Professor Gournay's commentary on the issues and roles in mental health nursing could equally have been titled: situation and process, skills and experience, genericism and specialism, clinical and eclectic, or proactive and preventive. His research review supports a viewpoint at the structured/tested end of this continuum, where he sees ready evidence that nurses now require clinically focused training and re-training if they are to provide care and treatment for patients with the most seriously disabling mental illnesses. This reinforces the Butterworth Report's conclusions, the Health of the Nation's expectations and the specifications in Building Bridges.

The first target of the government's mental Health of the Nation strategy is to improve the health and social functioning of mentally ill people. Most health service professionals would agree with the implication that there is substantial room for improvement. It is as important to be aware of the extent to which a service is failing as it is to know that needs are being met.

This paper explores the range of expectations of psychiatrists held by those in general management in the health service.

In most Western countries, including the UK, comprehensive mental health services are predominantly funded from State resources. The role of the psychiatrist has changed in the past 20 years and will without doubt change further in the next 20 years. Expectations of psychiatrists have changed and will continue to do so. We take the position that psychiatrists should continue to have the major leadership role in mental health and in so doing must become increasingly responsive to the changes taking place in health care planning and provision.

Ten per cent of the general adult population have a diagnosable personality disorder (Zimmerman & Coryell, 1990) and in 4% this is clinically severe (Tyrer, 1988). The clinical management of such patients may be difficult. However, much clinical difficulty is generated by interpersonal aspects deriving from the particular interaction of the patient and psychiatrist involved and the respective roles they play.

The forensic psychiatry of learning disability is a subspeciality which exists on the ‘borderlines’ between other areas. It takes in information from forensic psychiatry, learning disability, child and adolescent psychiatry, psychology, genetics and pharmacology to name but a few.

In many ways cognitive and behavioural therapies represent the acceptable face of psychotherapy for the general psychiatrist. They are brief, focused, problem-oriented treatments, which take symptoms seriously. They show an affinity for the medical model in their acceptance of diagnostic categories and their commitment to effective evaluation of treatments through randomised controlled trials. The wide applicability of these therapies is also attractive to the general psychiatrist. Cognitive and behavioural techniques are of major importance in the treatment of anxiety disorders, depression, eating disorders, and sexual dysfunctions, and beyond this core group the methods can be applied to enhance coping and change unwanted behaviours in conditions as diverse as cancer, chronic pain, substance abuse, anger control, schizophrenia, and challenging behaviours in people with learning disabilities.

The first line of treatment for patients with psychotic disorders such as schizophrenia is neuroleptic medication. Neuroleptics have provided substantial benefits to patients with this type of severe mental illness since their discovery as a treatment for psychosis in the 1950s. Despite this, there are still a large number of patients who do not respond fully to neuroleptic medication or who are not able to tolerate it. For example, although as many as 70% of patients are substantially improved following drug treatment, a considerable proportion continue to experience persistent, distressing and recurrent symptoms. In a survey of patients in a London psychiatric hospital, Curson et al (1988) found that just under half of the patients continued to experience hallucinations and delusions despite the prescription of medication. In addition, many patients experience intolerable side-effects or do not wish to comply with neuroleptic medication, yet look for some effective alternative. Depression, anxiety and a high rate of suicide are additional problems faced by patients with schizophrenia.

Although a rare form of ‘lethal’ catatonia, involving high temperature and rigidity, was first described long before the advent of neuroleptic drugs, Delay's description of a syndrome malin in 1960 is usually regarded as the first recognition of this syndrome. Over the next 20 years the number of case reports grew and the appearance of reviews such as Caroff's in 1980 marked the birth of the neuroleptic malignant syndrome (NMS). Reports of its incidence give variation rates of up to fiftyfold, possibly due to differences in diagnostic criteria, and mortality reports are similarly variable. Although it is debatable whether it is a rare, severe idiosyncrasy or one of many neuromuscular side-effects of dopamine antagonists (Levinson & Simpson, 1986), most clinicians nowadays regard it as a serious but recognisable risk of neuroleptic treatment which merits further attention.

Since the formation of the College in 1971 and the introduction of the examination for membership of the College in 1973, preparation of candidates for the examination has been subject to a wide range of influences which have shaped all aspects of psychiatric training. Possibly the most important factor has been the consensus that membership of the College should mark the end of general training and the beginning of specialist training in psychiatry. This is in contrast to some similar diplomas which may be required as an entry qualification to postgraduate medical training (e.g. MRCP) or others which may mark the end of specialist training and be awarded only shortly before achieving consultant status (e.g. MRCPath).

Electroconvulsive therapy (ECT) is a long established form of treatment for specific, serious mental disorders, but one which is still surrounded by much misunderstanding and fear. The use of electrical current administered to the brain to ‘treat’ illness remains a barbaric concept to many people. Much research has been conducted to establish the efficacy of ECT, which is now widely accepted. However, the working principles of the ECT machine itself are little understood, and more research remains to be done to establish, more scientifically, which is the ‘best’ way to administer the electrical stimulus. With the recent introduction of the concept of “stimulus dosing” (for a review see Lock, 1994), the need to be aware of the ECT machines available and their abilities and limitations is important.

This article discusses the misuse of drugs which act as stimulants, an effect mainly produced by enhancement of the central transmission of catecholamines, particularly dopamine. Stimulant misuse is extremely widespread in the UK and elsewhere, but primary users of such drugs present relatively rarely for treatment at drug services. At present such services mainly see heroin users, not only because the greater addictiveness of heroin produces generally higher levels of problems, but because a substitute treatment can be used in that group in the form of methadone.

Comorbidity and dual diagnosis have a fashionable, and thus ephemeral, ring that belies their relevance to day-to-day practice. The topic has been increasingly addressed in North American literature where there is a recognition of the extent of substance misuse in the severely mentally ill, and the need to find ways of effectively managing its consequences. Substance misuse may colour the diagnosis, management and prognosis of major mental illness and can adversely affect the relationship between staff and patients. Despite its common occurrence, it frequently remains undetected (Ananth et al, 1989). With burgeoning research interest, there is some consensus as to how to manage the problem, but, as yet, little agreement on the precise nature of causal relationships.

Historically, depressive disorders in adolescents have been conceptualised as variants of the nonspecific class of childhood emotional or neurotic disorder, which encompassed depressive, anxiety, hysterical and obsessional disorders. Over the past decade, however, the field has shifted towards greater diagnostic refinement. Research evidence has shown that severe depressive disorders differ from other mental disorders in this age group in their epidemiology, outcome and correlates (Harrington & Wood, 1995). Treatment therefore includes not only general techniques of clinical management, but also a variety of treatments targeted at the symptoms of depressive disorder.

People with mental illness have always been marginalised and economically disadvantaged. Warner (1987) has shown that this is particularly true in times of high unemployment. Poor inner-city areas have excessive rates of severe mental illness, usually without the health, housing and social service provisions necessary to deal with them (Faris & Dunham, 1959). The majority of those who suffer major mental illness live in impoverished circumstances somewhere along the continuum of poverty. Homelessness, however defined, is the extreme and most marginalised end of this continuum, and it is here that we find disproportionate numbers of the mentally ill.

Three recent advances have increased the importance of obsessive–compulsive disorder (OCD) for the general psychiatrist. It is a more common disorder than previously realised, there are effective treatments, and the basic neurobiological substrate for the condition is being identified. This review will consider these advances but focus mainly on the practical aspects of assessing the condition and planning treatment.

Most clinical psychologists and psychiatrists already work together constructively and cooperatively, although guerrilla warfare may descibe the situation in some areas. This outline of issues affecting work with clinical psychologists, looking not only at a mutual awareness of each others' profession-specific knowledge and clinical skills, but also at an understanding of mind-sets and value systems, is aimed at further improving working effectively together, while not glossing over actual and potential areas of role-confusion and conflict between the professions.

For centuries the conditions existing in institutions have been a cause of concern. Accompanying this has been a drive to improve the quality of care in such places. Until the second half of this century younger patients constituted the majority of the mentally ill residing in institutions. Now the balance has shifted and considerable numbers of elderly people, particularly those suffering from dementia, are residing in institutions (hospitals, nursing and residential homes). Perhaps never before has the question “What makes a good environment for the demented?” been so important.