A survey of one year's lithium results for a hearth district of 170 000 disclosed unacceptable delays in checking abnormally high values. Only 17% of moderately elevated levels were rechecked within a week. The problem was most marked with patients monitored in general practice, but one particularly high result in a patient monitored in psychiatric out-patients remained unchecked for over three weeks as a result of poor communication between general practitioner and psychiatrist. A trial of an on-the-spot monitoring service using new technology has simplified procedures and reduced to zero the number of results taking over a week to check.

There has been an increasing move to involve consumers in the assessment of health services. Needs assessment and consumer satisfaction of a recently setup community mental health team is described.

We examined the associations of violence, patient dissatisfaction and occurrence of rapid tranquillisation in psychiatric intensive care, using an on-line nurse-based computerised database over a two-year period. Non-Caucasians were over-represented in violent incidents with physical threat, and previous forensic history was associated with more violent means of attack. Dissatisfaction related to non-understandable provocation and the total number of violent incidents. There was no correlation between rapid tranquillisations or side-effects and dissatisfaction. Remedial action and education in the psychiatric intensive care unit may reduce violence, and better prescribing habits, avoiding anti-psychotic polypharmacy in rapid tranquillisation, should be encouraged.

Using a case note study, this paper presents a longitudinal survey of the effect of psychiatric inpatient care on benzodiazepine prescribing. Standards were proposed to assess the quality of this prescribing. Based on these standards, the study shows inappropriate use of benzodiazepines. Following admission, there was an increase in the number of patients prescribed benzodiazepines and in the number of benzodiazepines prescribed. Of the benzodiazepines withdrawn, most were contrary to the proposed standard. The quality of drug history showed little emphasis being placed on rationalising benzodiazepine prescribing. The issue of how benzodiazepines should be handled during psychiatric admission is discussed.

The demand for child and adolescent psychiatric services outstrips the supply of resources, leaving a large unmet demand. One way of managing this is to prioritise referrals. A sample of Norfolk general practitioners were interviewed face to face. They were asked to prioritise child and adolescent mental health problems that might present to them in the surgery. A high response rate was obtained. Anxiety provoking problems were considered to be of the highest priority. Service provision and prioritisation should take cognisance of the wishes of referrers themselves. Mental health care training priorities in general practice include substance misuse and psychiatric emergencies.

Long waiting lists are a common problem in child and adolescent mental health services. We describe how referrals to the service in York are considered and allocated by a multi-disciplinary team. The criteria for allocation to different professionals and specialist teams are described and data representing a snapshot of referrals and response rate over a three-month period presented, showing that most referrals are seen within two months. We postulate that consideration of referrals in this way is an effective and efficient way of running a service.

The Care Programme Approach and its accompanying register were introduced in response to difficulties encountered in a young adult population. This paper describes the use of the register by an old age psychiatry service who do not routinely accept ‘graduate’ patients. Few patients had a diagnosis of dementia and most had psychiatric histories in excess of 10 years.

As staff on the acute psychiatric unit at St Ita's Hospital had recently become aware of an increasing number of referrals from Dublin airport, a retrospective analysis of case notes of such patients admitted from 1987 to 1994 was undertaken. Twenty-three patients were admitted over this period, the majority arriving from the UK. Mania was the admission diagnosis in 11 patients, schizophrenia in eight, unipolar depression in two, and schizoaffective and personality disorder in one case each. All but two had a past psychiatric history. Seventeen had Irish friends or relations; five of these acting upon ‘Ireland-related’ delusions. Ten patients required temporary certification. The mean duration of hospitalisation was 19 days and the total 433 days. All patients were repatriated, nine being transferred directly to psychiatric hospitals, with the relatives eventually bearing the cost of transport in all but one.

All 34 patients admitted from a central area of London over a 10-week period were identified. The 25 (73%) who were subsequently interviewed were questioned about their whereabouts at various points in the past. Eleven (44%) of the interviewed patients had arrived in the area within one month prior to admission, nine (36%) within the last week. Seven (28%) of the total were identified as not being the responsibility of the local authority. Patients who have recently arrived provide a significant proportion of the clinical workload in this area.

The views expressed are based on experiences of a second opinion appointed doctor and refer to neurosurgery for mental disorder. Here the general issues are sharpened by the necessity to certify informed consent and the likelihood of the alleviation or the prevention of deterioration. In an age of evidence-based medicine the criteria by which these issues are judged are critical and need to be generally agreed. The evidence needed in clinical reports and in certification is considered from theoretical and practical viewpoints and suggestions are made in reference to treatment at both new and established centres.

The lack of official consideration of the legal and contractual implications of the informal admission of psychiatric patients has resulted in a situation in which individual hospitals and mental nursing homes have generated their own mistaken assumptions about the nature of this form of admission, often to the detriment of patients.

In our evidence-based journal club we appraised an article investigating the use of the CAGE questions in screening psychiatric populations for alcohol misuse. We calculated a likelihood ratio of four for a score of two or more positive CAGE questions, suggesting the CAGE is a moderately useful screening instrument.

Over a decade has now elapsed since the last national guidelines from Government health departments about the management of deliberate self-harm, although the scale of the problem has remained unchanged. Three years ago the Royal College of Psychiatrists issued a consensus statement which set standards for suitability of staff, particularly with regard to training, experience and supervision, the available facilities for assessment, the range of appropriate management options, communication of these and management of services. This postal questionnaire study in one health region of England of all senior house officers and registrars working in psychiatry found that levels of training and supervision varied widely and often fell below those suggested.

Apparently more than 15 books have already been written about the death of Diana and the associated phenomena, and as many again are shortly to be published. You will be glad to know that I am not writing one of them. Nor am I going to add to the numerous research papers, since I cannot write phrases like “Diana functions as a radical fetish of virtual reality, a move beyond alienation to a principle of otherness raised to perfection” (Diane Rubinstein in That's the Way the Mercedes Benz: Di, Wound Culture and Fatal Fetishism’; The Sunday Times, 5 April 1998). The humorist, Alan Coren writes that soon we will all have to undergo official tests on our attitude to Di before we will be allowed a mortgage, a credit card, or a subscription to Reader's Digest the catch being we will never know if we should be for or against her.

In 1979, I wrote a personal paper on psychiatry viewed from retirement (Jones, 1979). Six years later Wounded Healers included a chapter by me (Phoenix, 1985). In the first I was coy about the nature of my ‘personal crisis’; in the second, I could pseudonymously be frank. Now, at 76, my further account appears above my own name.