‘The practice of psychiatry is more vulnerable to criticism than any other area of medicine’ (Mason & McCall Smith, 1999). The interventionist philosophy of psychiatry and the legacy of the psychiatric practices of the past century have left an imprint on society's mind of coercive treatments against a background of unscientific evidence of benefit. Other medical specialities conversely are forgiven their history of barbarism (has anyone been to a medical museum lately?) on the grounds that they were using the only tools available to them at the time. Public attitudes, including stigma and suspicion, make it more difficult for us to claim a similar defence, and modern day psychiatrists appear to bear the indelible scars of our predecessors' actions.

Old age psychiatrists and their teams have a particular responsibility in the identification and prevention of elder abuse and in carefully examining the factors that foster ‘the corruption of care (Wardhaugh & Wilding, 1993).

In company with all other branches of the NHS, those concerned with mental health are currently the target of a plethora of standards, guidelines and derivatives thereof. In England and Wales, the responsibility for the production of national clinical guidelines rests with the National Institute for Clinical Excellence (NICE), and the Commission for Health Improvement (CHI) is charged with the monitoring of performance. In Scotland, the Scottish Intercollegiate Guideline Network (SIGN) and the Clinical Standards Board for Scotland (CSBS) undertake these respective responsibilities. However, NICE is also responsible for a rather different form of activity, and one that has forced it recurringly into the media limelight in the 2 years since its creation. This is the formulation of national advice on the clinical and cost-effectiveness of new and existing health technology. Health technology is a rather pedantic, if precisely defined, term that means essentially any health intervention and it includes medicines, devices, clinical procedures and even health care settings. Post-devolution and in the wake of the establishment of the Scottish Parliament, the Health Technology Board for Scotland (HTBS) was created by statute in April 2000. This organisation shares with NICE the responsibility for issuing advice on the clinical and cost-effectiveness of health technologies, in HTBS's case primarily to NHS Scotland. Therefore, two nationally-oriented organisations exist on either side of Hadrian's Wall, responsible to their respective Parliaments for providing authoritative opinions on whether or not a particular health intervention should be provided within the NHS. A crude approximation to the subject of this advice would be ‘value for money’. While, for reasons that will be explained, such a term is potentially misleading, it does serve to identify the basic elements of the need to which this activity is a response.

The purpose of this paper is to identify the important gaps in research coverage, particularly in areas key to the National Service Framework for Mental Health (NSF-MH) (Department of Health, 1999) and the NHS Plan (Department of Health, 2000), and to translate these gaps into researchable questions, with a view to developing a potential research agenda for consideration by research funders.

One of the best-known aphorisms of Harry Truman, US president at the time the atom bomb was dropped on Hiroshima, was “if you can't stand the heat, stay out of the kitchen”. This has a nice euphonious ring to it, but at first sight it seems an odd metaphor to describe an important truth. The problem with Truman's kitchen is that it pre-supposed the wish to be in it. The average man in the US at the time of Harry's utterance, and probably in the UK too, had no particular wish to be in the kitchen. This was the place for women, and indeed, in Lancashire where I was brought up, men were often banned entirely from this part of the house, most particularly when it was on heat. But, nevertheless, Truman had it right by pointing to the kitchen as an important central place in the household.

Health service provision now lies almost completely within the powers of the Scottish Parliament and accounts for 40% of the Executive's budget. There is a Minister and a Deputy Minister for Health. There are six key groups – the Scottish people, the Scottish Parliament, the Scottish Executive, the health service, the local authorities and the press, all with high expectations that things should get better.

The literature concerning psychiatrists' responses to patient suicide is sparse (Brown, 1987; Chemtob et al, 1988; Alexander et al, 2000) but even less attention has been given to the psychiatrist's role in the aftermath of such an event. Psychiatrists infrequently discuss their own experience of patient suicide with their colleagues, either at an individual level (Kaye & Soreff, 1991) or in group settings such as team meetings (Ruben, 1990). This is all the more remarkable when one acknowledges that the suicide of a patient is arguably the event that causes most concern for clinicians, irrespective of their experience or seniority (Kaye & Soreff, 1991).

Lack of resources has been a major restriction on the development of mental health services. However, even with the resources currently available there are insufficient numbers of trained medical, nursing, occupational therapy, psychology and social work staff to maintain services to adequate levels in many areas. This seriously interferes with provision of services, especially in acute wards but also in other areas. It certainly restricts developments and the use of skills attained through training (e.g. from THORN psychosocial intervention courses (Gournay & Birley, 1998)). The introduction of crisis resolution and early intervention teams, as described in the NHS Implementation Guide (Department of Health, 2001a), looks likely to simply deprive in-patient wards and community teams of staff, making the new teams ineffective through lack of core services. This will occur directly by recruitment of staff from them, or competitively through taking new entrants from nursing and social work programmes. Solutions proposed have included increasing numbers of support workers and administration staff; recruitment from abroad; or increased delegation of tasks, but there remains a need for more appropriately-trained professional staff.

Proposals for new mental health legislation make the case for using the ‘least restrictive alternative’ (Scottish Executive, 2001) and the ‘least restrictive environment’ (Department of Health & Home Office, 2000) as guiding principles in deciding the management and treatment of the patient. This appears to be the case made for introducing compulsory treatment in the community. The patient living in the community, while maintained on medication, rather than the hospital would appear to be defined as on the ‘least restrictive alternative’. This, however, takes only a limited approach to what is ‘restrictive’, which should be interpreted more widely, including the patient's view as well as that of clinicians and policy makers. Thus, a patient may see it as less restrictive during an acute phase to be in hospital and not on medication, than in the community but on medication. It is likely, given our knowledge of patients' attitudes to medication (Eastwood & Pugh, 1997), that many patients will prefer to be on oral medication rather than depot, which they see as less restrictive.

There are a number of different clinical circumstances in which the issue of incoming and outgoing mail to or from a patient in a psychiatric hospital, whether detained or not, may present particular difficulties. Under current mental health legislation there is provision for post to be stopped or inspected on clinical and legal grounds (Jones, 1999), but these are fairly limited and concern only outgoing mail in specific circumstances, other than for patients detained in special hospitals (Mental Health Act (MHA) 1983). The issue of patients' mail may lead to problems in day-to-day practice where patients' desire to send or receive correspondence is linked to their abnormal mental state, is a direct result of symptoms of their illness or when it might constitute a potential or actual criminal offence. This paper reviews the relevant part of the MHA 1983 and describes three case vignettes that illustrate some of the difficulties and potential solutions to problems associated with patients' correspondence.

Although there is an association between suicide and suicidal behaviour and homicide and violence to others (van Praag, 2000), few, if any, major texts on suicide comment on the phenomenon of the ‘suicide’ bomber. However, the events in the USA of what Americans have now come to call ‘9/11’, have left an enduring traumatic memory throughout the world. On the morning of 11 September 2001 four aeroplanes were hijacked and transformed from a means of mass transportation to a means of terror and destruction, killing a total of 233 passengers, 33 crew members and some 3000 people on the ground in the USA (Alexander & Swetnam, 2001). It is not clear whether all of the hijackers knew that they were on a ‘suicide’ mission because in only six cases were ‘suicide’ notes found (Jenkins, 2001). Indeed, the term ‘suicide bombers' may be misleading because the main objective seems to have been not suicide but mass homicide, albeit carried out by means of self-destruction designed to inflict lethal harm on others. Those who planned and perpetrated the acts of 11 September 2001 would not conceptualise the acts as suicide but instead would perceive them as martyrdom, rationally underpinned by a legitimate struggle in a conflict of national and religious dimensions (Juergensmeyer, 2001).

The Child and Adolescent Psychiatry Specialist Advisory Sub-Committee (CAPSAC) of the Royal College of Psychiatrists has produced a detailed set of advisory papers covering all aspects of training in child and adolescent psychiatry, the existence of which makes the audit of training a more straightforward task than in the past (Royal College of Psychiatrists Higher Specialist Training Committee, 1999). The paper by Sharp and Morris (see pp. 212–215, this issue) is part of a continuing tradition of audit and evaluation of higher training in child and adolescent psychiatry (Garralda et al, 1983; Bools & Cottrell, 1990; Smart & Cottrell, 2000). In the past, supervision (or lack of it) has been a preoccupation (see Kingsbury & Allsopp, 1994). However, the most recent national survey of higher trainees in child and adolescent psychiatry suggests that the number of trainees receiving inadequate supervision is continuing to fall (Smart & Cottrell, 2000). Sharp and Morris focus instead on case-load and case mix and are to be commended for persevering over three annual cycles with an audit that clearly demonstrates changes being made in the light of data collected, followed by re-audit and re-evaluation – audit projects rarely ‘close the loop’ so clearly.

Policy makers find much mental health research irrelevant to their concerns. What types of research would directly assist those who formulate policy? The two purposes of this paper are (i) to identify important gaps in completed research, particularly in relation to the National Service Framework (NSF) for Mental Health (Department of Health, 1999a) and the NHS Plan (NHS Confederation, 2001); and (ii) to translate these gaps into researchable questions that can contribute to a debate about the future research agenda for general adult mental health in England.