Increasing referrals to psychiatric clinics, combined with restricted medical manpower, require innovative ways of meeting the demands. We appointed a nurse to help in an out-patient clinic. The nurse recorded new patients' case histories and presented them to the consultant, who could then see the patients in less time. In the first 15 months the clinic saw 260 new patients, compared with 190 in the previous period. The median waiting time for appointments came down from 32.5 to 22.5 days (P=0.018). Patients reported a high level of satisfaction with seeing a nurse and a doctor.

Clinical studies suggest that risperidone is an effective antipsychotic with a low incidence of extrapyramidal adverse effects. In a prescription survey of several trusts, we found that risperidone was widely prescribed at high doses alongside typical neuroleptics and anticholinergic drugs. We also demonstrated that prescribing in a single trust can be improved by simple interventions. Risperidone should be prescribed as the sole antipsychotic at doses below 8 mg/day to realise fully its clinical advantages. Few prescriptions met this standard.

This is the first of two papers which summarise key concepts in health economics and explains the differences in the various types of economic evaluation published in the economics literature. Examples from the economic analysis of mental health care are used to illustrate the key points. This paper explains the concepts of scarcity, rationing, opportunity cost and efficiency from a health economics perspective, and presents an ethical argument for the use of health economics in making decisions on resource use in mental health care.

This paper is the second in a series explaining key concepts and techniques used in health economics in the context of mental health care. The paper describes the different types of economic analysis and the circumstances in which they should be used. It explains key aspects of the methods used in economic evaluation to measure costs and benefits. The purpose of the paper is not to enable clinicians to undertake economic analysis, but to familiarise them with the methods used in economic evaluation and to enable them to assess the rigour and results of published studies.

This exploratory study assessed staff perceptions to the reduction of maintenance neuroleptic medication in patients with chronic schizophrenia living in a long-stay hospital. Ten in-patients were assessed at regular times over six months. In addition to the Brief Psychiatric Rating Scale (BPRS), data were obtained from nursing staff on patients' ward behaviour (Ward Behaviour Interview Schedule, WBIS), clinical global opinion (CGI) and staff reaction (SR) to the reduction of medication plan. The average decrease of BPRS and WBIS was not related to keyworker's clinical global impression. The SR increased against the reduction of medication over the study period (P<0.05). Staff perceptions in the treatment of patients with chronic schizophrenia and their possible influence on prescribed closes should be taken into consideration in addition to psychopathology and clinical symptoms.

Parasuicide referrals and subsequent transfers to psychiatric in-patient care were recorded for January to April, 1972 to 1996. Information regarding the psychiatric outcome of transfers for the years 1985, 1990 and 1994 was obtained by case note review. Parasuicide referrals show a decline from 1972 to 1990 but they have more than doubled since then. Referrals transferred to in-patient psychiatric care fell from 10.7 to 2.8% during 1985 to 1994. Fewer patients with acute stress reaction, adjustment disorder, personality disorder and substance misuse are being transferred. Transfers of patients with ‘severe mental illness' have remained constant.

Previous audit of electroconvulsive therapy (ECT) standards has identified deficiencies in service provision. Little national information was available on ECT services in Scotland. Survey questionnaires were sent to all consultants in charge of ECT clinics in Scotland. There was a 100% response rate. The service provision varied across Scotland, and in some cases fell below Royal College of Psychiatrists' recommendations. There now exists a base of information on services available and an ongoing national audit system should be considered. Several recommendations have been made for the future of ECT services in Scotland and these have been distributed to consultants in charge of clinics.

All British mental health professionals will be aware of several highly publicised deaths at the hands of mentally ill people and will have seen the conclusions of inquiries and government reactions. To reduce the risk of future tragedies effective methods of risk assessment and prediction are needed.

The value and efficacy of psychotherapy is currently being debated both within (Gabbard et al, 1997) and outside the profession. One commentator has spoken of psychotherapy's populist synonym ‘counselling’, as the ‘valium of this era”, where counselling “does not cause the same clouding of consciousness as drugs, but its side-effects are twice as bad” (Dalrymple, 1996).

Little is known about how posts are allocated to enable Individuals to experience a comprehensive pre-membership psychiatric training. A questionnaire survey of 26 teaching hospital training schemes was carried out. This concentrated on registrar training – post-Part 1 MRCPsych (now known as senior house officers since the Caiman changes). Four main methods of allocation, with varying degrees of trainee involvement, were identified. The amount of prior notice given of the trainees' next placement and perceived advantages and disadvantages were compared between the four methods. Implications for practice are discussed.

Within the ageing population there exists a small number of elderly transsexuals. There is a growing impression that they are beginning to require the services of old age psychiatry. Most services are ill equipped to deal with this group and require specialist support. This case history illustrates this need and describes the social dilemmas involved.