For the purpose of this article, I am using a definition of whistle blowing which was used at a conference in November 1995 at the Royal Society of Medicine:

Hostage situations differ greatly – in the aims and goals of the hostage-takers, the frequency and intensity of maltreatment, the type and quality of conditions, the duration of captivity, and the processes by which they are ultimately resolved and concluded. Although there is a paucity of research-based data about hostage reactions, clinical management, and outcome, there are general descriptive accounts in the medical and popular literature. A number of key texts are highlighted in the references, and examples of different conditions are briefly summarised in Box 1.

Hyperkinetic disorder is the generic ICD-10 (WHO, 1992) term used to describe one of the most common childhood psychiatric disorders. It is a severe form of a syndrome which is referred to in DSM–IV (APA, 1994) and the American literature as attention deficit hyperactivity disorder (ADHD). Hyperactivity or hyperkinesis can be defined as “an enduring disposition to behave in a restless, inattentive, distractible and disorganised fashion” (Taylor, 1994). It is thus more than motor overactivity. Diagnostically there are three main groups of symptomatology: overactivity, inattentiveness and impulsiveness.

This article is an extended consideration of a recent editorial (Parker, 1996), and seeks to argue the importance of studying both onset and trajectories of improvement in those with depressive disorders.

1994 saw the publication of the report of the Mental Health Nursing Review Team (Department of Health, 1994). This report signified the end of a three year process where mental health nursing was examined from the perspectives of practice, education, research and management. The last review of mental health nursing took place in 1968, but since that time there have been enormous changes in our thinking about mental illness, in the delivery of services and a number of very exciting developments in treatment. The review process included the widest possible consultation with other professionals, user organisations, patients, relatives and carers. It also co-opted expert advisers and took written and oral evidence, and visited clinical services across England. There were altogether 42 recommendations and during this article reference will be made to a number of the most important of these.

Risk assessment is in vogue clinically and politically. The term is used in two ways. It refers to a method of balancing probable consequences of decisions which formalises the decision-making process. In psychiatry, it usually refers to the same method focused on the current clinical practice of assessing the risks of harm to self or others.

It is appropriate to be writing about psychiatric training in Europe as the joint meeting between the Royal College of Psychiatrists and the Association of European Psychiatrists is being planned for July 1996.

Somatisation remains a matter of bewilderment in medicine. Medical students have trouble defining it, psychiatry trainees wilt in its presence, and all doctors are prone to become entangled in it. The current spate of reviews on the topic is appropriate (Mayou et al, 1995a; Barsky, 1996; Gill & Bass, 1996). There is a great need for those required to manage patients with ‘medically unexplained symptoms’ to be informed sufficiently to take a stance on the theoretical issues involved and develop appropriate management plans.

A 25-year-old Bengali man was taken to casualty by relatives who were concerned about his unpredictable and dangerous behaviour. He lived close to his parents and five younger siblings, and there was no family history of mental disorder.

The treatment of acutely disturbed patients is a stressful area of psychiatric practice. Castle et al (1994) found that MRCPsych Part II trainees expressed a general dissatisfaction with training in the management of violence, and in our experience junior trainees are even less confident in the treatment of the disturbed patient. A survey by Cunnane (1994) found that no consensus exists among consultant psychiatrists on which drug treatment is most appropriate for the management of the aggressive, acutely disturbed psychotic patient. There was uncertainty as to optimal management, low expectation of quick results, unwillingness to express an opinion and the use of drug cocktails of dubious rationale.

The last 20 years have witnessed a surge of interest in assertive community treatment (ACT) for the severely mentally ill (Drake & Burns, 1995). ACT aims to help people who would otherwise be in and out of hospital on a ‘revolving door’ basis live in the community and enjoy the best possible quality of life. Services based on the ACT model seek to replace the total support of the hospital with comprehensive, intensive and flexible support in the community, delivered by an individual key worker or core services team. They are organised in a way that optimises continuity of care across different functional areas and across time.

Social, cultural, emotional and biological influences determine whether people drink to excess and whether they then experience harm or cause harm to others (Cook, 1994). Psychosocial treatments for alcohol dependence are only modestly successful, with most studies finding that at least 50% of patients return to harmful drinking in the following year. In the past decade there has been new evidence for the role of pharmacological treatments in reducing harm from drinking and in preventing relapse.

The severity of anorexia nervosa can vary from mild to life threatening. It is sometimes transient but often chronic. Such variety of disorder requires variety of response. The clinician must choose the right treatment to offer at the right time. The literature contains plenty of advice but most of this is based upon experience and opinion rather than on systematic research and treatment trials. For the most part, this paper will be no exception. Anorexia nervosa is a disorder which is distinct from other psychiatric syndromes but is of uncertain cause. In the face of this uncertainty, treatment tends to be informed by the favoured formulation of the clinician, usually some sort of ‘multifactorial theory’. Again this paper is no exception. It will concentrate upon the management of anorexia nervosa in late adolescence and adulthood. The treatment of children requires a different approach (Lask & Bryant-Waugh, 1993). The emphasis of the paper will be upon what can go wrong as well as what may be the best interventions to offer. Often the things that go wrong have more to do with the context of treatment and the way in which it is offered rather than with the treatment intervention itself.

There has long been considerable individual variation in the regimes for managing acutely disturbed patients, in terms of the drugs used, routes of administration and the dosages given. We all tend to learn from ‘accepted’ practice in the units in which we train, and the lack of good-quality controlled trials, published in leading and accessible journals, compounds the problem. Given the importance of this issue, when concerns about sudden death in the context of high dose regimes are generating considerable publicity (for example, MIND is calling for a blanket ban on dosages greater than those given in the BNF), the need for rigorous research has never been greater. Guidelines have, however, become established in a number of units, and this clear summary by Macpherson et al is therefore to be welcomed.

It is the intention of the Editorial Board to establish dialogue, discussion, debate and even dispute among our readership and we aim to publish correspondence, however derogatory! With this issue we are adding another contribution to the possibility of debate by having an item called ‘Commentary’ for some of the papers. The commentator will usually come from a different discipline or subspeciality from the original author and will therefore give the matter under discussion a different slant. We hope our commentators will be controversial or will at least produce some new ideas and perspectives. This will give another side to the arguments and discussions of treatment and will also expand particular areas. It is the nature of the article itself which will dictate the content of the commentary. We hope that this will make the journal both more lively and informative.

Prevalence and incidence rates of dementia in people under the age of 65 are difficult to determine. Surveys differ in design, examine different population samples and include varying levels of disease in estimating rates. Most of the surveys are small and are conducted through case note review.

It is difficult not to be won over by the description of assertive community treatment that promises nearly total caring for the most chronically disabled mentally ill, including “the material essentials of life such as food, clothing and shelter, coping skills necessary to meet the demands of community living and motivation to persevere in the face of life's adversity”. If we keep in mind that this approach is for patients who in previous decades would have spent their life in a mental institution, one can readily justify the transfer of expense and resources to this hopefully more humane form of treatment which allows patients to live within the context of open society, a preference they inevitably opt for when surveyed after a move from hospitalisation to community care.