There has been little published on the use of Guardianship Orders in mental handicap (the term ‘mental handicap’ is used rather than ‘people with learning disability’ to avoid ambiguity). Its use in the mental handicap services in four health districts in the Mersey region was surveyed. The study was retrospective, covering a five year period ending August 1994. Guardianship was used on ten occasions. Health professionals have been divided over the interpretation of the definition of “mental impairment” in the Mental Health Act (MHA) 1983. They have tended to exclude many mentally handicapped adults who do not, in their opinion, exhibit “abnormally aggressive or seriously irresponsible conduct”. It is clearly shown by our study that some health professionals are willing to classify self-neglect and vulnerability as “seriously irresponsible conduct”, thererefore allowing wider usage of the order.

With the emphasis on ‘care in the community’ there have been moves to provide psychiatric care away from the large psychiatric hospitals, which have resulted in the development of community mental health teams and the expansion of primary care and health centres to cater for people with psychiatric needs. The opinions of patients attending a hospital-based depot neuroleptic clinic are reported. A 17-item questionnaire was designed addressing the functioning of the clinic, including aspects of the medical and nursing care offered and the overall service provided. The majority of patients were in favour of attending this facility and expressed their wish for the service to continue.

The closure of large psychiatric hospitals and the opening of community-based mental health facilities is a central part of British health policy for the care of people with mental illness. The North East Thames Regional Health Authority's (NETRHA) psychiatric hospitals closure plan started in 1985. As part of this a programme was established to assess the closure process (Leff, 1993). This study was carried out between 1988 and 1992 and was designed to study the reactions of the public to the hospital closure decision (Reda, 1993).

Registered care homes have been developed in Newham, a deprived inner city borough of about 220000 population, by a number of different housing associations. Some of these provide the care component themselves while others purchase it from separate agencies. The formats of the homes also vary. Features common to all the provision include prolonged preparation of future residents in rehabilitation houses on the Goodmayes Hospital campus prior to taking up residence, particular attention to their compatibility and social networks, and regular individual reviews by a community rehabilitation team which also provides training and support to care staff.

The psychopathology of 20 subjects who presented to psychiatrists with facial dysmorphophobia was examined. Seven had body dysmorphic disorder and 13 had dysmorphophobic symptoms secondary to an underlying psychiatric disorder (usually depression). The body dysmorphic group had a younger age of onset and overvalued ideas about their appearance. In both groups there was a high proportion of associated personality disorder, usually of the anxious (avoidant) type.

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.

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.

A survey of psychiatrists was conducted to determine their current knowledge of the Driver and Vehicle Licensing Authority (DVLA) regulations and the advice they give to their patients regarding driving with psychiatric illness and/or medication. The results indicate that both knowledge and practices vary widely. In view of the potential risks of driving when not well or fully alert, information regarding driving should be a standard part of the advice given to all psychiatric patients.

The comprehensive implementation of the care programme approach is described within a large Mental Health Unit serving two London boroughs. Methods used to introduce an incremental improvement in the care programme approach (CPA) practice and documentation are outlined together with an account of the development of a set of quality standards and a CPA annual audit system.

Clozapine is well known to be an effective treatment for neuroleptic-resistant schizophrenia. However, its use is complicated by a variable and delayed response and by a range of troublesome adverse effects. Current practice is usually to increase the dose initially to around 450 mg/day and then by small increments to a maximum of 900 mg/day according to response and tolerability. While this method is often successful, it has been suggested that a better way of optimising the dose of clozapine might be to monitor plasma concentrations of the drug.

Prolactin, a protein hormone synthesised and released by the anterior pituitary, promotes mammary tissue development and lactation and suppresses gonadotrophin secretion. Dopamine is the natural inhibitor of prolactin release and so standard antipsychotics, which block dopamine receptors, will cause prolactin levels to rise. This hyperprolactinaemia can lead to gynaecomastia, galactorrhoea, menstrual disturbances, a reduction in sperm count, erectile dysfunction, failure of ejaculation and reduced libido. Prolactin-related adverse effects are frequently encountered in patients on antipsychotics and are a cause of substantial morbidity.

We describe our training experience as members of a drug and alcohol liaison service within a major general teaching hospital. This type of liaison work offers valuable experience in the joint management of patients with well established substance misuse problems and also provides the opportunity for early recognition and preventative interventions.

Psychiatric trainees in the Wessex Region gave their own lectures on an MRCPsych course and received feedback on their performance from their peers. The form and content of the lectures were given high ratings and the presentations were considered at least as good as those given by more experienced lecturers. The experiment can serve as a model to supplement existing courses for trainees and as a ‘do-it-yourself form of education for areas and countries that have inadequate access to centres for postgraduate education.

The Fregoli delusion is one of a number of misidentification syndromes. It is characterised by a patient recognising a familiar person, usually seen as a persecutor, in various strangers who, although they do not show physical resemblance, are believed to be psychologically identical to the familiar person. It usually occurs in the context of a schizophrenic illness but has been reported in affective disorders and organic psycho-syndromes (Förstl et al, 1991). It was first described by the French authors Courbon & Fail in 1927, who used the term ‘Fregoli illusion’ after the Italian actor who enjoyed enormous popular success on the Paris stage at the time. It has also been called the ‘illusion of negative doubles'. However, as the psychopathology is a delusional interpretation of normal visual stimuli rather than an abnormal perception the terms Fregoli delusion or ‘delusional hyper-identification of the Fregoli type’ are preferable. The original case description has recently been translated and annotated (Ellis et al 1994) but there remains little background information available on the figure of Fregoli himself. Biographies have appeared in French and Italian but there are few English language references and this paper is intended to provide an account of the life and career of one of the most extraordinary entertainers in theatre history.

An account of the thoughts of a fictional Assistant Medical Officer (AMO) on duty at the County of Lancaster Asylum, Rainhill in 1890 is given. It is based on the contemporary case records and other literary sources and is as factually accurate as possible. However, any similarity to persons living or dead is coincidental and unintentional.

John Thomas Arlidge was a prominent alienist in the mid 19th century. After thirteen years involvement with asylum psychiatry in London he changed direction to become a physician in North Staffordshire, achieving fame as an expert in occupational disorders. This paper describes his contributions to the psychiatric literature and suggests that disaffection with the way psychiatry was progressing may have led to his change of career.

Rwanda was the most densely populated country in Africa. It is two-thirds the size of Switzerland but contained a larger population (9 million people), growing by almost 40% every two years. Few square inches are left uncultivated. The Tutsi people (never more than 14% of the population) are said to have arrived in the 14th century ad, bringing with them a feudal and totalitarian system of government. There was significant intermarriage with the result that today the Hutu and Tutsi people share the same language, cultural beliefs and religions (predominantly Catholic). In reality the terms Hutu and Tutsi now more accurately describe caste than ethnicity (Delcros, 1994).