Antidepressant prescribing in New Zealand

to give consent was compromised by his illness. There are legal tests of capacity but these are not useful in clinical practice. A further dilemma is posed as, while wanting to respect the autonomy of patients, the alternatives available with respect to consent are perplexing. Many people with serious long-term mental illness cannot give informed consent but treating each under sec tion 3 of the Mental Health Act would swamp the system, might mar therapeutic relationships and is often resisted by other staff.

the proposed treatment. For this to happen, the patient needs to be given the relevant infor mation, to be able to understand and weight it and to state his or her choice. The patient must have the 'capacity' to do this and not be under duress.
White's patient had been given the information and the fact that he was able to withdraw his consent suggests he was not under duress. My concern is whether or not the patient's capacity to give consent was compromised by his illness. There are legal tests of capacity but these are not useful in clinical practice. A further dilemma is posed as, while wanting to respect the autonomy of patients, the alternatives available with respect to consent are perplexing. Many people with serious long-term mental illness cannot give informed consent but treating each under sec tion 3 of the Mental Health Act would swamp the system, might mar therapeutic relationships and is often resisted by other staff.

Antidepressant prescribing in New Zealand
Sir: I read with interest Dr Thompson's paper on antidepressant prescribing (Psychiatric Bulletin, August 1994. 18, 461-462). Having worked in the same community team and at the local inpatient unit, I feel the article brought up an interesting point relating to the consultation fee that New Zealand residents pay to see their GP (but not to see a mental health professional).
This fee caused problems in the management of people with mental ill health. People developed a reluctance to visit their GP (often voiced in clinic) with a resultant pressure on GPs to have longer intervals between consultations and therefore having to write prescriptions to cover longer periods. This created problems, especially where there was a suicide risk as the patient could have a larger quantity of medication in his or her possession. There may therefore have been a reluctance to prescribe a therapeutic dose and to opt for a sub-therapeutic prescription. This perversely may leave patients at greater risk as their depression remains untreated. It was also my impression that referrals present earlier in the course of illness which may be a result of the fee. Finally, there was a lack of shared care between the GP and mental health team as a consequence of the reluctance of patients to see their GP, because of the financial burden. This may have a secondary effect of de-skilling the GP. KEITHR. LINSLEY. St George's Hospital, Morpeth.

Northumberland NE61 2NU
Training in a home treatment team Sir: Smyth & Bracken (Psychiatric Bulletin, July 1994, 18, 408-409) describe their training experience in a home treatment team. Having worked as a registrar with the same team I share many of the experiences they describe. I would like to add a few further observations.
Smyth & Bracken describe how "working with out the apparent security of hospital wards initially provoked anxiety." My previous working experience as a junior doctor in various hospital settings had not been free from anxiety. There were worries and uncertainties about patient and staff well-being and safety but more notice able to me were anxieties provoked by the way 'hospital systems' operate. The need for control and request that the patient should fit into hospital routine are central to treatment within institutions.
Behaviour that is unacceptable within these regimes will frequently be inter preted as part of mental illness and result in the increase of control in various forms. My anxieties were related to the fact that I often felt unsure whether 'mental illness' or the 'social context' were the source of a particular presentation.
My working experience with a home treatment team has not given me an altogether different picture of psychiatric illness. Psychotic experi ences seen similar whether at home or in hospi tal. 1was, however, struck by the different kinds of relationship that seem possible between patients in their own home environment and the professionals offering support. As a result 1 have started to look at psychiatric illness In a different light and I have become more aware of the extent to which 'the illness' is a social con struct rather than a clear medical entity. This broader view of psychiatric illness has in my case led to a very positive and fulfilling working experience.

IRENELAMPERT, North Birmingham Mental Health
Trust, East Sector. Birmingham BIO 9JH

Cardiopulmonary resuscitation
Sir: The study by McNaughton, Hall & Stark [Psychiatric Bulletin, July 1994, 18, 403-404), revealing the poor technical proficiency of junior doctors in cardiopulmonary resuscitation (CPR), confirms the fears of many junior doctors who are often the only medical cover for a large num ber of in-patients.
However, the recommen dation of the authors that junior doctors receive regular refresher courses in cardio-pulmonary resuscitation is insufficient.
Many psychiatric hospitals are on extremely large sites, while many on-call duties involve covering a number of different sites. It is there fore essential that all clinical staff, especially Correspondence 703