The high-security hospitals are undergoing a retraction process. In conjunction with this, regional services are being developed for those patients who require longer-term treatment at medium-security units.

It is difficult to disagree with Chilvers & Clark that, overall, recent work to bring a more systematic approach to the organisation of mental health research in England has been a good thing. It is also necessary if mental health is to compete for research funding with other branches of healthcare. However, recent changes in the research system have not all been positive and there is a danger that the process of centralisation, which is inherent to the model they describe, will have unintended adverse consequences.

In June last year, the committee on safety of medicines (CSM) advised against the use of paroxetine in depressed children and adolescents. This was subsequently followed by a similar warning regarding the use of other selective serotonin reuptake inhibitors (SSRIs), with the exception of fluoxetine (http://www.mhra.gov.uk/). The basis of this decision was a detailed review of both the published and the unpublished data. The latter were obtained from pharmaceutical companies who had not reported negative results from clinical trials to the medical community. The addition of the pharmaceutical industry data to published results exerted dramatic effects on the efficacy of available compounds. Thus with the exception of fluoxetine, the risks outweigh the benefits of the SSRIs in the treatment of childhood depression. In particular, there is evidence of a non-significant trend towards increased suicidality with most SSRIs compared with placebo. These findings have been supported by a further recent meta-analysis of the available published and unpublished data (Whittington et al, 2004). A review of the safety and efficacy of antidepressants in children and adolescents by Jureidini et al (2004) has also criticised the quality of reporting of the published trials. The review concluded that the benefits of SSRIs have been exaggerated, including those of fluoxetine, and the adverse effects have been downplayed. The authors suggest that psychological treatments are probably safer and more effective.

There is increasing concern about the relationship between medicine and the pharmaceutical industry. In July the BMJ devoted a themed issue to this, and critical discussions have featured in other leading medical journals recently. The industry has grown in profitability and influence over the past 20 years, and is now second only to armaments in the US economy (Public Citizen, 2002). Its influence is enhanced through its control of research, and it employs sophisticated and wide-reaching marketing strategies. This level of influence is concerning because the private investment necessary to enable drug development demands ever more vigorous struggles to maintain and expand market presence. In other words, commercial rather than clinical or scientific demands are becoming the dominant driving force for ‘innovation’. This leads to the popularity of developing cheaper ‘me too’ options, and the promotion of new ‘disease concepts' to allow the re-badging of old products to expand markets without major development costs.

There was a time in my life, not that long ago, when I could have given a very simple answer to this question. Where would I have been without pharmaceutical companies, specifically without Wyeth? Life was terrible with the pills, but I dared not contemplate it without them.

Bailly's review describes the author's perspectives on the ‘intense controversies' surrounding attention-deficit hyperactivity disorder (ADHD) and its treatment with stimulant medications. Drawing on a range of literature sources, including the UK press, pharmaceutical industry websites and peer-reviewed scientific papers, he questions the validity of ADHD as a concept and disorder, the accuracy and reliability of diagnosis, the use of stimulant medications and the impact of advertising by the pharmaceutical industry. There are, however, additional sources and alternative interpretations.

At its meeting in June 2004, the Court of Electors approved the proposals indicating changes in training and assessment in psychiatry to enable consultant psychiatrists to practise in 2020. The main recommendations are presented elsewhere in this issue (Bhugra & Holsgrove, pp. 49–52, this issue).

Luty (2005, this issue) performs a valuable service by directing attention to the new guidelines from the National Treatment Agency. He explains clearly why he thinks these guidelines are wrong. I was a member of the expert advisory group that produced the guidelines, and will therefore attempt to defend them (my arguments do not necessarily reflect the views of all members of the group).

Chilvers & Clark make it clear that research and development (R&D) in the National Health Service (NHS) is now a managed process. There is a coherent strategy and much thought has been given to the use of resources. I welcome this development and the ‘Health Research System’ that forms its framework.

Until recently, the UK led the addiction field worldwide as the only country to prescribe diamorphine for the treatment of opiate drug dependence. However, the approach was inconsistent, with development conducted in a haphazard and arbitrary manner (Audit Commission, 2002), with variation in criteria, individualistic approaches and many doctors ‘inheriting’ patients on these long-term prescriptions from other doctors. There were relatively few restrictions once the doctor had been granted a licence by the Home Office.

It is timely to review the relationship between the pharmaceutical industry and psychiatry, given the continuing move towards more evidence-based practice in medicine, as well as two recent government initiatives to improve the value of research in the National Health Service (NHS), especially research that is commercially driven.

Adolescents with mental health problems are poorly served by mental health services, since responsibility for care often falls between child and adult services. Within the UK, there is no consensus on how service boundaries should be delineated. Some services use an age cut-off at some point between 16 and 18 years, whereas others consider child services to be appropriate only for those in full-time education. The Audit Commission (1999) reported that nationally 29% of health authorities commissioned child and adolescent mental health services for young people before their 16th birthday only, although adult services were not considered suitable for those under 17 years old. The report highlighted the poor development of adolescent services and their inadequate links with other agencies, including adult mental health services.