A controlled study of community care in serious mental illness (SMI) was carried out. Patients with SMI were randomised to have hospital care or be looked after by a community psychiatric care team in a Daily Living Programme (DIP). The day-to-day work of a clinical team with the difficulties encountered in delivering community psychiatric care in an inner city is described. There were seven deaths from self-harm during the 45-month study. One DIP patient committed homicide. An ordeal by media following this and the suicides are described. Lessons learnt include the need for the community care team to be responsible for discharge from any in-patient phases and for attention to team morale, especially during adversity, and to time spent working under pressure.

Six yean ago, Edinburgh's community drug problem service established a model of shared care between drug specialists and general practitioners who were encouraged to prescribe oral methadone and other drug substitutes in an attempt to reduce drug injecting and the spread of HIV in a city with a high seroprevalence rate. Of Edinburgh's GPs, 70% now prescribe for around 1200 drug users who have altered their pattern of drug taking, with a marked shift away from injecting drug use, and towards oral pharmaceutical drugs. HIV rates among new referrals to the service have fallen from 21% to 8%.

The need for psychiatrists to be residential when on call is questionable, To determine whether becoming non-residential resulted in duty doctors being unable to provide the same quality of care in dealing with psychiatric or medical emergencies, a prospective study was carried out logging calls received by the duty doctor before and after transition from a residential to a non-residential on-call system. Outcome showed that requiring doctors to be resident did not seem Justified.

A postal survey was conducted among doctors practising psychiatry in the Mersey Region to ascertain attitudes, beliefs and practice with regard to psychotherapy, achieving a response rate of over 60%. There was a surprising absence of very strong feelings for or against psychotherapy which was not seen as a powerful treatment modality. There was little knowledge of the facilities provided by the regional service, and no general support for their expansion. The role of training in psychotherapy and its significance in light of guidelines for general trainees ore discussed. A need is recognised for greater awareness and contact between psychiatrists and the psychotherapy service.

Recent questions have been raised regarding the development of policies by Trusts for the treatment of their locally resident staff outside the hospitals in which they work. A questionnaire was developed to elicit views of mental health care workers on this issue. Overwhelming agreement was found among a wide variety of staff groups on the need for provision of treatment options outside the local service. Considerable thought and planning are needed in the development of formal operational policies to ensure such a service is provided by all hospitals/Trusts.

In a textbook of psychopharmacology published as recently as 1990, Hollister and Csernansky wrote about antipsychotics “It is most discouraging that more effective pharmacotherapy has not been developed. Present drugs have many deficiences: they are not curative; their ameliorative effects are often limited, many patients remain totally unresponsive; they are unpleasant to take so that many patients are less than fully compliant; they produce major side effects such as tardive dyskinesia whose full implications are still uncertain”.

Changing methods of recording psychiatric histories by a community mental health team for the elderly was associated with a dramatic improvement in the quality of recording of clinical Information and of communication with general practitioners. Comparison is made with published studies of case note audit with feedback. It is suggested that restructuring the way we work may be more effective than simple review of case notes with feedback.

The closure of large mental hospitals, the move of services into the community and the formation of multi-district rotations have led to a dispersal of trainees onto many sites. This paper seeks to raise awareness of the problems faced by trainees working and training on disposed sites and suggests some solutions. It is the product of discussions within the Collegiate Trainees Committee, the Education Committee and the Psychiatric Tutors Sub-committee.

The Internet opens up brand new possibilities for medicine. Nowhere before has it been possible to confer with colleagues from all over the world to swap ideas on an hour-to-hour basis on all manner of subjects.

Why do children always know when we want them to behave beautifully and do the opposite? No doubt Lady Cockburn thought it a delightful idea to pose as Cornelia with her children in the classical style so fashionable in 1773. Sir Joshua Reynolds has caught a moment of formal harmony just before it dissolves into all too human chaos. Who can doubt that at any second George, the imp on the right of the picture, will tighten that chubby clasp into a strangle-hold and pull down the temptingly loose coils of mother's hair? James, the child on the left, will not be slow to join in and baby William will howl as he is trampled on by his lively brothers. One small boy on his own is (sometimes) manageable; three together in any century spell trouble for grown-ups! Their mother already has a faintly strained look behind her lofty pose. She is distancing herself from the situation by fixing her eyes on the middle distance in a way well known to those who have discovered from experience that pleas, bribes, prayers and even threats cannot prevail against the exuberant life in a group of children. Will she eventually give way with good humour and indulge in a romp, or will it be smacks and tears all round and nursemaids summoned to remove the guilty parties, roaring, back to the nursery? She looks quite young in spite of the stuffy pose so who knows which way it will go. We tend to assume that youngsters in the old days were always brought up with harsh discipline. Of course life was hard and brutal for everyone and child abuse common, but many parents have also loved, petted and delighted in their children throughout the ages. The stem puritanical manuals that grate on us so much – “You must break a child's will by the age of five”, “Spare the rod and spoil the child”, “Rule by fear” – were written by disapproving experts to counteract what were seen as lax tendencies to over-fondness and spoiling of children.

The Clinical Practice Guidelines (CPG) Steering Group commissioned a survey to find out which areas of clinical practice the mental health community view as priority for the development of clinical practice guidelines (CPGs). Fifty per cent of all professionals and service users surveyed considered the assessment of risk and management of deliberate self-harm and dangerousness' a priority area for guideline development. These findings provided the basis for a successful bid to the Department of Health for the development of The Royal College of Psychiatrists' first CPG.

Over the past five decades, services for the mentally ill in India have steadily improved. From a predominantly mental hospital based service, provision has now moved to general hospitals and primary health centres. A variety of factors have contributed to changes in the quality of services. This paper briefly reviews the changes and discusses the relevance of some of them.

I would like to describe my brief impressions of psychiatry in Khartoum, Sudan and raise some ethical issues that arose for me there.

From a group meeting in one room at Friern Hospital, the annual conferences of TAPS (Team for the Assessment of Psychiatric Services) have grown after ten years to overflowing a large hall, with participants from many countries. Dr Rachel Jenkins of the Department of Health, in introducing the meeting, emphasised that mental illness now had a central place in national health targets. The reduction of suicide was a special objective, particularly as it is now estimated that one in six of the severely mentally ill eventually kill themselves. She pointed out that although this conference was focused on deinstitutionalisation, there had been very little research on why such major national differences in this process had occurred.

A postal questionnaire survey of nearly a thousand doctors investigated their awareness of the Defeat Depression campaign. Nearly all the consultant psychiatrists had heard of the campaign compared to less than half of the geriatricians and the general practitioners (GPs). Just over half of the psychiatry trainees had heard of the campaign. GPs who had not heard of the campaign were also less likely to continue antidepressant treatment beyond three months after recovery, less familiar with the psychological therapies, and less confident about treating depression in the elderly. The campaign may benefit from an increased emphasis on doctors other than psychiatrists.