The human search for tranquillity has embraced the use of numerous substances of which alcohol is probably the most widely used. Alcohol acts in part by facilitating neurotransmission at γ-aminobutyric acid (GABA) synapses and until recently the pharmacological treatment of anxiety was based principally on drugs that produce similar actions on this neurotransmitter and its receptor complex (Cowen & Nutt, 1982) (Box 1).

The treatment of anxiety is one of the more contentious issues in therapeutics. It is also one of the most important, as pathological anxiety is such a common symptom in the population. The recent Office of Population Censuses and Surveys survey of psychiatric morbidity indicated that one in eight of all those interviewed had an anxiety disorder of sufficient severity to receive a formal diagnostic label in the week before interview (Meltzer et al, 1994). Clearly, only a proportion of these should be treated with drugs, and selection for pharmacotherapy is one of the more difficult issues in clinical practice. It is a matter of some concern that changes in the National Health Service are increasingly shifting the onus of responsibility for treatment from the psychiatrist to the general practitioner. As a consequence, it behoves both disciplines to keep liaison active, so that best practice can be maintained from whatever source it is being provided.

Anxiety is a very common and disabling condition which has serious consequences for patients, their families and society in general. The past decade has witnessed an increase in the recognition and understanding of the problem but considerable confusion and debate remains over attitudes towards treatment. The background to this controversy dates from the late 1980s when widespread and vehement criticism of doctors and drug companies over the use of benzodiazepines began. Although the litigation was unsuccessful, it resulted in a pervading feeling of uncertainty (both within the medical profession and among patients) about prescribing or taking any drug as a treatment for anxiety. The situation has been further confounded by the split that has occurred between the proponents of pharmacological and psychological approaches to management. These controversies have left the practising clinician in an unenviable position, with few practical or relevant guidelines to follow. Developments over recent years, however, should put an end to this confusion; new pharmacotherapies such as the selective serotonin reuptake inhibitors (SSRIs) and buspirone, and older ones such as the tricyclic antidepressants (TCAs), have emerged as effective alternatives to the benzodiazepines and have been paralleled by a similar growth in effective and available psychological treatments, particularly cognitive and cognitive–behavioural therapy. This progress seems set to continue with the rapid expansion of knowledge about the brain circuits and transmitters regulating anxiety that is now emerging from imaging studies.

Until 50 years ago chronic pain was not considered to be a medical condition that required special evaluation and treatment facilities. Pain was considered to be an indicator of tissue damage and appropriate medical or surgical treatment was prescribed for this. The many patients who had continuing pain because of the results of disease or trauma or because acute treatment was unable to relieve the condition were not seen as suffering from a recognised pathological entity. It was not until a doctor, Sicilian-born John J. Bonica, had to pay his debts as a medical student through wrestling professionally, and later suffered persistent pain as a result, that chronic pain became a recognised condition in its own right. Bonica started a pain clinic in Tacoma, Washington State, in 1949 and wrote the first textbook on pain treatment, The Management of Pain, in 1953. There are now 2000–3000 pain clinics in the USA and almost 5000 worldwide.

Autism is a pervasive and life-long disorder that is characterised by profound deficits in communication and social understanding, together with ritualistic and obsessional behaviours and a general resistance to change. Although usually associated with additional cognitive impairments (approximately 50% of those affected have an IQ below 50) the condition can occur in individuals of all levels of ability, and around 20% of cases have an IQ within the normal range. Estimates of prevalence vary from 3.3 to 16.0 per 10 000 and rates may be even higher if children within the autistic wider spectrum are included (Wing, 1993, 1996). Understanding of causation is still limited, although genetic factors are now known to play a major role (Lord & Rutter, 1994).

Different cultures vary in their perceptions of mental illness (Karno & Edgerton, 1969), which can affect their utilisation of orthodox psychiatric facilities (Padilla et al, 1975; Sue, 1977). Mental health services may be seen by ethnic minorities as challenging the value of traditional support systems, reflecting dominant Western cultural values and harbouring implicitly racist psychological formulations. The clinician-patient interaction may become fraught with misunderstandings if the two parties come from different cultural backgrounds and bring distinct cultural expectations to the encounter.

The prime duty of specialist mental health services is to provide effective care to often non-compliant and unstable severely mentally ill (SMI) patients. Society expects such care to be humane and effective, but also demands that the severely ill are closely supervised to minimise risk to the public. Sadly, specialist services all too often fail on both counts. In part, this is due to the sheer complexity of care that is needed, going far beyond purely medical or therapeutic interventions. SMI patients have profound difficulties accessing and using everyday services and opportunities. Negative symptoms of apathy, self-neglect and low motivation, coupled with irrational beliefs and compounded by inadequately resourced and tightly rationed provision of social care, require mental health care services to be constantly active across areas of both medical and social provision. Services that ignore the importance of long-term, integrated care do so at their peril. A steady stream of disasters has been blamed on a lack of communication and coordination between agencies (Spokes, 1988; Ritchie et al, 1994), and follow-up studies of SMI patients managed by traditional hospital out-patient services repeatedly note a mismatch between levels of need and service uptake, with the least needy consuming the greater amount of service (Goering et al, 1984; Melzer et al, 1991).

This half-joking remark from the Specialist Adviser to a national mental health charity, sums up the dilemma every consultant faces from time to time: how to be all things to all people. What is more, it tunes in to our own sense of omnipotence. A recent review of ethics in psychiatry (Adshead, 1995) urged consultants to follow the four principles in practice: respect for the autonomy of the patient; beneficence (actively doing good); non-maleficence (avoiding doing harm); and the pursuit of justice – an incontestable but formidable remit.