People with learning disability and behavioural disturbance can be difficult to treat in the community, frequently requiring specialist in-patient assessment. The impact which a new community-based ‘challenging behaviour service’ has had on a district's in-patient bed use is described.

There has been a great deal of debate and uncertainty about the role of day hospitals. The current emphasis is on their use as an alternative to acute-in-patient care. There are, however, difficulties with this approach. This paper looks at developments in service provision in a day hospital in Northern Ireland, where the focus is on multidisciplinary assessment and group and sessional treatment, rather than day care.

We reviewed all 112 suicides and self-harm open verdicts in Central Nottinghamshire between 1987 and 1991. The rate of consultation with general practitioners of completed suicides was similar to control patients a year before death. It then increased during the succeeding months, particularly in the month before death, when 41% consulted their general practitioner. A further 12% saw another doctor in their last month. Those who did not consult were more likely to be middle-aged, male, divorced or separated, to have experienced a recent broken relationship, and to show evidence of planning the suicide. Better awareness may have detected and possibly prevented some suicides in consulters. Those who did not consult a doctor had different characteristics. Additional strategies would be needed to prevent these deaths.

Formal teaching in ethics is neglected in psychiatric training. This paper takes a practical approach in outlining ethical issues relevant to different stages of a research project. It is suggested that whatever the scale of the research, it is important to examine the ethical issues which surround the development of a project, as well as those which are integral to the protocol.

Assessment of patients referred for psychotherapy has more commonly consisted of a psychodynamic assessment with less emphasis on a formal psychiatric diagnosis, whereas the reverse tends to be the case in the general psychiatric services. Within the National Health Service there are close links between the two services. A common frame of reference regarding the definition of the patient groups using the services could Improve communication, the planning and evaluation of specific treatment programmes, and outcome studies. A retrospective case-note study was carried out at a regional psychotherapy unit in order to define the population referred between 1991 and 1992 according to ICD–10 (WHO, 1992).

The Joint winners of the second Merck Essay Prize for 1994 were Drs Andrew Smith and Swaran Singh. Their essays are published below. The number of entries was 15.

Depression is the commonest psychiatric disorder in the industrialised world. Many patients are now diagnosed and treated with effective antidepressants by primary care physicians. A large proportion of depressed individuals fail to reach their premorbid level of functioning following a course of treatment; estimates vary from 10% to 30% (Nierenberg & Amsterdam, 1990). These individuals require a major input from the services and suffer prolonged distress, with many adverse personal, social and economic consequences.

The notes of 24 individuals attending a clinic for people with learning disability and epilepsy were reviewed for all visits in the year preceding and following the Implementation of medical audit standards for out-patient review. There was no deterioration in any standard. A significant improvement was seen in recording of seizure frequency by seizure type, legibility of signatures, regular letters to general practitioners and the recording of seizure type and frequency in these. Medical audit can improve standards in epilepsy care, though its influence on outcome is not known.

It has been common knowledge that professional carers in the community, institutions, and perhaps also in hospitals lack appropriate training in issues related to mental health problems in the elderly. Many crises in the community appear to be precipitated not so much by the gravity of the problems the elderly pose, but by panic or the fear of the unknown among the carers. Arie et al (1985) postulate that the joint teaching of different professions can be a fruitful training for subsequent team work, while Beynon & Croker (1983) reported that shared tutorials in geriatrics at the Middlesex Hospital in London were very successful. The negative features of institutionalised care can be counteracted through training and management (Wilkin et al, 1985).

Psychiatric trainees' knowledge and understanding of the therapeutic principles underlying the appropriate use of psychotropic medication comes from many sources. They receive a grounding in neuropharmacology as a medical student and this is updated and expanded by attendance at a university lecture course in preparation for the MRCPsych examinations. Practical advice is handed down by supervising consultants and is augmented by reference to standard textbooks and research literature. Pharmaceutical representatives occasionally provide useful information though this may be biased, concentrating on specific drugs in isolation and without comparisons to competitors. Because of the variety and uneveness of these sources there is a risk, especially in the earlier years of training that knowledge is patchy, impractical or unsoundly based on dogmatic or out of date advice. There have been calls for training in psychopharmacology to be improved and suggestions as to how this may be achieved (Ferrier & Cooper, 1994). This paper describes the clinical pharmacy services in Fife and their value in improving the knowledge and practice of therapeutics amongst psychiatric trainees.

Publications in the Psychiatric Bulletin have highlighted trainees' interest in part-time training and described different kinds of part-time training, but the feasibility of working as little as four hours a week has not been addressed. I have made unusual use of a Retainer Scheme for Doctors with Domestic Commitments to support part-time psychiatry in a general practice setting. This has proved a useful short-term option for bridging a career gap.

Thought disorder, perhaps the most telling symptom of schizophrenia, presents itself in an infinite variety of ways. This ranges from unintelligible gibberish on the one hand to far more subtle disturbances on the other, disturbances which in other circumstances might be construed as examples of donnish games with twisted logic. Here is one that sticks in my memory.

The term Afro-Caribbean is used to describe black people of Caribbean origin in Britain. Migrants from the Caribbean, their children and their children's children are all covered by this term. The group as a whole is reported to have a higher incidence rate of schizophrenia than white groups, (King et al 1994), and British-born children of Caribbean parents have an even higher rate (Harrison et al, 1988). These reports have led to the hypothesis that Afro-Caribbeans may have a special vulnerability to schizophrenia. While limitations to these studies have been identified, (Wessly et al 1991) none has sought to question the use of the term Afro-Caribbean as a valid and reliable ethnic grouping. If we are to be able to produce good hypotheses for the aetiology of the reported increases in incidence, or to produce research which is useful to Black and ethnic minority groups, we need a clear understanding of the people under study.

The political and economic changes in Russia in the last five years have been enormous, however, Russian psychiatry remains isolated from the mainstream. This isolation started in the aftermath of allegations in the seventies about the misuse of psychiatry, and has been exacerbated by recent economic uncertainty. I was therefore interested to receive an invitation to stay with a Russian psychiatrist for a week in September 1994, to investigate the possibilities of research collaboration between the Institute of Clinical Psychiatry in Moscow and the Department of Psychiatry in Southampton.