Consultants psychiatrists have a limited time to offer their services. Current contracts, based on population norms, do not establish limits to consultants' workload. Reorganisation of service provision, rising demands and marked social differences in different localities have brought these population norms into question. What is the desirable workload for a consultant to ensure a decent level of care to patients? A model is proposed that specifically applies to whole-time consultants within a catchment area, and those working in adult general psychiatry. It will need to be adapted for other specialities. The figures given are estimates, which will need to be audited appropriately for refinement. It is hoped that such an analysis will facilitate the process of purchasing care for specific patient groups, and be a clearer way of identifying gaps in clinical service.

Clozapine is effective in treatment resistant schizophrenia, but unfortunately is associated with a 3% incidence of neutropenia. Regular haematological monitoring is mandatory for all patients. We asked forty patients who had been taking clozapine for more than six months why they thought they had to have regular blood tests. Almost half did not know and only a small proportion were subject to a Mental Health Act (MHA) second opinion for consent to treatment. Initial explanations of the potentially serious side effects of clozapine may not be understood or retained. Ongoing education of patients is essential. The wider use of MHA second opinion doctors should also be considered.

In order to investigate bias in history taking among psychiatric trainees, a retrospective study of case-notes was undertaken in an emergency psychiatric clinic in a teaching district. Two hundred and twenty-seven consecutive new patient assessments were assessed for quality of alcohol, substance use and forensic histories. Trainees were more likely to take alcohol, substance use and forensic histories from men, and more likely to take substance use histories from younger patients. It is concluded that trainees make sexist and ageist assumptions when they assess patients. There is a need for the education of doctors in this area.

Patients often ask psychiatrists for advice on how to answer questions about their health, when seeking employment. They fear not being employed if they declare that they have suffered from a mental illness. The attitudes of personnel directors of 200 randomly chosen public limited companies were measured. This confirmed significant reluctance, stigma and ignorance about employing and believing the mentally ill. Employers decided whether to employ someone by considering the fob description, the standard of previous work, whether the applicant was receiving treatment, previous time off sick, and the particular illness suffered. Those with depression were more likely to be employed than those with schizophrenia or alcoholism. The largest companies were significantly more likely to employ patients and were less likely to seek dismissal than the smallest. Employers would welcome more information about mental ill health. Potential employees should approach large firms and seek treatment.

The quality of written communication between psychiatrists and general practitioners has become increasingly important, with the introduction of the Access to Health Records Act as well as with demands placed by the purchasers of psychiatric services. We investigated if a hospital-based audit could be used to monitor the quality of written communications with general practitioners, and if ‘closing the audit loop’ could improve the standards. We found that audit may have helped improve standards, particularly in making letters less potentially offensive and easier to read by non-psychiatrists. A method of measuring the quality of letters is described.

Opinions on the value of measuring tricyclic plasma levels vary substantially. In the United States, plasma levels of several tricyclics are frequently used to ‘optimise’ therapy. In the UK, plasma level monitoring is less often undertaken and measured levels are more usually used simply to assure compliance rather than as a guide to dose adjustment.

As postpartum depression can occur in up to 10% of mothers, antidepressants will often be required in mothers who are breast-feeding. The judicious use of antidepressants is important since all psychotropic drugs cross into the breast milk. Drug excretion into breast milk occurs primarily by passive diffusion. Small, highly lipid soluble, unionised drugs diffuse more rapidly than other drugs. It must be remembered, however, that for those drugs with a high volume of distribution, such as the highly lipid soluble drugs, most of the drug is outside the plasma compartment, leaving only a small proportion free to transport from plasma to milk. Also, most lipophilic drugs are concentrated in hind milk which is richer in fat than fore milk. All of the antidepressants are highly lipid soluble with large volumes of distribution.

Although pharmaceutical companies report side effects that may occur with use of their medications, little data on specific groups of patients that may be at risk of particular side effects is available (Katz et al, 1991). Patients with diabetes mellitus form an important group for psychiatrists since the occurrence of depression is relatively common with this group and guidance on its treatment is lacking.

The variations in structure and content between Masters degree courses offered to psychiatry trainees around the country are documented. Most courses are integrated to some degree with statutory Membership teaching. The extent to which courses differ is likely to surprise readers. The implications for the junior trainee as well as for consultant or senior registrar appointment committees is discussed. Universities act autonomously, hence a Masters degree awarded by one may bear no relation to that awarded by another.

The benefits of experience in paediatric genetics to child psychiatrists are discussed. Pursuing a special interest within a child psychiatry rotational training scheme is an important way of widening experience in light of the proposed reforms to training for hospital doctors.

D. Hartman looks at the work of the painter De Kooning, following the BBC1's Omnibus programme of 21 February 1995.

One of the most enduring images of the BBC2 Horizon States of Mind: ‘Hearing Voices' was of an exercise used by Ron Coleman from the Hearing Voices Network. Dividing his audience of mental health professionals into groups of three, he asked two to hold an ordinary conversation while the third whispered comments, repeated sentences or gave orders to one of those trying to talk.

On 31 December 1992 Ben Silcock, a 27-year-old man, climbed into the lion's den at London Zoo where he was mauled by a lion. In the newspaper accounts it was evident that he suffered from schizophrenia. His father Bryan Silcock added that “he would sit up in his room smoking dope”. One national newspaper asked why people like Ben were not in hospital and his father blamed the health authorities for letting his son down.

At the time of independence (1947) Pakistan with a population of 40 million had three asylum-like hospitals with a total of less than 2000 beds. The hospitals were prison-like and they provided custody with little care. Patients were mostly brought in chains. Detention and reception orders were used for admission as provided in law and the law was and continues to be the Lunacy Act of 1912. The common man referred to them as pagal-khanas (mad houses) or jail hospitals. The doctors appointed were mostly general duty doctors with no training and often no interest in psychiatry and their average stay was two to three years. In place of nurses there was a cadre of attendant staff, most of them illiterate, untrained and acting more like police sepoy or jail warder than nurse.

I lay in the neurosurgical ward recovering from insertion of my ventriculo-peritoneal shunt and listening to the incessant talk of my neighbour. He had decided that as we shared a battle-front we were the best of friends. Much disclosure on his side called for me to reveal my way of life – as a doctor – to which he retorted “Oh, so it's a busman's holiday”!