In October 2003 the report was published of an inquiry into the death of a psychiatric colleague that raised a number of important questions – not least regarding our management of women with bipolar disorder in pregnancy and the postpartum period (North East London Strategic Health Authority, 2003). Dr Daksha Emson took the life of herself and her 3-month-old daughter, Freya. This tragedy took place during a psychotic episode triggered by childbirth and was a consequence of her history of bipolar affective disorder. Sadly, the case of Dr Emson is far from unique. The Confidential Enquiries into Maternal Deaths (2001) found that suicide had become the leading cause of maternal mortality in the UK, accounting for 28% of maternal deaths (Oates, 2003a). The majority of the women who died by suicide suffered an abrupt onset of a severe psychotic illness within days of childbirth – a ‘puerperal psychosis', to use the traditional nosological label. For some women an episode of puerperal psychosis will be the first experience of severe mental illness, but a significant proportion of women will have had previous episodes. In the Confidential Enquiries into Maternal Deaths (2001), for example, 46% of the women who killed themselves (the majority by violent means) had previously been in contact with psychiatric services – and half of these had had a previous admission with a severe episode of illness following childbirth (Oates, 2003b). In many maternal suicides, therefore, the occurrence of an episode of severe post-partum psychiatric illness is an eminently predictable event. Although some women in the report were in contact with psychiatric services, none had received a detailed risk assessment, none had a formal management plan, and none was under close surveillance in the puerperium. It is also worth noting that none of the women in the cases of maternal suicide reported in the Confidential Enquiries was under the care of a mother and baby unit or perinatal psychiatric service (Oates, 2003a). The report on maternal deaths in 2000–2002 has now been published (Confidential Enquiries into Maternal Deaths, 2004) and, sadly, the findings are similar.

Metabolic syndrome – a cluster of disorders comprising obesity (central and abdominal), dyslipidaemias, glucose intolerance, insulin resistance (or hyperinsulinaemia) and hypertension – is highly predictive of type 2 diabetes mellitus and cardiovascular disease. In order to improve detection of this syndrome and estimate its prevalence, both the World Health Organization (Alberti & Zimmet, 1998) and the National Cholesterol Education Program Adult Treatment Panel (National Cholesterol Education Program, 2001) have provided working criteria for its diagnosis (the World Health Organization criteria are reproduced in an appendix to this paper; copyright restrictions prevent the inclusion here of the National Cholesterol Education Program criteria). Using the latter criteria, Heiskanen et al (2003) found that the frequency of metabolic syndrome was 2–4 times higher in a group of people with schizophrenia, treated with both atypical and typical neuroleptics, than in an appropriate reference population.

Under current proposals for new mental health legislation, psychiatrists increasingly will be involved in tribunal processes examining the grounds for compulsory detention and treatment, both in hospitals and in the community. They will lose some authority over admission and discharge, with decision-making instead being given over to legal bodies that will regulate admission and discharge. The proposals for wholesale change in UK mental health law are an opportunity to devise a new type of legal hearing where all ‘sides' are properly represented. However, the new mental health tribunals proposed in the draft UK bill sit in a twilight zone of ‘quasi-criminal’ courts. The use of single joint experts or ‘expert panels', consistent with the recent civil law reforms, means that problems of undisputed medical evidence may become even more acute. American experience shows that judicial deference to clinical opinion, even in overtly adversarial commitment hearings, is considerable (Bursztajn et al, 1997). In this editorial, we argue that these proposals justify a re-examination of the values of law and psychiatry.

Psychedelic or hallucinogenic drugs such as lysergic acid diethylamide (LSD), 3, 4, 5-trimethoxy-β-phenethylamine (mescaline), psilocybin, 3, 4-methylenedioxymethamph-etamine (MDMA), N, N-dimethyltrypta-mine (DMT) and their relations occur in abundance throughout the natural world, and have been used by humankind for thousands of years.

The relationship between combat and psychiatric breakdown has been well recognised for decades. The change to smaller, professional armed forces has reduced the risk of large-scale acute psychiatric casualties, and should have led to a corresponding decrease in long-term ill health, but this expected reduction seems not to have happened. Likewise, attempts at preventing psychiatric injury, by screening before deployment or debriefing after, have been disappointing. Three reasons for this are proposed: a rethinking of the relationship between trauma and long-term outcome, catalysed by the attempts of US society to come to terms with the Vietnam conflict; a broadening of the scope of psychiatric injury as it moved to the civilian sector; and the increased prominence of unexplained syndromes and contested diagnoses such as Gulf War syndrome. Traditional psychiatric injury is predictable, proportionate and can, in theory, be managed. These newer forms of injury are in contrast unanticipated, paradoxical, ill understood and hard to manage. Traditional approaches to risk management by reducing exposure have not been successful, and may increase risk aversion and reduce resilience. However, the experiences of civilians in wartime or the military show that people are not intrinsically risk-averse, provided they can see purpose in accepting risk.