National policy in the UK emphasises the importance of involving service users and caregivers in all types of mental health provision. The training of mental health care and social service professionals has always relied on seeing patients, but the patients' role has usually been a passive one. This is now changing, and service users and carers are becoming active educators in professional training, benefiting both the teachers and those taught. Provision is still very variable and is dependent on local initiatives. Voluntary organisations are active in this field, and there are now two academic posts for service users in the UK. This article explores the current forms of service user training, its benefits and drawbacks, and makes recommendations for future work.

General principles of management of patients with personality disorders admitted in crises to the in-patient unit are discussed. The role of the acute ward in the overall plan of care, the clinical thresholds to consider in deciding whether admission is appropriate and the main elements of the in-patient care plan are outlined. The management of patients with borderline personality disorder, who constitute the majority of such admissions, is discussed in detail.

Less-common personality disorders affecting patients admitted to in-patient units are discussed in some detail. These disorders are rarely a direct cause of admission, but they are often associated with other Axis I disorders and can therefore be obstacles to successful treatment. A knowledge of the clinical picture and underlying dynamics and an awareness of countertransference feelings that these patients are likely to provoke can enhance therapeutic alliances and improve the chance of effective care plans.

Research evidence has shown that morbidity and mortality rates are higher in psychiatric patients than in the general population. This article describes factors that affect the physical health of psychiatric patients living in institutions and the steps that can be taken to review, monitor and improve their physical health. The physical health care of long-stay patients should reach the same standards as those expected in the general population.

All people with learning disabilities should be able to choose from a variety of residential placements as a way of achieving greater community integration. However, many are still placed away from their borough of origin, resulting in complex consequences for them, and their families and for clinicians. This article explores the nature of the problem, defining the current issues, and examining the role of the stakeholders and the implications for psychiatrists working in this field.

The care programme approach (CPA) should be implemented across all mental health services. However, the specific needs of psychotherapeutic settings were not recognised in the official documentation. The scope for conflict between therapeutic practices and CPA requirements may have increased following revision of CPA guidelines. A recent survey of consultants in psychotherapy confirmed that implementation of CPA remained uneven. The additional time required, threats to confidentiality and a negative impact on the therapeutic relationship were common concerns. Positive effects on assessment procedures and liaison between services were also reported. Practical suggestions for minimising potential negative effects of CPA are given. It is recommended that all services providing psychological therapies develop a written policy for the local implementation of CPA.

Both antidepressants and psychological treatments are effective in the management of late-life depression. Nevertheless, there remains a considerable challenge to improve the prognosis for depression in older people. Endlessly increasing the range of antidepressants does not seem to be the answer, so attention is turning to new combinations of treatments and new ways of delivering care and improving treatment uptake. Collaboration between specialist and primary care, case management and multifaceted interventions are currently the most exciting prospects. There is good evidence for the role of both medication and psychological treatment in keeping the patient well after recovery.

This article addresses how mental illness and psychiatry are dealt with in fictional narrative. The starting point is Charlotte Bronte's novel Jane Eyre. The characterisation of madness in that novel provides the basis for exploring how the physical and psychological differences of mentally ill people are portrayed, and how violence and the institutional care of people with mental illnesses are depicted. It is also argued that the fact that in Jane Eyre, Bertha Mason, the madwoman in the attic, is rendered voiceless is not accidental but emblematic of the depiction of mentally ill people in fiction. A number of novels are used to illustrate these issues.

In psychiatry we are perhaps fortunate that the death of our patients is not such a regular occurrence as for our colleagues in other specialties or in primary care. However, when death does occur it is more likely to result from some unnatural cause such as suicide. Consequently, the prospect of being involved in a coroner's inquest is a very real and anxiety-provoking possibility for many psychiatrists. This article considers the role of the coroner in England and Wales and the process of investigation of sudden and unexplained deaths, and offers some practical advice regarding such proceedings. It illustrates a number of issues that have been highlighted in coroners' verdicts and have implications for the process of clinical governance. It also considers possible changes to the coroner system that have been proposed recently in several high-profile reports.

Pervasive refusal syndrome is a severe, pervasive and life-threatening disorder. Most commonly seen in girls between the ages of 8 and 15, although also affecting boys and younger age groups, it is characterised by a profound and pervasive refusal to eat, drink, talk, walk and engage in any form of self-care. A determined resistance to treatment is a striking component of the condition. The causes are unclear, but likely to be complex, multiple and associated with a sense of hopelessness. Treatment needs to be comprehensive and is based on supporting the child in recovering at her own pace, while ensuring physical safety and well-being. The prognosis is good, provided treatment is appropriate, but recovery tends to take a year or more.