Despite the fact that suicide and its prevention continues to be a priority area for health care in the UK, suicide in the elderly remains a neglected subject receiving little interest and research attention. The Green Paper Our Healthier Nation (Secretary of State for Health, 1998) maintained the concept of setting targets for suicide reduction originally proposed in The Health of the Nation strategy. The new target proposes that by the year 2010 the death rate from suicide and undetermined injury will be reduced by at least a further sixth (17%) from the baseline of 1996. The setting of such targets has always been a contentious issue among many psychiatrists, who have concerns that they may be used as a quality measure of psychiatric services, especially as some consider that social influences predominate over health care issues. The subsequent debate has focused on targeting specific at-risk groups, notably severely mentally ill young men, Asian women and those who deliberately harm themselves.

There are four high-security hospitals in the UK: Broadmoor Hospital in Berkshire (founded in 1863), Rampton Hospital in Nottinghamshire (1914), Ashworth Hospital in Merseyside (1990), which opened following the amalgamation of Park Lane (1974) and Mosside Hospitals (1913), and the State Hospital at Carstairs in Lanarkshire (1948). The first three are known as the special hospitals and serve England and Wales. The latter offers a special security service, combining high and medium secure care, for the whole of Scotland and Northern Ireland – there is no form of medium secure psychiatric provision in these countries. All four hospitals provide care for patients with mental disorders and dangerous, violent or criminal propensities. There are approximately 1550 beds in these facilities and all patients are formally detained under mental health or criminal legislation. The special hospitals are currently administered by the high-security psychiatric services commissioning team, managed locally as individual authorities, although in the future it is intended to integrate them more fully into the National Health Service (NHS) and to organise both high and medium secure services at a regional level. Carstairs is administered by the State Hospital Board for Scotland which has the status of a special health board.

What is happening in and around psychiatric services that raises fears of a harmful separation between psychiatrists and the rest of the medical fraternity? The last National Health Service (NHS) reforms at the beginning of the 1990s split some mental health services into separate organisations from their local acute services. Paragraph 5.14 in the Government's White Paper The New NHS (NHS Executive, 1997a) seems to favour specialist mental health trusts. Combined whole district trusts are under threat. Shotguns are loaded to ‘encourage’ the marriage with social services. All this may seem to conspire against psychiatrists maintaining close professional relationships with physicians and surgeons in general hospitals. Instead it puts the emphasis on aligning psychiatric work much more closely with social services and primary care. Much restructuring is already afoot. It is a time for sober reflection on what is in the best interests of patients now and in the future (see Box 1).

A male farmer in his forties from the Irish Republic was referred for an opinion on his mood swings and their possible relationship with organophosphate exposure. He had been regularly exposed to organophosphorus sheep dips for around 15 years prior to the assessment.

In the interest of road safety, driving license holders who suffer from a medical condition likely to affect fitness to drive must notify the Driver and Vehicle Licensing Agency (DVLA) and not drive. The Secretary of State for the Environment, Transport and the Regions (of the Department for the Environment, Transport and the Regions, DETR) has the responsibility, via his Medical Advisers at the Drivers Medical Unit of the DVLA, to ensure that all licence holders are fit to drive.

At present, the treatment options for Alzheimer's disease are largely symptomatic giving rise to temporary remissions in cognitive decline or the amelioration of troublesome behavioural and psychological symptoms. However, as more is becoming known about the molecular biology of Alzheimer's disease, there is a clear movement to treatments directed towards disease modification. Disease modification is now a realistic option and its importance is highlighted by the fact that a delay in the progression of the disease by just five years would halve the disease prevalence. Ultimately, however, drug therapy based on the molecular biology of Alzheimer's disease will be preventive. These treatment strategies are still in their infancy, but our understanding of the processes requiring therapeutic manipulation is improving at a dramatic rate.

Contextual rating of social adversity has its origins in the work of George Brown and colleagues (Brown & Harris, 1978). This review evaluates its strengths and weaknesses in rating the effects of social adversity on depressive disorder. We write from the perspective of its usefulness for clinical and training purposes both to the consultant psychiatrist and to the community mental health team working in general adult psychiatry.

This term refers to mushrooms that grow naturally and have hallucinogenic (sometimes called psychedelic) properties. Consumption of different species has occurred in various cultures over the centuries, with use in ritual ceremonies in Mexico being particularly well known. In the UK at present the species most commonly used is Psilocybe semilanceata, also known as the ‘liberty cap’ mushroom. This grows in many areas, particularly in dark places and after heavy rainfall, with fruition occurring from September to November. It is creamy-yellow or brown in colour, very small (5–15 mm across) with a thin fragile stalk. In the USA a closely related type is used.

Neuroimaging is traditionally divided into structural and functional imaging. Structural imaging looks at brain structure or anatomy and includes computed tomography (CT) and magnetic resonance imaging (MRI). Functional techniques seek to examine the physiological functioning of the brain, either at rest or during activation, and include single photon emission computed tomography (SPECT), positron emission tomography (PET), MRI spectroscopy, functional MRI (fMRI) and encephalographic brain mapping. Although fMRI, MRI spectroscopy and brain mapping are likely to have clinical applications in the near future, the main imaging modalities of current clinical relevance to psychiatrists are CT, MRI and SPECT, which will be the focus of this article.

Mental disorder and mental illness are common. Delinquency, offending and offending behaviour are widespread. The two things therefore occur frequently together, but are not always necessarily causally linked (Humphreys et al, 1994). Access to appropriate psychiatric services and care does not depend solely upon the presence of disturbed behaviour or offending that is obviously directly related to symptoms or signs.

There is increasing evidence that substance misuse among British adolescents is escalating (Miller & Plant, 1996; Sutherland & Willner, 1998). Swadi (1992) found that, among adolescents aged 12–17 years referred to mental health services, the prevalence of drug use was 13.1% (16.3% among boys and 9.3% among girls). Despite this relatively high prevalence, there are very few organised treatment services for adolescents in the UK. Instead, there is extensive emphasis on prevention even though there is no universal agreement on what prevention can achieve. This approach also overlooks the fact that a significant number of adolescents fail to respond to preventive measures in any form.

Dr Humphreys is right to emphasise that the majority of offenders with mental disorder have not committed serious offences (conversely, a number of general psychiatric patients are admitted to hospital after incidents in the community which, in different circumstances, might have attracted official attention) and that the principles of treatment and management are the same as for patients in general psychiatry. However, psychiatric assessment of more serious offending does call for careful consideration of additional issues, such as ‘psychiatric defences’ to criminal charges (including fitness to plead, insanity, automatisms, and in cases of charges of murder, diminished responsibility) and the role of security in their management.

There is a current gap in the nomenclature of psychiatric in-patient services. There are few descriptions of types of in-patient care and over recent years the literature has abounded with debates concerning alternatives. However, it may be argued that these debates have been based on the creation of the ‘straw man’ of the psychiatric admission, which is only fit for knocking down. Although a post-war consensus has emerged concerning the need to abandon the Victorian asylums, this has often been misrepresented as the need to avoid in-patient admission. The poorly articulated and emotional concept of community care and its lack of clear and consistent definition in public policy and key legislation have contributed to this (Bulmer, 1987). Recent changes in our view of community care have led to a refining of the concept and a shift from its comforting appellations (Titmus, 1968) to a pragmatic approach that matches it to empirical experiences and new resources. This approach sees psychiatric services for adults as being based locally and provided by a spectrum of services – in-patient, residential and ambulatory (Department of Health, 1996) – based on best available evidence. This article has been written with these issues in mind. We will address the current problems of in-patient care and the current literature on alternatives and supplements to traditional in-patient units.

“Once the patient's biography becomes part of the care, the possibility that therapy will dehumanise the patient, stripping him of what is unique to his illness experience becomes much less likely” (Kleinman, 1988).

“The loss of story making and telling has its impact on failure to care for the long term chronic or incurable patient” (Hunter, 1991).

The sexual behaviour of older people is more often the target of jocularity or ridicule than the subject of serious scientific research. As a consequence, relatively little is known about the sexual behaviour of the over-65s and such information as is available shows a polarisation according to gender, male sexual behaviour and dysfunction being viewed very much in the light of physical problems, whereas women's sexual behaviour revolves around attitudes towards sexuality and the psychological effects of ageing. This review will address the biological changes associated with ageing, the psychological and social concomitants, the prevalence of sexual dysfunction, its aetiological factors, and the management of common sexual problems including those found in an institutional setting.

The huge majority of people with an alcohol dependence problem that is uncomplicated by serious mental illness or social chaos receive treatment in the community. Tackling Alcohol Together: The Evidence Base of a UK Alcohol Policy (Raistrick et al, 1999, chapter 9) provides strong evidence supporting the move towards briefer and community-based treatments, while at the same time recognising the need for intensive and in-patient treatments for people with more complicated problems. It follows that the traditional sequencing of care, which might be characterised as having four phases – assessing and engaging patients, detoxification, specific therapy and aftercare – is less tidy than it used to be. Detoxification is seen much more as a standalone procedure that should be undertaken when the patient is ready, rather than as a prerequisite of starting treatment. Of course, there are also instances where detoxification may be required as an expedience, for example during an unplanned admission into hospital, or where regular high levels of intoxication are a barrier to treatment. Equally, where the focus of treatment is on mental illness rather than alcohol dependence, then detoxification may well be viewed as a necessary first step.

In a recent article (Davies et al, 2000) we covered the background to and clinical presentation of the neuropsychiatric consequences of chronic exposure to organophosphates. In particular, we dicussed a syndrome that appears to develop in about 10% of chronic exposees: chronic organophosphate-induced neuropsychiatric disorder (COPIND). In this article we consider the diagnosis and management of patients with this condition, and related issues.

Young offenders with a learning disability may encounter a variety of different psychiatrists, most of whom do not claim any particular expertise in helping them. Child and adolescent psychiatrists, learning disability psychiatrists and forensic and prison psychiatrists may all see young offenders referred to them who have a learning disability –that is, ‘mental retardation’ as defined in ICD–10 (World Health Organization, 1992) (Box 1). Many of these psychiatrists do not see such referrals as a core part of their role, and perhaps because of this, surprisingly little is known about this group of young offenders. They frequently fall into the borderlands between different types of service provision, and as a result can become marginalised. This is of particular concern since recent work has suggested that young offenders with a learning disability may have substantial mental health needs. This article aims to summarise what is known about this group and describe how some of their mental health needs might be met.

Patients with borderline personality disorder (BPD; known in ICD–10 (World Health Organization, 1992) as emotionally unstable personality disorder) pose some of the most difficult management problems facing the clinical psychiatrist. They frequently present in crisis, but are often difficult to engage in any form of treatment. Their behaviour causes considerable anxiety but their ambivalence about treatment often leaves professionals feeling frustrated and resentful. These feelings can all too easily be transformed into therapeutic nihilism. As well as being a significant problem in its own right, comorbid personality disturbance complicates the management of other psychiatric disorders and has a negative effect on their prognosis (Reich & Vasile, 1993).

People with learning disability have an increased risk of developing a mental disorder. When they need acute psychiatric hospitalisation, they are frequently admitted to general psychiatric beds under the care of general adult psychiatrists, many of whom have had little training in the assessment and treatment of mental illness in this group. They may have unusual presentations of common mental disorders leading to difficulty in diagnosis and idiosyncratic responses to treatment. Boundary disputes between general adult and learning disability services frequently lead to a reduced quality of care for people with complex needs (see Bernal & Hollins (1995) for an overview of psychiatric illness and learning disability). This paper will focus on the issues specific to the management of people with learning disability on general psychiatric wards, and is aimed at psychiatrists working in both general psychiatry and learning disability.