As Castle & Harrison note in their fine review, imagined ugliness is a not uncommon problem presenting to psychiatrists. The “considerable lag before the disorder comes to the attention of health professionals” was a mean of seven years in the 30 cases of Gomez-Perez et al (1994). Whether the problem is called dysmorphophobia, body dysmorphic disorder (BDD) or something else, its coherence of features resembles that of other psychiatric syndromes.

Making effective use of psychotherapy can be difficult for patients and their doctors, for a number of reasons. First, the term ‘psychotherapy’ itself is unsatisfactory, used by some people to indicate a particular type of psychotherapy (usually psychodynamic), and by others to embrace all forms of psychological treatment. When we use the term ‘medication’ we usually add a qualifying adjective (e.g. antidepressant or antipsychotic medication) and it is helpful to do so in psychotherapy (e.g. dynamic therapy, cognitive therapy, etc.).

Recent research has highlighted the fact that a significant number of patients with bipolar affective disorder have a poor outcome (Cole et al, 1993). The most common poor outcome is the development of rapid or ultra-rapid cycling, but mixed states, prolonged depression and severe mania are also associated with poor outcome. It is estimated that approximately one-third of patients with bipolar affective disorder do not respond fully to lithium and a significant number of patients discontinue lithium (Post, 1990) which may itself cause further problems.

“Contrary to popular belief, partial recovery from Korsakoff's Psychosis is the rule and 21% recover more or less completely. However the extent to which the patient will recover cannot be predicted with confidence during the acute stages of the illness. Failure to appreciate these facts about the natural history of the mental illness may result in the premature confinement of the patient to a mental hospital” (Victor et al, 1971).

Sleep disorders are common among elderly people, affecting about 50% compared with about 26% of younger adults. About two-thirds of residents in long-term care have sleep disturbance (Karacan & Williams, 1983; Becker & Jamieson, 1992). This high prevalence of sleep disorders results in excessive daytime napping, fatigue, cognitive impairment, increased psychiatric morbidity and increased prescribing of hypnotics, with an associated increase in mortality (Kripke et al, 1979). Karacan & Williams (1983) quote figures varying from 26 to 100% for the prescribing of hypnotics to residents in institutional care. This has major implications. There is a risk of both accidental and deliberate overdose. There may be interactions with other drugs and a hangover effect can impair daytime functioning. Excessive sedation can make the patient difficult to rouse in an emergency. Dependence may occur and the drugs may further disrupt sleep. They also increase the likelihood of sleep apnoea.

Much of the drug testing available today is able to determine the presence or absence of a variety of psychoactive substances in a range of body fluids and tissues. For the results of such tests to be confidently interpreted, additional information is required, including general assessment and history-taking. In a wide range of large psychiatric surveys, substance dependence emerges as one of the most common mental health-related disorders, and it is also the one that is least likely to be treated. The range of available tests can be best considered as acting to support and complement a broader assessment and diagnostic procedure.

In the 1960s, most people with severe mental illness were treated in large mental hospitals, receiving all their care under one roof, ensuring its continuity and accountability. Deinstitutionalisation resulted in discharge into the community, where care was fragmented between many agencies, making continuity and accountability very difficult. Countless individual programs were developed with few links between them. Not surprisingly, deinstitutionalised patients, in an unfamiliar environment and with poor coping skills to navigate services, did not receive the care they needed.

The January 1997 issue of this journal contained four reviews that compared tricyclic antidepressants with selective serotonin reuptake inhibitors (SSRIs) and other newer antidepressants in terms of their pharmacology (Palazidou, 1997), adverse effects, potential drug interactions and toxicity (Henry, 1997), efficacy in the prevention of relapse and recurrence (Edwards, 1997), and findings from meta-analyses (Anderson, 1997). In July 1997 reboxetine was promoted as the first selective noradrenaline reuptake inhibitor (NARI), and in October of the same year mirtazapine was promoted as the first noradrenergic and specific serotonergic antidepressant (NaSSA). Milnacipran is presently being registered by the manufacturers, after which it will be the second antidepressant drug promoted as a specific serotonin and noradrenaline reuptake inhibitor (SNRI).

Treatment of people with drug problems requires a consideration of those inviduals in their personal and social context, while being mindful of the complex interaction of genetic and developmental influences. Approaches to treatment should reflect this often complex aetiology and phenomenology, and the totality of treatment will typically include social, psychological, educational and pharmacological therapies. Treatment should result in a health benefit; consequently the goals of treatment should be tailored to the health care needs of the individual. Thus, with many patients, treatment will include abstinence as an explicit objective, whereas with other patients, intermediate goals, such as reduction of harmful injecting, may be more realistic and achievable.

Depressive disorder has no single cause. Arguably, in old age it is a more heterogeneous condition than in earlier adult life, in both clinical presentation and causation. A broad distinction is often made between early- and late-onset depression in later life. The aetiology of these may differ and is currently the subject of new research.

Adolescence is a transitional stage of development between childhood and adulthood. The physical changes of puberty are generally seen as the starting point of adolescence, while the end is less clearly delineated. Adolescence ends with attainment of ‘full maturity’, and a range of social and cultural influences, including the legal age of majority, may influence this. In developed societies, these tend to delay progression to adulthood. The extension of compulsory schooling and development of further education, with its economic consequences, generally contribute to a delay in reaching full independence. This may, in turn, lead to difficulties in adjusting to the responsibilities of the next stage of life.

Complaints of poor memory are common in the healthy elderly and to many it may seem unsurprising that cognitive function declines with ‘normal’ ageing. Virtually every biological system alters with age and, just as a 70-year-old cannot run as fast or hear as well as when he or she was 20, it is perhaps inevitable that cognitive function also becomes impaired. However, far from being straightforward, the nature, classification and clinical significance of age-related cognitive changes that fall short of dementia remain a most controversial and difficult area (see O'Brien & Beats, 1994; Dal Forno & Kawas, 1995). The recent emergence of new drugs for the treatment of Alzheimer's disease (donepezil and rivastigmine) and related disorders has emphasised the need to study groups with milder degrees of cognitive impairment. It is necessary to determine whether such conditions are benign and non-progressive, or harbingers of progressive dementia and so appropriate conditions to target for early therapeutic intervention. The presence of age-related cognitive changes raises other important issues including why such changes occur, how they should be classified and whether, even if ‘benign’, they can and should be treated.

Attention-deficit hyperactivity disorder (ADHD) and hyperkinetic disorder are well-established diagnoses in children, with estimates of prevalence in pre-adolescent children from 3 to 5%. Until recently ADHD was not thought to persist beyond adolescence, but results from long-term prospective outcome studies indicate that 30–70% of children with ADHD exhibit some symptoms as adults. Recognition of this disorder is important as the persistence of ADHD symptoms has been shown to be associated with academic and occupational failure and high rates of psychiatric comorbidity. With the establishment of a UK support group (LADDER) and increasing media attention highlighting this problem it is likely that there will be an increased demand for psychiatric assessment of adult ADHD in the next few years.

The development of effective pharmacotherapy has revolutionised the treatment of obsessive–compulsive disorder (OCD), and has generated an explosion of interest in this previously poorly understood area of psychiatry. Once considered a rare, refractory form of learnt behaviour, we now recognise OCD to be a common, treatable illness, with a distinctive pathophysiology and pharmacology. Wide-ranging epidemiological surveys have demonstrated a surprisingly high lifetime prevalence amounting to 2–3% of the general population worldwide (Robins et al, 1984). Yet only a fraction of sufferers come forward for treatment and often the diagnosis is missed.

The main aim of genetic counselling is to inform about disorders that may have a genetic basis. The following definition is a helpful starting point:

We would like to comment on some issues raised by the very helpful paper by Cotgrove & Gowers.

Do busy psychiatrists need to pay any attention to the history of their discipline? Surely clinicians should concentrate on keeping up-to-date with the latest developments in their field. Medical history may provide amusing anecdotes about practice in the past, but can it inform modern treatment? Such a response, although familiar, seems rather strange, coming from psychiatrists, who, after all, spend their clinical day, taking ‘histories'. By doing so, they seek to understand their patients' problems in the context of their life history. They try to make sense of the present by reference to the past, whether it be events in the patient's childhood, previous conflicts or the individual's genetic inheritance. Given such a perspective, it seems reasonable that psychiatrists might also take an interest in the history of their profession. By attending to the history of its development, its past disputes and its intellectual inheritance, the psychiatrist can reach a deeper understanding of the current state of psychiatry.

The economically developing countries face a perpetual challenge to provide essential health care. The available health care delivery systems are primitive and lack organisation and resources. Mental health care suffers even more acutely for want of attention, widespread ignorance and prejudice. The services in this field are inadequate and often inappropriate. The urge for a qualitative change has led to a focus on higher training of specialist doctors.

Psychosocial aspects of treatment have become increasingly important with the changes in psychiatric practice away from the hospital to the community. Effective psychosocial interventions and high staff morale are likely to be the key to the success of a community-based mental health service. There is a growing expectation that all psychiatrists should have a basic knowledge of therapeutic approaches in order to take a leading role in the multi-disciplinary team. They should be able to assess patients for a range of psychological and psychotherapeutic treatments. This role is vital as the matching of the patient's needs with the appropriate treatment is the key to a successful outcome.