Medicine thrives on dissent. Of all the medical disciplines, psychiatry seems to generate the highest level of dissent, both from inside and outside the profession: no other medical discipline, for example, has some of its own members consistently argue that its very foundations are rooted in a series of harmful myths (Szasz, 1974, 2003). The best responses to this type of criticism identify the core concerns of the critic, dissect out the most relevant arguments and develop ways to integrate useful suggestions with existing knowledge, so as to advance the field in a pragmatic, sensible and evidence-based fashion. Such constructive responses to controversy are rare.

The placebo effect is a fascinating phenomenon in clinical practice. Studies have shown that there is a significant placebo effect in a wide range of medical conditions including psychiatric disorders. This article looks at the background of the placebo effect, defines the common terms used, describes the various hypotheses that have been put forward to explain this seemingly inexplicable phenomenon and also covers the issue of using placebos in research trials, highlighting the important ethical dilemmas involved. Throughout, specific emphasis is given to psychiatry.

I was one of the initial applicants to the NHS International Fellowship Scheme and joined the North Staffs Combined Healthcare NHS Trust in November 2003 as a consultant at the Greenfield Centre, Stoke on Trent. It had always been my dream to work in the UK as a consultant. I always wondered how similar it was to the consultant/ faculty position I held at the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Here I describe my experiences.

Have you ever wondered why the well-known Mill Hill Vocabulary Scale was named after a suburb of North London? Little known to most psychiatrists or to local people in Mill Hill, a major part of the Maudsley Hospital was evacuated there from central London during the Second World War. Mill Hill School had been evacuated en masse to St Bees in Cumberland. The vacant buildings were requisitioned by the Emergency Medical Service for the Maudsley Hospital. Much innovative psychiatric treatment and research took place there throughout the war with a star-studded cast, including some outstanding clinicians and researchers. This brief review of historical sources aims to give a flavour of the clinical work of the Mill Hill Maudsley.

Esther Rantzen created the Jobsworth Award before the National Health Service (NHS) invented clinical governance. One wonders sometimes if the NHS would have scooped all their awards had the programme continued. Television presenters also caution against involvement with children or animals, or worst of all both simultaneously. Clearly child and adolescent mental health professionals planning to involve animals in therapy should be cautious even in a semi-rural locality. Animals and children are, however, within our knowledge and skills framework, but not so the finer points of clinical governance.

The ‘brain drain’, resulting from the recruitment by the UK of highly qualified mental health professionals from middle- and low-income countries, has been described as a serious problem effecting the service provision, training and research capacity of these countries (Doku & Mallett, 2003; Thara et al, 2004). Although this issue is important, the benefits of such migration are seldom highlighted. Professionals who migrate often invest in families and businesses in their home country and are a source of valuable foreign income. Many professionals undergo specialised training and gain experience not available in their home countries and then return to provide an enhanced level of service (Tareen, 2000). Such movement may also serve a catalytic purpose. An example of a sector that has gained enormously from the so-called brain drain is information technology in India, which is built largely around expatriates in the USA and their networks back home. The high profile of Indian information technology experts has encouraged a whole new generation to pursue excellence in this field.

The Highland Users Group (HUG) is a collective advocacy group run through 13 branches spread throughout the Scottish Highlands. It has over 360 members and has two tasks: (a) to speak out about the lives of its members in order to press for changes to improve their lives and (b) to raise awareness of mental ill health in an attempt to challenge the stigma and discrimination that users face. Our work has been recognised as being of a consistently high quality, both locally and nationally within Scotland.

Francis Dixon Lodge is a therapeutic community in Leicester with a capacity for up to 15 residents. The Lodge also runs a day and out-patient service. The residential programme runs from Monday to Friday (with residents returning home at weekends), and comprises twice daily community meetings, twice weekly small group psychotherapy sessions, a once weekly art therapy group and a once weekly care-planning group. There is also structured time for recreational activities, housekeeping tasks and involvement in assessment of referrals. In addition to planned groups, a crisis meeting can be called at any time by any community member who feels they or another member are struggling in some way. This involves calling on the community to think about how to manage the situation, and is the way that therapeutic communities challenge impulsive behaviours. Individuals may not be at a stage where they feel able to manage their feelings at the time and are likely to ‘act out’ in self-destructive ways, but others around them may be able to offer advice and support. With time, it is hoped that they are able to develop more elastic impulse control (Campling, 2001).

Telepsychiatry is the delivery of healthcare and the exchange of healthcare information for purposes of providing psychiatric services across distances (Yellowlees et al, 2003). In practice, this most often means an interaction between a patient and clinician who are in different sites, through the use of transmitted live sound and video images. The term telepsychiatry was first used by Dwyer in 1973 who described the use of closed-circuit television at Massachusetts General Hospital for consultations between psychiatrists and patients. However, telemedicine was pioneered at the Nebraska Psychiatric Institute nearly 20 years earlier (Wittson & Dutton, 1956).

Moving to a different country for work can be an interesting experience but can be demanding for healthcare professionals as the systems across countries are vastly different. At the same time, such an opportunity can enable professionals to broaden their skills and experiences. The National Health Service (NHS) provided such an opportunity by recruiting consultants from overseas under the International Fellowship Scheme. In this paper three psychiatrists (M.S., S.G. and G.S.) who moved to the UK under this scheme describe their initial experiences.

Developing new ways of working for consultant psychiatrists can be done differently depending on the consultants concerned. A group of consultants in rural North Yorkshire made some changes in their working patterns resulting in benefits to them, their teams and their patients. Close working relationships between managers and clinicians were the key to facilitating these changes.

Rollo May Ward, a long-term medium secure facility integrated within the West London Mental Health National Health Service (NHS) Trust, is the first dedicated long-term NHS medium secure unit to have opened in England. It caters for a group of men with complex clinical needs and risk assessment issues who had previously been inappropriately detained within high secure services owing to a lack of suitable, less secure placement facilities. We describe the background to the development of the long-term medium secure service, the referral and assessment processes, the structure of the ward and the therapeutic programmes available to patients. We also outline the characteristics of the first 21 patients to be admitted to the ward and offer advice for similar future developments.

The day I leave Ampara on Sri Lanka's east coast, a wild elephant kills a woman and severely injures two others on the road near my house. This is the second fatal attack in town this year and, as before, the animal is rounded up and bundled back to the jungle in a truck. The incident seems to encapsulate something important about the nature of Sri Lanka: dark forces coiled beneath an appearance of calm. In the past month, for example, three security guards have been gunned down at hospitals in Ampara, Batticaloa and Sammanthurai. Yet the world of crisp nursing bonnets and clinical order remains intact throughout. No one knows who the killers were or how they chose their victims, but in this smoke and mirror conflict, rumours are fuelled of a final push by one side or the other. Then nothing happens, just more of the same, daily isolated encounters, as if it were in no one's interest to go for all-out war. Meanwhile the world's attention moves on to Lebanon.

Refugee doctors differ from other international health professionals in that most left their country of origin under duress, rather than being part of the induced migration of many healthcare workers from low- to highincome countries. There are now over 1000 such doctors registered with the British Medical Association Refugee Council voluntary database of refugee and asylumseeking doctors (British Medical Association, 2006). Having obtained refugee status (or indefinite leave to remain), many wish to use their skills within the National Health Service (NHS) and contribute to their host country. However, they need to obtain the requisite qualifications (i.e. 70% in the International English Language Test and passes in both the written and clinical parts of the Professional and Linguistic Assessment Board) before being registered with the General Medical Council. They also need to gain an understanding of the culture and context of medical practice within the UK, as well as good references, if they are to compete successfully for training posts with UK graduates and other international medical graduates. The most recent figures available (September 2005) show that only 77 of those registered with the database are currently working in the NHS and 207 doctors have the required accreditation but are not yet employed (British Medical Association, 2006).

In the UK, postgraduate medical educational events are commonly sponsored by pharmaceutical companies, often with the provision of food and gifts with a small monetary value (e.g. pens and torches). The involvement of pharmaceutical companies with doctors has been discussed extensively (Abbasi & Smith, 2003; Shooter, 2005). We have chosen to consider sponsorship of educational events from an ethical point of view in order to see if this approach can provide guidance for a situation that is the norm in many hospitals, but of increasing concern to educationalists. We also hope to illustrate how the application of ethical principles can be applied to a medical education issue.