Hyperkinetic disorder is the generic ICD-10 (WHO, 1992) term used to describe one of the most common childhood psychiatric disorders. It is a severe form of a syndrome which is referred to in DSM–IV (APA, 1994) and the American literature as attention deficit hyperactivity disorder (ADHD). Hyperactivity or hyperkinesis can be defined as “an enduring disposition to behave in a restless, inattentive, distractible and disorganised fashion” (Taylor, 1994). It is thus more than motor overactivity. Diagnostically there are three main groups of symptomatology: overactivity, inattentiveness and impulsiveness.

1994 saw the publication of the report of the Mental Health Nursing Review Team (Department of Health, 1994). This report signified the end of a three year process where mental health nursing was examined from the perspectives of practice, education, research and management. The last review of mental health nursing took place in 1968, but since that time there have been enormous changes in our thinking about mental illness, in the delivery of services and a number of very exciting developments in treatment. The review process included the widest possible consultation with other professionals, user organisations, patients, relatives and carers. It also co-opted expert advisers and took written and oral evidence, and visited clinical services across England. There were altogether 42 recommendations and during this article reference will be made to a number of the most important of these.

It is the intention of the Editorial Board to establish dialogue, discussion, debate and even dispute among our readership and we aim to publish correspondence, however derogatory! With this issue we are adding another contribution to the possibility of debate by having an item called ‘Commentary’ for some of the papers. The commentator will usually come from a different discipline or subspeciality from the original author and will therefore give the matter under discussion a different slant. We hope our commentators will be controversial or will at least produce some new ideas and perspectives. This will give another side to the arguments and discussions of treatment and will also expand particular areas. It is the nature of the article itself which will dictate the content of the commentary. We hope that this will make the journal both more lively and informative.

Professor Gournay's commentary on the issues and roles in mental health nursing could equally have been titled: situation and process, skills and experience, genericism and specialism, clinical and eclectic, or proactive and preventive. His research review supports a viewpoint at the structured/tested end of this continuum, where he sees ready evidence that nurses now require clinically focused training and re-training if they are to provide care and treatment for patients with the most seriously disabling mental illnesses. This reinforces the Butterworth Report's conclusions, the Health of the Nation's expectations and the specifications in Building Bridges.

The first line of treatment for patients with psychotic disorders such as schizophrenia is neuroleptic medication. Neuroleptics have provided substantial benefits to patients with this type of severe mental illness since their discovery as a treatment for psychosis in the 1950s. Despite this, there are still a large number of patients who do not respond fully to neuroleptic medication or who are not able to tolerate it. For example, although as many as 70% of patients are substantially improved following drug treatment, a considerable proportion continue to experience persistent, distressing and recurrent symptoms. In a survey of patients in a London psychiatric hospital, Curson et al (1988) found that just under half of the patients continued to experience hallucinations and delusions despite the prescription of medication. In addition, many patients experience intolerable side-effects or do not wish to comply with neuroleptic medication, yet look for some effective alternative. Depression, anxiety and a high rate of suicide are additional problems faced by patients with schizophrenia.

Comorbidity and dual diagnosis have a fashionable, and thus ephemeral, ring that belies their relevance to day-to-day practice. The topic has been increasingly addressed in North American literature where there is a recognition of the extent of substance misuse in the severely mentally ill, and the need to find ways of effectively managing its consequences. Substance misuse may colour the diagnosis, management and prognosis of major mental illness and can adversely affect the relationship between staff and patients. Despite its common occurrence, it frequently remains undetected (Ananth et al, 1989). With burgeoning research interest, there is some consensus as to how to manage the problem, but, as yet, little agreement on the precise nature of causal relationships.

The general psychiatrist and the addiction specialist have a shared agenda of concerns and interests about the misuse of alcohol. The task of this paper is to highlight and develop thoughts on items for inclusion on the shared agenda, rather than to define, or limit in any other way, how the generalist role might unfold in a particular place at a particular time. It is certain that the general psychiatrist will see a role that is more than just signposting their own specialist colleagues, local counselling services, or self-help groups such as Alcoholics Anonymous, but opinion on just how broad that role could or should be will vary considerably. One point of difference may be a mismatch of views as to where patients with alcohol misuse problems are best treated: the general psychiatrist seeing alcohol misuse, or even dependence, as having little to do with general psychiatry and belonging within a specialist service, the specialist seeing alcohol misuse as very much part of the every day work of the general psychiatrist. Happily both positions can be correct, but not totally and not without dialogue.

Psychotic disorders in the elderly can be divided into three types: disorders that have started in earlier life and persist into old age; disorders that start de novo after the age of 60, and psychoses associated with brain disease, including the dementias. The classification of psychoses in late life has provoked controversy for nearly a century. The debate concerns whether schizophrenia can present at any stage of life or whether functional psychoses, arising for the first time in late life, represent different illnesses. The nomenclature of such disorders consists of numerous terms including late onset schizophrenia, late paraphrenia, paranoid psychosis of late life and schizophreniform psychosis. This plethora of terms has made research difficult to interpret.