The experience of violence towards members of community mental health teams was explored using a questionnaire. Response rates were 97%. The number of staff experiencing various types of violence was greater than in previous studies. Staff were generally well-informed about the theoretical issues and had sensible attitudes towards the risk of violence. Appropriate training was found to be lacking and other Department of Health and Social Security recommendations were not being followed. These included information about whereabouts of staff, and mechanisms for communication. We recommend that training issues are addressed locally and that safe theory should be translated into safe practice which is regularly monitored.

Standard approaches to the prevention of suicide have concentrated on the rigorous assessment and management of suicidal risk. Using deliberate self-harm as a specific example, we discuss the relative merits of this ‘high-risk’ strategy and compare it with a population-based preventive strategy. We conclude that a combined approach offers the best hope for reducing the rate of suicide, although it may not fit easily with medical models of care.

The effects of service expansion and change (including Joint working with social services) following the provision of a community mental health centre and the introduction of care management were examined by auditing service activity. Data were collected on service provision to 20 randomly selected patients who met the local criteria for care management, and also on the general level of service activity as judged by service contacts for all disciplines. Compared to the baseline period, face to face contact with care-managed patients increased six-fold. There were more home contacts, a wider range of professional contacts occurred, and a greater variety of types of treatment provided. A substantial (though not statistically significant) reduction in day hospital attendance was seen over the period studied. The number of service contacts for non-care-managed patients also rose. The introduction of care management was simplified by changes in service organisation. Increased resources were needed to both implement care management and provide an adequate service to the remainder of patients. Both aspects of the service functioned efficiently in parallel.

Recent changes in the law and mental health policy have forced psychiatrists and other mental health professionals to review the traditional cloak of secrecy that surrounds record keeping and letter writing. This paper establishes what proportion of patients attending a psychiatric out-patient clinic are interested in receiving letters from their psychiatrist. Those who are interested tend to be better educated, whereas those who are not interested are much more likely to have an ICD–10 diagnosis of schizophrenia. Overall, there appear to be high levels of satisfaction with the nature of the letters received. The significance of these findings is discussed in relation to the difficulty of engaging people with the most severe and enduring forms of mental health problems as active participants in the process of care.

In January 1991, the adolescent in-patient unit in Leeds became a seven-day residential unit. This study set out to review the first five years' intake of patients, with regard to basic demographic details, diagnoses, use of regularly prescribed psychotropic medication and episode length. Using clinical case notes as the primary data source, we reviewed 154 completed patient episodes, representing 128 patients. The study revealed that about a third of patients had been prescribed regular psychotropic medication, and that this group had significantly longer episodes and were significantly more likely to return to the unit than those for whom there had not been regularly prescribed medication.

The release of the antipsychotic agents risperidone, sertindole and olanzepine forces difficult choices upon clinicians. The new compounds are better tolerated than neuroleptics, expensive and their long-term side-effects unknown. These choices can be made easier by the dose and side-effect minimisation procedure set out below, which aims to produce the greatest benefit and least harm from conventional neuroleptics.

Prescription charts including a prescription for olanzapine were evaluated for 202 patients from 15 National Health Service trusts. In patients prescribed olanzapine for less than six weeks, the mean dose was found to be 12.4mg/day but 56% of patients were prescribed olanzapine as the sole antipsychotic. For patients prescribed olanzapine for longer than six weeks (when dose titration and drug crossovers were assumed to be complete) the mean dose of olanzapine was 15.8mg/day and 64% received olanzapine as the sole antipsychotic. A substantial proportion of patients were prescribed concurrent anticholinergic drugs (but relatively few when on olanzapine alone). Olanzapine was used in doses higher than the standard dose recommended by the manufacturers, often in combination with typical antipsychotics. Such practices increase costs and, at least in the latter case, very probably adversely affect outcome. Studies are needed to evaluate the relative effectiveness of commonly used antipsychotic regimens in naturalistic settings. In the absence of these, olanzapine should be used as the sole antipsychotic and patients should be property assessed on lower doses before dose increases are undertaken.

A widespread perception exists that attendance at child psychiatry clinics is especially poor. The reported rate of non-attendance at a child psychiatry outpatient clinic is 61%. However, other child health clinics also suffer a high rate of non-attendance. In this paper we examine the hypothesis that rates of non-attendance are higher in child psychiatry than In other child health out-patient clinics.

Bullying is a common problem. There has been much written on the subject, mainly relating to schools. In this study a questionnaire was sent to 66 child and adolescent psychiatric units in the UK, 50 (75%) were returned. The units were surveyed on frequency of bullying, whether an anti-bullying policy was in place and whether difficulties had been encountered setting up the policy. An anti-bullying policy was present in only 10% of units. Further research is needed on bullying and appropriate and effective methods of dealing with it on child and adolescent psychiatric units.

This paper describes the social and clinical characteristics of patients who attended a mental health promotion drop-in clinic that was set up in a primary care group practice. From consideration of the characteristics of the patients, the problems they presented with and the results of the consultations, we argue that there is a viable role for mental health promotion as a form of primary prevention of mental health problems, distinct from an extended treatment or therapeutic role. It is open to question whether the particular way we delivered the service is necessary to achieve such an objective and we draw attention to some of the constructive criticisms the primary health care team made at the final evaluation of the project.

This study aimed to describe the prevalence of dental pathology in patients receiving electroconvulsive therapy and to prospectively determine the incidence of dental complications arising during treatment. Of 30 subjects, 93% complained of a dry mouth and 83% were taking drugs with anticholinergic properties. A third wore dentures and the dentate population had a mean of 15 decayed, missing or filled teeth. Oral hygiene and periodontal condition was poor with one-third requiring scaling and 30% complex periodontal treatment. Temporomandibular pain followed 44% of treatments, and minor buccal lesions occurred in 22%. Greater emphasis must be placed on dental care, and guidelines are suggested to improve practice.

Idiopathic unconjugated hyperbilirubinaemia (Gilbert's syndrome) is a common benign disorder that, when seen in association with psychiatric illnesses, often leads to the inappropriate withholding of psychotropic medication. We describe three cases with Gilbert's syndrome and psychosis in which diagnosis of Gilbert's syndrome was delayed. This led to unnecessary investigations, further relapses and increased admissions to hospital. We emphasise the need for psychiatrists to be more aware of this benign condition.

In this paper concepts related to the field of non-linear dynamics and chaos theory are discussed, and their relevance to psychiatry is considered.

Recommended changes in services for adults with mild learning disabilities are likely to have training implications. A case vignette study examined the effect of coexistent mental illness and learning disability on trainees' clinical assessment and management. Mental illness was more likely to be diagnosed in those with a mild learning disability than in a control group who had no learning disability. Despite this, the learning disability group was less likely to receive treatment. Service and training issues are discussed.

The similarity between the work of the fictional detective and that of the psychiatrist has often been remarked. Both Marcus (1984) and Shepherd (1985) have compared the technique of the archetypal sleuth, Sherlock Holmes, with that of Sigmund Freud. The sage of Baker Street attempted to solve criminal cases by finding links between items in the external world, such as footprints, bloodstains or broken locks, while Freud tried to make sense of the mysteries of the mind by making connections between events in the inner world, such as dreams, thoughts and desires. Both attempted to provide an all-encompassing explanation of seemingly disparate phenomena. Over the years, the literary descendants of Holmes have become increasingly similar to psychiatrists, because, as well as attending to the external events, they also take account of the individual psychology of the criminal and the social context of the crime.

Throughout the 19th century some 20–25% of all known pauper lunatics in England and Wales were accommodated in workhouses. Early on, the lunacy commissioners considered that all pauper lunatics should be admitted to asylums and were highly critical of the conditions under which they were kept in workhouses. As the century progressed the lunacy commissioners were forced to compromise because of the lack of space in asylums and diminishing confidence in the results of asylum treatment. By the end of the century the lunacy commissioners were reconciled to the accommodation of feeble-minded, imbecile, idiot, chronic psychotic and demented paupers in workhouses, but held to the view that the acute pauper insane should be admitted to asylums.

It was in early 1984 when, after receiving my basic postgraduate training in the UK, I returned to my home country, Pakistan. As I began to settle down in my professional work I soon realised that I was facing problems on more than one front. Whereas some of these I have been able to overcome with time, others remain largely unresolved. Psychiatrists from the developing world who receive their training in the West and subsequently return to their home countries may be facing similar dilemmas. Here I would like to share some of my own.

The Internet provides information on virtually any subject. This is readily accessible to the public, although of variable quality. The Internet also plays an important role in contemporary psychiatry with the dissemination of information on disorders, research and clinical practice. Our patients may have access to mental health web-sites, consulting electronic sources when making decisions that affect their health. The implications of patient power on the Internet are discussed.

I was wandering through the ward clutching an auroscope in search of a patient suffering from severe psychological and behavioural problems who was complaining, inter alia, of a blockage in her ears. I encountered her consultant, a Jungian, who when informed of my purpose, responded that this was the most important development in years as it meant she was ready to listen!