One of the authors was asked recently why he was deliberately being ‘politically incorrect’ in writing about leadership in mental health services. Leadership, although considered essential to effective working by many professions and commercial organisations, has for years been very much out of favour in the NHS generally, among doctors in particular and, perhaps, among psychiatrists most of all. In part, the roots of such a prejudice lie in the tradition of consensus management which held sway throughout the first three decades of the NHS.

The general psychiatrist and the addiction specialist have a shared agenda of concerns and interests about the misuse of alcohol. The task of this paper is to highlight and develop thoughts on items for inclusion on the shared agenda, rather than to define, or limit in any other way, how the generalist role might unfold in a particular place at a particular time. It is certain that the general psychiatrist will see a role that is more than just signposting their own specialist colleagues, local counselling services, or self-help groups such as Alcoholics Anonymous, but opinion on just how broad that role could or should be will vary considerably. One point of difference may be a mismatch of views as to where patients with alcohol misuse problems are best treated: the general psychiatrist seeing alcohol misuse, or even dependence, as having little to do with general psychiatry and belonging within a specialist service, the specialist seeing alcohol misuse as very much part of the every day work of the general psychiatrist. Happily both positions can be correct, but not totally and not without dialogue.

Over the past 10 years or so, management has gained greater significance as a career choice for doctors. They see enormous opportunities to improve clinical care by having a greater say in setting the agenda of their organisation and directing the deployment of the local healthcare budget. While doctors have always enjoyed a position of major influence over the direction of the health service, real opportunities to operate as managers only became available in the mid 1980s with the implementation of the Griffiths Report (Department of Health and Social Security, 1983). Although mental illness hospitals had Medical Superintendents until the 1970s, professional hierarchies and consensus decision making, combined with incremental planning and an administrative culture, resulted in few opportunities for meaningful involvement of doctors in management.

Psychotic disorders in the elderly can be divided into three types: disorders that have started in earlier life and persist into old age; disorders that start de novo after the age of 60, and psychoses associated with brain disease, including the dementias. The classification of psychoses in late life has provoked controversy for nearly a century. The debate concerns whether schizophrenia can present at any stage of life or whether functional psychoses, arising for the first time in late life, represent different illnesses. The nomenclature of such disorders consists of numerous terms including late onset schizophrenia, late paraphrenia, paranoid psychosis of late life and schizophreniform psychosis. This plethora of terms has made research difficult to interpret.

JB is a 31-year-old man who has been described as having borderline intelligence/mild learning disability. (His overall IQ is difficult to assess, but has been estimated as around 70, or above.) Over the period of his childhood, he was assessed by numerous child psychiatrists and psychologists, all of whom agreed that he had a diagnosis of autism or some related pervasive developmental disorder, although his presentation was always described as ‘atypical’. The cause of his developmental disorder has never been established, despite the conventional extensive biological, genetic and other physical investigations (Gillberg, 1990).

This review considers the place of psychiatry in the complex area of management of the sexually abused child. A model is described in order to guide psychiatric perspectives in the field of child sexual abuse, before describing an approach to management in mental health teams.

The concept of autism has widened from the typical, classic or nuclear autism of Kanner (1943), to include those with the ‘triad of social impairments’ (Wing & Gould, 1979); that is impaired social interaction, communication and imagination which is associated with narrow, stereotyped, repetitive patterns of behaviour. These features make up the ‘autistic spectrum disorders’ and include Kanner's and Asperger's syndromes (Box 1).

Although common and disabling, depression in old age remains both underdetected and under-treated. This is particularly regrettable in view of its high risk of chronicity, recurrence and suicide, as well as the considerable burden of associated health care costs. Despite the availability of a variety of physical and psychological treatment options of well-established efficacy, there is little recent evidence of improvement in either clinical practice or patient outcome. An understanding of the principles of management of depression in elderly patients requires some knowledge of the differences between such patients and their younger counterparts. The clinical presentation and diagnosis of depression in old age, its epidemiology and prognosis are reviewed briefly below, before focusing on the practicalities of treatment.