As part of a project designed to assess the impact of the NHS and Community Care Act 1990 upon the care of patients discharged from special hospitals, an attempt was made to obtain local authority community care plans. The difficulties encountered during this exercise and the level of planning obtained for the mentally disordered offender as identified in those plans, may be a cause for concern to all those working in this field.

There has been little published on the application of the Mental Health Act (1983) in the elderly. We therefore surveyed its use in a district old age psychiatry service covering a mixed rural and urban population with about 60,000 people over 65 years. The MHA was applied 36 times to 32 patients over a two year period. The primary diagnosis was a functional psychiatric illness in 64% patients (usually depression) and dementia in 36%. Functionally ill patients were most frequently detained on a treatment section (S3) and demented patients on an assessment section (S2). Only one patient with dementia was placed on a guardianship order. The outcome of treatment is described.

This study involved a case-note review of referrals to community psychiatric services in a university town in New Zealand. About one third of all 163 patients referred were taking antidepressants for depression; of these one third were taking therapeutic doses, with the remainder taking inadequate doses. This tends to confirm the findings of other studies that have identified problems relating to GP prescribing of antidepressants.

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.

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.

From April 1994, over 95% of health care services will be provided by NHS trusts. Mental Health services have a choice of remaining within the acute hospital trust or forming part or all of a community trust. Using data from trust directories, the distribution of mental health services within the first three trust waves is described. Forty per cent of acute hospital trusts currently do not include mental health services. Unlike other specialities, a significant proportion of mental health services are choosing to form specialist mental health trusts. The implications of the alternative trust arrangements for psychiatry are discussed.

In the new style NHS an annual report is essential for all services. Senior registrars have the necessary skills and are ideally placed to co-ordinate such an enterprise as part of their management training. The typical structure for such a report is described and suggestions are made on content and format. Pitfalls are outlined from the authors' experience.

The Royal College of Psychiatrists specifies that supervision of trainees is the single most important ingredient of training. This paper reports the results of a pre-audit survey about trainee supervision. Eighty-three per cent of consultants (n=52) and 67% of trainees (n=51) responded to a 21-item Likert questionnaire. There was unanimous agreement for seven items. A significant number of consultants and trainees were dissatisfied with the existing arrangements despite the majority being involved in weekly supervision. The minimum standards proposed served as the basis for providing guidelines against which practice may be audited.

The evaluation of medical practice dates back many centuries. However, the concept of systematic medical audit is relatively modern. It is recognised that audit of every area of health services (including that of trainee's work and training) has been taking place. This article briefly discusses some of the basic issues in audit, which include the principles, levels and types of audit, from a trainee's point of view.

Referrals from general practitioners to a sectorised mental health team were audited for time delays and quality over three months. A referrers' guide was then designed to reduce referral delays and improve their quality. This was sent to all GPs. Referrals were again audited over two three month periods. There was no significant difference between corresponding time delays in the three periods. Only one item, the presence or absence of past history, was significantly improved in the third period. These results and their implications are discussed.

Candidates taking multiple choice question (MCQ) examinations are often unsure of the best strategy to use when uncertain of the answer to a question. Some authorities advocate a cautious ‘never guess' strategy and others suggest a bold ‘guess everything’ approach. In this study, candidates who had taken a MCQ paper were asked to go back and guess the questions initially marked ‘don't know’. The resultant ‘guess scores' ranged from −0.6% to 6%. It was concluded that many candidates could substantially increase their scores by adopting a bolder approach. It is proposed that the guess score is a useful measure of the effectiveness of the candidate's MCQ technique.

Very few trainees have experience in group psychotherapy. I describe my experience of co-facilitating a group for pre-adolescents who were being bullied. This proved a valuable learning experience as part of a multidisciplinary team, and increased my understanding of how groups function and the particular problems involved in running a group for children.

The benefits of paediatric experience towards training in child psychiatry are discussed, with emphasis on the differences between hospital and community posts. Proposed reforms to training for hospital doctors are discussed with respect to specialised training in child psychiatry. It is concluded that future training regulations should allow trainee child psychiatrists to benefit from training in hospital and/or community paediatrics.

Professor Jan Scott conducts a prospective survey of the ways psychiatry is presented in the media.

The New Poor Law Amendment Act of 1834 led to the admission of considerable numbers of pauper “lunatics, idiots and imbeciles” to parish workhouses. The Stoke-upon-Trent workhouse, erected in 1832, had progressively to increase its accommodation for this class of inmate who, by 1899, numbered about 100. Brief details are given of nursing staff and of improvements in conditions of care following recommendations of the Lunacy Commissioners. Primary sources of information are indicated and emphasis is laid on the importance for the history of English psychiatry of documenting the care of the mentally ill and mentally impaired in Union workhouses.

Living in London one gets used to seeing teenagers living rough on the streets, sleeping in shop doorways, and begging for money. Similarly in São Paulo and other large cities in Brazil homeless and destitute children are a common sight, but there are several striking differences. First, in Brazil there are many more of them, they are noticeably younger and they are often seen doing some form of job or ‘bicos' to earn money, such as cleaning shoes or car windows, ‘guarding’ cars, and selling small items, e.g. sweets, fruits and flowers. Another important difference is the danger to which these children are exposed. There have been frequent reports, some of which have reached the international media, of street children being massacred by vigilantes (some of whom have links with the police).

On 30 November 1993 a nine year political debate on euthanasia closed; the first chamber of the Dutch parliament ratified the law on undertaking, including euthanasia regulations. This political step concluded, for the time being at least, a legal, public, political and medical debate, which started in 1973, when a medical doctor was convicted for performing euthanasia on her mother. In a first effort in 1983, parliament failed to legalise euthanasia. In 1989 a new government introduced an initiative to improve the existing law in this regard. As a part of the process, empirical data on the extent of euthanasia in The Netherlands were required. Therefore, the Minister of Justice installed a committee. Its findings have been reported nationally and internationally (van der Maas et al, 1991a, 1991b); about 2,300 euthanasia cases in 1990, being 1.8% of all deaths. These empirical findings reduced the uncertainties about the extent of euthanasia, thereby providing a sound basis for the parliamentary decision-making process. Although by the current law euthanasia and assisted suicide still remain illegal, under strict guidelines for behaviour provided by the Ministry of Justice in November 1990 and distributed among physicians in January 1991, euthanasia can be exempted by the public prosecutor from criminal punishment on the basis of the ‘opportunity’ principle, this being the opportunity for the public prosecutor not to bring all reported crimes to court (Letter of the Minister of Justice to Parliament, 1990).