The Department of Health has emphasised the need for a patient-centred National Health Service (NHS), and the involvement of users and carers in mental health services is often a policy recommendation (Mental Health Task Force User Group, 1995; NHS Health Advisory Service, 1997; Department of Health, 1999a,b, 2001). The Patients' Forum and Consumers in NHS Research are established national bodies concerned with stakeholder involvement. The Commission for Patient and Public Involvement in Health was established in 2003.

As highlighted in the recent systematic review by Stimpson et al (2002), we know little about the relative efficacies of the treatment interventions that are routinely deployed for those with depressive disorders that have not responded to standard, first-line treatment approaches. Accepted practice is, at best, systematic ‘trial and error’, with sequential antidepressant monotherapy and/or combinations of antidepressant drugs with ‘augmenting agents'. This haphazard medicinal approach to managing the patient with poorly responsive depressive disorder is compounded by the lack of available information on the effectiveness and optimal role for psychological treatment methods. Given the high prevalence of depressive disorders and their frequent presentation to both primary and secondary care health services, it is a source of embarrassment that we remain so ignorant. Nevertheless, it is against this backdrop of uncertainty that we must now evaluate the relative merits of a novel intervention that has captured considerable media and lay interest: vagus nerve stimulation (VNS™).

The statistics about depression clearly identify it as a major public health problem (Greenberg et al, 1993). About 6% of the population meet the criteria for major depressive disorder or dysthymia at any time, and 20% of those with major depressive disorder will have symptoms that persist beyond 2 years (Keller et al, 1992). The disorder is highly recurrent; 30% of individuals experience a relapse within 3 months of recovery and (in the absence of continuation or maintenance treatment) 50% experience a further episode within 2 years. The standardised mortality ratios for unipolar depression for accidental deaths, for deaths by natural causes and for suicide were 1.4, 1.7 and 19.7, respectively (Ustun, 1999). In the National Health Service the cost of treating depression ($887 million) exceeds the cost of treating both hypertension ($439 million) and diabetes ($300 million) (Department of Health, 1996). However, the direct health care costs are dwarfed by the indirect costs (Berndt et al, 2000). Days lost from work owing to depression exceed all other disorders and the economic burden on family members and society is considerable (Broadhead et al, 1990). This may account for 60–85% of the total cost of the illness and represents a significant proportion of the gross national product (Kind & Sorensen, 1993; World Health Organization, 2001).

The need for accurate information about the mental health problems of multicultural communities requires valid measures of mental health for use in a number of languages and cultural contexts. Measures of psychopathological symptoms leading to a diagnosis have been especially criticised for their universal application, without attention to their limitations across cultures. Yet, measures are crucial to assess recovery and the performance of services, and to take account of carer and user views. We summarise the main challenges in the cultural adaptation of such measures in our work with adults and adolescents of South Asian, African and Caribbean origin.

The system of scientific authorship is based on trust. Journal editors, reviewers and readers expect that a paper's content reflects the opinions of the authors and all the available data. Recently, there has been concern that this trust may be undermined by the involvement of industry-paid writers in the preparation of publications (Bodenheimer, 2000). These professional writers are either employed directly by pharmaceutical companies or work for medical communications agencies; their contribution to a paper varies, but may include writing the first draft of a manuscript for the authors to revise or editing a paper written by the authors (Lagnado, 2003). Despite much discussion about the merits of industry-funded writing assistance, there has been little research into its effects on the biomedical literature.

Liaison psychiatry has been recognised in many countries as a special interest or sub-speciality of psychiatry concerned with the management of general hospital patients with psychological problems. However, despite increasing awareness of the emotional and behavioural aspects of illness, it has yet to achieve substantial influence within psychiatry and, more importantly, has had only modest effects on the delivery of medical care by physicians and other specialists. Recognition of its potential by planners and commissioners has been disappointing. Regrettably, in the UK and elsewhere, recent changes in the organisation of health care could hinder its development. This paper argues that in order to make substantial progress there is a compelling need to solve a fundamental obstacle – the separation between psychiatric and general medical care. This requires:

(a) convincing the psychiatric profession that consultation-liaison is a distinct sub-speciality;

(b) continuing efforts by liaison psychiatrists to define their special expertise and to demonstrate that their services are effective and acceptable to medical colleagues and to patients;

(c) persuading those who organise health care that liaison psychiatry services need to be provided and administered as an integral component of comprehensive medical care.

The use of illicit substances such as cocaine and heroin during pregnancy is common. Anonymous screening of consecutive urine samples testing positive for pregnancy from a UK inner-city clinic demonstrated that approximately 16% of the women had taken one or more illicit substances (Sherwood et al, 1999). The prevalence of drug misuse in the USA appears to be even higher: prospective screening of newborns in a high-risk urban population revealed that 44% of 3010 babies tested positive for opiates, cocaine or cannabis (Ostrea et al, 1992). The aim of this editorial is to emphasise the importance of this topic by describing the unfavourable effects illicit substances can have on both pregnancy and infant outcome. In addition, discussion of the evidence base for current management highlights the need for appropriately designed studies to optimise treatment and reduce morbidity.

Codes of ethics have existed for medicine since the time of Hippocrates. However, a written code of ethics (like a written constitution) has so far eluded British psychiatry. In this editorial we discuss the arguments for and against a code of ethics as an essential aspect of our identity as medical professionals. Our professional identity as psychiatrists is coming under scrutiny from the General Medical Council, the emergence of the user movement and the proposals in the draft Mental Health Bill. At a time when psychiatry is seen increasingly as a guardian of public safety, there has never been a more pressing need for a code of ethics.

When does a therapeutic intervention become an accepted part of standard clinical practice? Is it when there is sufficient research evidence? But what constitutes ‘sufficient’? What about available resources and acceptability to patients? Do we have to wait until the National Institute for Clinical Excellence pronounces? A convincing evidence base for family work in schizophrenia (Kuipers, 2000) has existed for many years but has been poorly implemented (Anderson & Adams, 1996). Will cognitive-behavioural therapy (CBT) for psychosis suffer the same fate? Which professional group will champion such an implementation? The evidence for other psychological treatments is less robust. Psychoeducation may prolong time to relapse and improve insight but at the cost of increasing suicidal ideation (Carroll et al, 1998). Personal therapy (Hogarty et al, 1997) may be of value but is contra-indicated for patients who are living alone in the community. Psychodynamic approaches are advocated (Mace & Margison, 1997) but most psychiatrists do not support their use in practice, owing to lack of evidence of efficacy.

Recent proposals for reforming the Mental Health Act show that the Government is keen to increase restrictions on current psychiatric patients and to extend the boundaries of psychiatric legislation. The proposals contained in the new Mental Health Bill (Department of Health, 2002) seem destined to make it easier to be subject to compulsory powers and more difficult to be rid of them.