Following the publication of the 1994 Consensus Statement on the use of high-dose antipsychotic medication, we identified our high-dose patients and undertook an audit of the recommended physical investigations. The patients were identified by scrutiny of prescription records. Data were collected retrospectively at six-monthly intervals for four audit cycles. Results were fed back to clinicians at the hospital journal club.

The percentage of patients identified in the high-dose category fell from 35 to 23% over 18 months. Electrocardiograph monitoring of the group increased from 5 to 63%. Other tests showed a similar improvement. A very small number of abnormal results was shown. There were no untoward cardiac events.

Introduction of the standards of physical monitoring advised in the Consensus Statement has implications of cost to the NHS to be balanced against risk avoidance for patients. The number of abnormalities detected in our population was low. Changing prescribing behaviour in response to reported abnormal findings proved unexpectedly slow and a new system was required.

The Royal College of Psychiatrists' Consensus Statement on “The use of high-dose antipsychotic medication’ suggests only fully qualified psychiatrists (MRCPsych) should recommend the prescribing of high-dose antipsychotic treatment. We observed changes in anti-psychotic prescribing in two surveys of psychiatric in-patients conducted eight and 32 months after publication of the Consensus Statement.

Overall mean chlorpromazine equivalent doses of antipsychotic drugs reduced between the surveys. When p.r.n. (as required) prescribing (usually done by junior doctors) is included, mean potential doses and numbers of patients who might receive ‘high-doses' increases substantially, although the reduction between surveys in total mean dose and proportion of patients on high-dose antipsychotic medication is preserved, and the actual use of p.r.n. medication was low (4–5% of p.r.n. prescriptions).

We recommend the development of local guidelines for junior staff concerning antipsychotic drug prescribing, regular monitoring of p.r.n. medication by consultants, and pharmacists' involvement in reviews of patients prescribed high-dose antipsychotic medication.

The study investigated the reasons that influence medical staffs' choice of a specific drug over another given the same clinical situation, by use of a questionnaire-based survey. The study population was 88 clinicians of various ranks, at psychiatry units in National Health Service university and district general hospitals In Greater Manchester. Responses in the factors: personal experience, scientific evidence, influence from colleagues, economic consideration, influence by drug representatives, ward or unit policy and other in choice of prescription, were the main outcome measures.

Of the 546 responses generated by the 88 clinicians, 263 (48.2%) were for personal experience as the most important influence on choice of prescription. Scientific evidence was the second most important factor with 117 (21.4%) responses. Economic consideration and influence by drug representatives were least important. This trend held for all ranks except for registrars, where scientific evidence was as important as personal experience.

As prescribers, clinicians trust mostly in their own personal experience. This may not be unique to psychiatrists. An understanding of how clinicians gain ‘personal experience’ could be important in improving rational prescribing.

There is considerable confusion at present among clinicians as regards the appropriateness of prescribing off-licence. Because of the nature of the registration process it is likely that a considerable proportion of prescribing will always be off-licence. This paper seeks to clarify when it is appropriate to prescribe off-licence. We convened a workshop on behalf of the British Association for Psychopharmacology involving clinicians and regulators from a variety of countries to explore this issue both generally and for specific childhood and learning disability clinical situations. Recent statements from the defence unions and consumer groups were also scrutinised.

Across senior clinicians and regulators from a number of European countries and North America there is a consensus that prescribing off-licence is a necessary part of the art of medicine.

Current advice to clinicians on the issue of off-licence prescribing can sometimes overemphasise the hazards and neglect the benefits that may stem from appropriate off-licence prescribing. Good prescribing involves specifying treatment goals and monitoring outcomes and it is more important to share this with the patient than it is to communicate the licensed status of the drug being prescribed.

A postal questionnaire of Trent Region's consultant child and adolescent psychiatrists was used to investigate the two-year period prevalence rates of antipsychotic medication prescription, and the ICD–10 psychiatric disorders it was used to treat.

The response rate was good (92.3%) and 78% of respondents had prescribed antipsychotic medication for a range of conditions over the period, albeit very infrequently. Antipsychotics were used for a range of psychotic and non-psychotic disorders. The older antipsychotic agents (thioridazine, chlorpromazine and haloperidol) comprised the bulk of prescriptions. Newer, atypical, antipsychotics were prescribed only four times over the period and no patients in residential in-patient units received this form of treatment.

These results highlight a pressing need to address antipsychotic prescribing in children and adolescents and, especially, the role of new antipsychotic drugs.

A retrospective case note study examining the effects of increased supervision on practice of electroconvulsive therapy (ECT).

Increasing the level of supervision of ECT sessions was associated with patients receiving on average almost two fewer treatment applications per course of ECT.

The risk of treatment is reduced because patients receive fewer anaesthetics, and they may be discharged home sooner. Such improvements in ECT practice should be relatively easily achievable in many ECT clinics.

The impact of major organisational change in a psychogeriatric service was examined in a naturalistic and opportunistic study, which was prospectively conducted.

A positive association between the organisational change of the proposed closure and relocation of a psychogeriatric ward and stress among the nursing staff as measured by the General Health Questionnaire was demonstrated.

Policy-makers, purchasers and providers need to consider the implication of such stress and develop strategies to minimise stress prior to any major policy change.

A prospective study was undertaken to evaluate the effect of a stamped addressed envelope, as compared to a non-stamped but addressed envelope or no envelope, on response to a mailed questionnaire. The correlation between questionnaire response and subsequent attendance at the first appointment was also studied.

The overall response rate was 26% of 176 families offered first appointments at a local child psychiatry service. Families provided with a stamped addressed envelope were more likely to return their questionnaire and those families who returned the questionnaire were more likely to attend their first appointment.

The return of patient questionnaires has significant clinical and resource implications. Only essential questionnaires should be sent out to referred families as nearly three-quarters will not be returned. The return rate can be enhanced by providing a stamped addressed envelope but, if questionnaires are not returned within 10 days, the likelihood of return is minimal. As more than half of the families who failed to return the questionnaire also failed to attend their first appointment, questionnaires can be used as a measure of motivation and likelihood of attendance as well as a source of clinical information.

Most medical diagnoses are made from the physical history alone. In the psychiatric literature, physical assessment usually focuses on examination rather than history. We aimed to ascertain the relative importance that trainee psychiatrists attach to the physical history and examination, and to investigate their actual method of physical assessment. The relative weight that trainees attach to physical history and examination was assessed with a postal questionnaire. Their actual practice was evaluated by reviewing a selection of case notes from patients under their care.

Trainees weighted the physical examination as more important than the history in theoretical terms (P=0.02). They also indicated that they attached more importance to examination in their own practice (P=0.03). On review of the case notes, 34 (71%) of inpatients had been physically examined, but only one (2%) had evidence of a physical history.

It appears that many psychiatric trainees do not adhere to the basic medical principle of taking a physical history on which to base a physical examination. ‘Blind’ examinations are unlikely to yield medical diagnoses. These findings have implications for our patients' health and psychiatric training.

Prompted by a clinical question, we critically appraised a meta-analysis of neuroimaging in our evidence-based journal club.

The results of the meta-analysis suggested differences in ventricular size and sulcal width between controls and people with schizophrenia and mood disorders. However, we were unable to answer the question that prompted this exercise.

Although the evidence-based medicine approach facilitates appraisal of complex articles, some clinical questions are not yet answerable.

This article aims to describe qualitatively attempts in one NHS trust to improve psychotherapy training for psychiatry trainees, according to the Royal College of Psychiatrists' Guidelines, using existing multi-disciplinary resources.

Training opportunities in a wide range of interventions were identified. A psychotherapy supervision group was established, and a psychotherapy training post was introduced for a trial period. The costs and benefits are discussed.

Substantial improvements in psychotherapy training can be made using existing resources, even in the absence of a consultant psychotherapist. Flexibility and coordination are required.

The Joint Committee on Higher Psychiatric Training lists the ability to carry out a thorough clinical assessment including physical and mental state examination, as one of the essential core skills in child and adolescent psychiatry. Experience of the assessment of comparatively rare disorders may depend upon the organisation of regional services, as well as good working relationships between teams willing to involve the trainee.

This paper describes a six-month attachment to the first multi-disciplinary Specialist Assessment Clinic for Pervasive Developmental Disorders to be created in Northern Ireland. Assessments are multi-dimensional and multi-professional. Attachment to this specialist clinic has become a valuable resource, with demand exceeding availability of places.

The pervasive developmental disorders are characterised by onset before 36 months, qualitative impairments in social interaction and communication (both verbal and non-verbal), and a pattern of repetitive or stereotyped activities or interests (DSM-IV). Diagnostic criteria for these disorders have broadened since the introduction of DSM-IV and ICD–10. For example, both have now agreed the validity of Asperger's syndrome, featuring difficulties in social interaction, restricted and repetitive areas of interest, without clinically significant impairment of intelligence or language development.