phenothiazines and a butyrophenone.

The fortuitous detection of SIADH is described in a patient receiving clomipramine therapy.

The diagnostic process in a case of dementia associated with physical and emotional dependence is described. The utility of sodium amylobarbitone abreaction is considered. The role of both psychodynamic and organic factors are emphasised in the aetiological work-up. The organic factors discussed include alcohol, sedative tranquillisers, solvents, and metals. The term ‘pseudodementia’ is not favoured, and the phrase ‘dementia syndrome of dependency’ is proposed.

A relatively normal 16-year-old Chinese woman with a six-month history of compulsive water drinking resulting in a comatose state is reported. The drinking was perpetuated by an enjoyable altered state of consciousness after ingestion of an average of 20 litres of water per day. Treatment by fluid restriction and, later, simple education was successful. The subjective dimension of an altered state of consciousness may provide an important explanation for the obscure aetiology.

Although initially considered safe for the foetus, lithium has been shown to have teratogenic effects if used during the first trimester of pregnancy. Its use is also associated with a higher than expected frequency of still births and perinatal deaths. Our patient, in whom lithium prophylaxis was considered essential for clinical and social reasons, continued to take lithium without medical supervision throughout her pregnancy and had a still birth. We suggest avoiding the use of lithium at least during the first trimester of pregnancy.

Growths in communication technologies, voluntary travel, and forced migration are fostering reciprocal awareness and a sense of interdependence among people from distant parts of the world. In line with these, there is increasing interest in health status and illness conditions across different geographical and cultural regions. Adequate identification of health problems in each region serves not only to enhance planning of treatment and preventive activities for both individuals and communities, but also may point out types of pathology that would require greater attention in diagnostic systems intended for wide international use, such as the prospective 10th Revision of the International Classification of Diseases (ICD) (Sartorius, 1988).

A case of suspected subacute sclerosing panencephalitis is described, presenting to a psychiatric hospital 39 years after a natural measles infection.

A 27-year-old neuroleptic-stabilised schizophrenic patient presented with a three-day history of psychomotor retardation, disturbed sleep, and social and emotional withdrawal following reduction of his anticholinergic dosage; his symptoms had intensified after an increase in neuroleptic dosage, based on a diagnosis of psychotic decompensation. Recognition of a cholinergic syndrome and institution of appropriate anticholinergic treatment resulted in rapid improvement. The clinical distinction between a cholinergic overdrive state and schizophrenic exacerbation, while sometimes difficult, can be critical in selecting appropriate management.

A case of a psychotic illness following an induced termination of pregnancy is described; this is discussed in relation to the literature on the subject, and possible aetiological factors in the case are reviewed.

A patient is described who suffered from the neuroleptic malignant syndrome, complicated by a pneumomediastinum. This has not been reported previously.

The proliferation of large-scale organisations is a phenomenon of modern society. As Etzioni (1968) puts it, “We are born in organisations, educated by organisations and most of us spend much of our lives working for organisations”. Most public organisations in modern society are bureaucracies and the field of psychiatry is no exception: a trend toward growing bureaucratisation, of both public and private mental health services organisations, can be observed everywhere. To a large extent, this is because, as standards of care become regulated and quality controls increase, the tasks that mental health professionals and administrators perform become better understood, more predictable, and more programmed. There is still room for creativity and innovation, but only in incremental, well controlled steps.