Schizophrenia is a devastating chronic disorder that typically presents in early adult life and impacts on a broad swathe of social and psychological functioning. It is not surprising that psychiatrists have tended to be circumspect about making this ominous diagnosis in children and adolescents. Genuine concerns about the validity of applying ‘adult’ psychotic diagnoses in this young age group, together with the lack of diagnosis-specific interventions, have suggested a cautious approach to diagnosis. Furthermore, the relative rarity of schizophrenia in this age group has meant that most psychiatrists have relatively little experience with ‘atypical’ early presentation of the disorder.

Relapse in schizophrenia remains common and cannot be entirely eliminated even by the best combination of biological and psychosocial interventions (Linszen et al, 1998). Relapse prevention is crucial as each relapse may result in the growth of residual symptoms (Shepherd et al, 1989) and accelerating social disablement (Hogarty et al, 1991). Many patients feel ‘entrapped’ by their illnesses, a factor highly correlated with depression (Birchwood et al, 1993), and have expressed a strong interest in learning to recognise and prevent impending psychotic relapse.

Despite the fact that suicide and its prevention continues to be a priority area for health care in the UK, suicide in the elderly remains a neglected subject receiving little interest and research attention. The Green Paper Our Healthier Nation (Secretary of State for Health, 1998) maintained the concept of setting targets for suicide reduction originally proposed in The Health of the Nation strategy. The new target proposes that by the year 2010 the death rate from suicide and undetermined injury will be reduced by at least a further sixth (17%) from the baseline of 1996. The setting of such targets has always been a contentious issue among many psychiatrists, who have concerns that they may be used as a quality measure of psychiatric services, especially as some consider that social influences predominate over health care issues. The subsequent debate has focused on targeting specific at-risk groups, notably severely mentally ill young men, Asian women and those who deliberately harm themselves.

Neuroimaging is traditionally divided into structural and functional imaging. Structural imaging looks at brain structure or anatomy and includes computed tomography (CT) and magnetic resonance imaging (MRI). Functional techniques seek to examine the physiological functioning of the brain, either at rest or during activation, and include single photon emission computed tomography (SPECT), positron emission tomography (PET), MRI spectroscopy, functional MRI (fMRI) and encephalographic brain mapping. Although fMRI, MRI spectroscopy and brain mapping are likely to have clinical applications in the near future, the main imaging modalities of current clinical relevance to psychiatrists are CT, MRI and SPECT, which will be the focus of this article.

There is a current gap in the nomenclature of psychiatric in-patient services. There are few descriptions of types of in-patient care and over recent years the literature has abounded with debates concerning alternatives. However, it may be argued that these debates have been based on the creation of the ‘straw man’ of the psychiatric admission, which is only fit for knocking down. Although a post-war consensus has emerged concerning the need to abandon the Victorian asylums, this has often been misrepresented as the need to avoid in-patient admission. The poorly articulated and emotional concept of community care and its lack of clear and consistent definition in public policy and key legislation have contributed to this (Bulmer, 1987). Recent changes in our view of community care have led to a refining of the concept and a shift from its comforting appellations (Titmus, 1968) to a pragmatic approach that matches it to empirical experiences and new resources. This approach sees psychiatric services for adults as being based locally and provided by a spectrum of services – in-patient, residential and ambulatory (Department of Health, 1996) – based on best available evidence. This article has been written with these issues in mind. We will address the current problems of in-patient care and the current literature on alternatives and supplements to traditional in-patient units.

People with learning disability have an increased risk of developing a mental disorder. When they need acute psychiatric hospitalisation, they are frequently admitted to general psychiatric beds under the care of general adult psychiatrists, many of whom have had little training in the assessment and treatment of mental illness in this group. They may have unusual presentations of common mental disorders leading to difficulty in diagnosis and idiosyncratic responses to treatment. Boundary disputes between general adult and learning disability services frequently lead to a reduced quality of care for people with complex needs (see Bernal & Hollins (1995) for an overview of psychiatric illness and learning disability). This paper will focus on the issues specific to the management of people with learning disability on general psychiatric wards, and is aimed at psychiatrists working in both general psychiatry and learning disability.

Anorexia nervosa is often a chronic, severe disorder in which morbidity and mortality are high. After 20 years, as many as 20% of clinical series have died (Patton, 1988) and another 20% have experienced poor outcome (Tolstrup et al, 1985).

Certain areas of child and adolescent mental health generate a degree of polarised debate, both within and outside the profession. Media attention, the development of self-help groups and the Internet lead to the publishing of papers and opinion, which exist alongside peer-reviewed research and evidence-based medicine. Parents reading such material may find it hard to know what advice is best. One area that falls into this category is chronic fatigue syndrome (CFS).

In the second of my previous two articles on the role of the expert witness, I anticipated the implementation of Lord Woolf's proposed reforms to the civil justice system in England and Wales (Rix, 1999). These changes came into effect on 26 April 1999 and they represent the most radical changes to the civil justice system for a hundred years. In the previous article, it was not possible to do more than list a few of the key points relevant to experts. The purpose of this article is to describe the changes in detail and show how they will, or can be expected to, affect the role of the expert.