There is increasing concern about the relationship between medicine and the pharmaceutical industry. In July the BMJ devoted a themed issue to this, and critical discussions have featured in other leading medical journals recently. The industry has grown in profitability and influence over the past 20 years, and is now second only to armaments in the US economy (Public Citizen, 2002). Its influence is enhanced through its control of research, and it employs sophisticated and wide-reaching marketing strategies. This level of influence is concerning because the private investment necessary to enable drug development demands ever more vigorous struggles to maintain and expand market presence. In other words, commercial rather than clinical or scientific demands are becoming the dominant driving force for ‘innovation’. This leads to the popularity of developing cheaper ‘me too’ options, and the promotion of new ‘disease concepts' to allow the re-badging of old products to expand markets without major development costs.

There was a time in my life, not that long ago, when I could have given a very simple answer to this question. Where would I have been without pharmaceutical companies, specifically without Wyeth? Life was terrible with the pills, but I dared not contemplate it without them.

It is timely to review the relationship between the pharmaceutical industry and psychiatry, given the continuing move towards more evidence-based practice in medicine, as well as two recent government initiatives to improve the value of research in the National Health Service (NHS), especially research that is commercially driven.

There is increased recognition that the role and function of a consultant psychiatrist is ill-defined and associated with excessive workloads, low job satisfaction, high levels of stress and high rates of premature retirement (Kennedy & Griffiths, 2001). This has led to an examination and debate about how consultants in general psychiatry could adapt models of working to address these difficulties, and also face the agenda of change facing the NHS as a whole and the mental health services in particular (Kennedy & Griffiths, 2001; De Silva & Sutcliffe, 2003). These challenges are not, of course, unique to general psychiatry, but as yet, there has been little debate about how consultants in other specialities, including old age psychiatry, could begin to try and address these difficulties. This article aims to stimulate debate, by describing an adapted model of working adopted by two consultants in old age psychiatry within the Hull and East Riding Community Health NHS Trust.

Physicians caring for people with severe learning disabilities are frequently faced with the problem of self-injurious behaviour, which often takes a chronic course. Among neurotransmitter systems the serotonergic system in particular is thought to be involved in the initiation and maintenance of self-injurious behaviour, and pharmacological treatment with serotonin enhancers or serotonin reuptake inhibitors has been shown to reduce impulsive aggressive behaviour.

There has been an increasing awareness of the usefulness of psychotherapy as a treatment modality for people with learning disabilities and mental health problems over recent years. However, the difficulties involved in providing appropriate training and supervision in this field has resulted in a patchy and erratic development of service provision nationally (Royal College of Psychiatrists, 2004). A review by Hollins and Sinason (2000) of all the available published evidence found that nationally there was inadequate availability of psychological treatments for people with learning disabilities, that there had been few outcome studies published and most of the literature consisted of single case studies. They recommended that ongoing clinical audit, using standard outcome measures, should be part of learning disability psychotherapy service protocols, and that psychotherapy training and supervision should be made available to health and social care practitioners in the learning disability field.