Among the proposed changes in the current review of mental health legislation in England and Wales is the abolition of the right of the nearest relative to discharge patients from assessment and treatment orders (Sections 2 and 3 of the Mental Health Act 1983). We aimed to determine the clinical outcome of patients whose nearest relative applies for discharge. A retrospective case–control cohort study in a south London NHS Trust of 51 patients successfully discharged by their nearest relative and 33 patients whose nearest-relative applications were blocked by the treating psychiatrist on the grounds of ‘dangerousness'.

Patients discharged from section by their nearest relative did not differ significantly from controls in all the measures of clinical outcome examined.

This study suggests that discharges by the nearest relative against psychiatric advice are not associated with a poor clinical outcome.

The study aimed to identify the predictors of drop-out from clozapine treatment by examining the demographic and clinical characteristics of patients registered on clozapine within a 6-month period in one NHS Trust.

During the study period, 54 patients were registered and began clozapine treatment and 31% had discontinued within 6 months. Two people died and the remainder discontinued because of non-compliance or side-effects, including neutropenia. Two factors were predictive: the age of the patient (older patients were more likely to discontinue) and the hospital where the initial registration was made.

Neither ethnicity, previous registration nor the individual prescriber are a bar to successful persistence with clozapine. However, one set of hospitals with a history of evidence-based practice and high clozapine prescribing was more successful in retaining patients on maintenance treatment. Although specific data are needed to identify more subtle contributing factors to continuation, it is clear that there is scope for improving the rate of persistence with clozapine treatment.

The National Institute for Clinical Excellence (NICE) has issued guidance regarding the treatment of Alzheimer's disease. A postal survey of old age psychiatrists, geriatricians and neurologists was conducted to establish working practice pre-NICE and investigate expectations about the effect of this guidance.

The overall response rate was 26.3%. Old age psychiatrists prescribe the majority of drugs for the treatment of Alzheimer's disease. There was variation in the annual expenditure on such treatment. The main reason for non-prescription was a lack of funding. Over 80% of doctors thought that patients with mild disease should now be targeted for treatment.

In order to implement the guidance it will be necessary to address the issue of funding and have clear role allocation between local services.

Clinical governance implies a need to engage in a demonstrable form of clinical audit. We decided to pilot a pre–post-therapy questionnaire study, involving both therapists and patients, with the aim of assessing its feasibility as a routine measure of outcome in our service. Questionnaires were chosen to reflect both the symptom profile Clinical Outcomes in Routine Evaluation (CORE) and the general level of functioning Global Assessment of Functioning Scale (GAF). The patients were also questioned about their satisfaction with the therapy.

Of 53 eligible patient–therapist pairs, 26 patients and 19 therapists responded pre-treatment (overall 51% response rate). The mean (s.d.) CORE score per item was 1.93 (0.78), whereas the GAF score was 55 (15.2), somewhat belying the idea that psychotherapists only treat the ‘worried well’. The post-therapy response rate was poorer, rendering statistical analysis of change difficult to perform. The trend, however, was towards an improvement in both symptoms and level of functioning over the course of therapy.

Our patient group presents with a considerable degree of impairment. Although the response rates in this pilot study were poor, the data trend suggests that patients do benefit from the treatment offered. The aims of the study were met in that implementation of a clinical audit process within our department is feasible and the data are obtainable. The main interest, however, lies in what we learned from the process. We offer a dynamic and practical assessment of the impediments encountered, with implications for how these might be confronted.

To describe the outcomes of electroencephalography requested by general adult psychiatry over a 12-month period.

187 electroencephalograms (EEGs) were performed. In 71%, the request was to look for evidence of epilepsy. In 22%, it was to determine whether there was organic brain dysfunction. In only one patient was unequivocal evidence of an epileptic focus found. A further 11 patients demonstrated a liability to epilepsy. In none of the 33 patients where aggression was mentioned on the request form were any diagnostic features found.

The yield of EEG in psychiatry is low. To diagnose epilepsy, clinicians should continue to rely on the clinical history of attacks and not the EEG. The presence of aggression is rarely associated with meaningful EEG changes.

In this study we aimed to identify negative life events, especially those associated with repetition, in the background histories of patients in a 2-year prospective monitoring study of hospital-treated deliberate self-harm (DSH). Thematic analysis of the narratives recorded during assessment was used to produce general categories of life events.

In 3031 DSH episodes (n=2287 individuals), women reported more life events than men. Family and interpersonal problems were most commonly reported. Reporting a dysfunctional family of origin, a history of sexual abuse and the imprisonment of self or other were associated with repetition retrospectively and prospectively.

The background history of patients who harm themselves should be explored routinely on assessment in order to help establish risk of repetition and to determine appropriate follow-up.

To describe the characteristics and diagnoses of patients admitted to a general adolescent psychiatric in-patient unit. We describe the age, gender and psychiatric diagnosis of the patient, as well as whether the patient exhibited violent behaviour in the ward, whether he/she needed to be transferred to a different service and whether he/she was admitted under a section of the Mental Health Act 1983.

Patients were evenly distributed in terms of gender, with most being 14–16 years old. Diagnoses were varied with adjustment disorder predominating, but could be separated into four main groups. Levels of violence were high, being associated with detention under the Mental Health Act 1983, and often resulted in transfer to another service.

The needs of certain adolescents admitted to a general-purpose adolescent unit may not be best met in this environment. Current services must change to meet the needs of their patients. There may be a need for greater specialisation.

All mental health services are expected to aim for equality of access to people from minority ethnic groups. Psychotherapy services typically have a low proportion of ethnic minority clients. Specialist services such as therapeutic communities are no exception. It is also possible that ethnic minority residents are more likely to leave group treatments early if they are clearly in the minority. The study examined records between 1996–2000 to ascertain whether ethnic minorities show a different pattern of exit from the process than people from other backgrounds.

Just over 9% of referrals to Henderson Hospital were from ethnic minorities. Ethnic minority referrals were less likely to be invited to a selection interview. However, there was no difference in length of stay in treatment. There was a trend towards ethnic minority referrals having more severe symptomatology and histories than those from White backgrounds.

Ethnic background should be taken into account when considering referral for specialist psychotherapy. Routine monitoring of the processing of ethnic minority referrals should be conducted in all psychotherapy services.

Recent government legislation has highlighted the importance of implementation of the Care Programme Approach (CPA) within prisons, as part of the expectation that prisoners receive equivalent standards of healthcare to those provided by the National Health Service. To effectively plan the service provision at HMP Belmarsh, we retrospectively established the number of prisoners in a one-year period who would have fulfilled the criteria for enhanced CPA.

Of the 91 prisoners found to fulfil the criteria for enhanced CPA, the majority (77%) had a diagnosis of schizophrenia, schizoaffective or delusional disorder, and 58% required transfer to a psychiatric hospital. Of those who required hospital treatment, 75% needed conditions of high- or medium-security.

Successful implementation of the CPA for all prisoners who meet enhanced CPA criteria is likely to have significant resource implications, both for mental health teams working within prisons and local psychiatric services.

This study was designed to clarify the nature and extent of psychiatric provision that would be needed if a new health screening protocol were to be introduced into the prison system. The reception screening questionnaires for every inmate coming into the prison over a 15-week period were reviewed using the new protocol. A further mental health assessment was undertaken on those who had screened positive.

201 men (32.6%) were found to be positive for serious mental illness

Based on this analysis, large increases in psychiatric resources would not be needed if the proposed new reception health screening processes were in place, although a reorganisation of the way in which services are delivered may be required.

We observed a pattern of combining depot antipsychotic medication with the newer ‘atypical’ antipsychotics in forensic patients. We aimed to determine the prevalence and rationale for such ‘combination therapy’.

The medical records of forensic patients in 3 forensic hospitals in New South Wales, Australia, were reviewed and the responsible psychiatrists asked to explain the rationale for treatment of those patients on combination therapy.

Twenty-two per cent of the forensic patient population were receiving combination therapy. The reasons given for combination therapy were the presence of treatment-resistant illness, to ensure adherence to at least part of the treatment and to assist transfer to lower security units.

Such a high prevalence of a practice that is discouraged and without theoretical justification is a cause for concern. It appeared to reflect the practical difficulties of managing forensic patients.

To identify the proportion of arrested drug misusers with prior contact with treatment services, police surgeons' records were examined over a 12-month period and compared with the records of the local drug misuse services. Both referrals and those who attended with face-to-face contact were noted.

Sixty-seven per cent of drug-related cases had been referred to services prior to arrest and 58% had attended with face-to-face contact on at least one occasion. Homeless and male drug users were more likely to have had no past contact. Police surgeons treated three-quarters of the cases for opiate dependence. Drug misusers were much more likely to have had past contact with services than arrested alcohol misusers, and were more likely to reoffend.

The evidence base for motivational enhancement in the transient coercive setting of police custody is not established, and arrest referral schemes might not be cost-effective in areas where most cases have had previous contact with services. Local research may contribute to more informed decisions about these treatment-related criminal justice initiatives.

This paper compares the case mix and clinical activity in a specialist mental health service for deaf people within a general psychiatric population, using ICD–10 diagnostic criteria.

Out-patient and in-patient caseloads differ between the two services: 27% of the deaf out-patient caseload have schizophrenia, schizotypal and delusional disorders (compared with 19% of hearing patients) and 19% have neurotic, stress-related and somatoform disorders (compared with 8% of hearing patients). The general psychiatric service out-patient case-load had rates of 8% and 43% for bipolar affective disorder and unipolar depression, respectively, compared with 3% and 17% in the deaf group. Deaf patients have a mean length of stay of 59 days, compared with 30 days for the hearing group. In-patient treatment accounts for 89% of the annual treatment cost for the deaf patient population.

Expansion of community services for deaf people as recommended by a recent Health Advisory Service report could reduce admission rates for deaf patients, delivering treatment benefits and cost savings.

We aimed to assess the contents and tone of articles on mental health care in the UK print media by comparing them with reporting in the USA and Australia. Two broadsheets from each country were analysed using the Internet for a random 4 months over a 1-year period. The number of articles, their content and the views expressed in them were identified and compared.

A total of 118 articles on mental health care issues were found. The predominant tone of the articles in all three countries was negative, though there were slightly more positive articles in the USA and Australian media. Positive articles highlighted in the UK media covered mostly medical conferences and research findings.

Efforts to achieve a more positive attitude towards people with mental illnesses in the public, such as anti-stigma campaigns, operate against a background of predominantly negative coverage of mental health care issues in broadsheets. The coverage in the UK may tend to be even less positive than in the USA and Australia. Medical conferences and research findings can, however, be used to promote positive views of mental health care in the media.

To assess the attitudes of relatives of patients with psychosis to early diagnosis, the respective consequences and to specialised out-patient services for early detection, we undertook a postal questionnaire survey.

Eighty-five per cent of the respondents (n=200) would have visited a specialised out-patient service for early detection and 79% would have preferred to find out the diagnosis earlier. Some consequences of an early diagnosis (facing the problems associated with the illness earlier, having more appropriate behaviour towards the affected, earlier contact with other relatives and earlier treatment) are frequently mentioned.

Being favourable to both early diagnosis of psychosis and specialised out-patient services, most relatives are a useful source of support for professionals in convincing patients of diagnostic procedures and treatment.

A medical second opinion is an expert clinical case evaluation requested by a colleague for a patient already under specialist care. There is no literature on the provision for second opinions in psychiatric practice other than those relating to the Mental Health Act 1983, and the availability of clinics offering second opinions varies greatly from one area to another. We undertook a survey of an expert second opinion service in Leeds over the period 1988–2000 and examined the case notes of 103 referred patients, of whom 71 were included in the analysis data.

In the majority of cases diagnoses were not changed, but alternative treatment strategies were suggested. The exception was for patients with a diagnosis of personality disorder, in whom neither a new diagnosis nor alternative management was commonly suggested. Half of the assessments were completed in a single visit, but a substantial minority required further evaluation as outpatients, close follow-up or even hospital admission for detailed review.

We believe that a second opinion service offers clinicians valuable support and expertise, especially in sector psychiatry. Evidence presented suggests that further therapeutic options are available for many patients regarded as ‘difficult to treat’. In some cases this may involve a period of observation free of all psychotropic medication. As in other specialities, psychiatrists should be aware of the value of further advice for patients with particularly refractory or unusual disorders.

To estimate specific time and resource implications for professionals, if proposed changes to the Mental Health Act 1983 (England & Wales) in the Government's white paper were to be implemented unchanged. An audit of time spent on current procedures was extrapolated.

The amount of time required to comply with the Act will rise substantially (by 27% overall). Social workers and independent doctors will spend 30% and 207% more time respectively, complying with the Act, but psychiatrists providing clinical care to forensic patients should be largely unaffected.

If the Government presses ahead with its plans for mental health law reform as currently proposed, extra resources will be required to provide additional social work and independent medical time – or other services for patients will suffer.

Prescribing of venlafaxine in The South London and Maudsley NHS Trust was found to account for over 50% of the antidepressant costs, but only 15% of the prescriptions. There is evidence to suggest that higher doses of venlafaxine may be effective in treating treatment-refractory depression. We aimed to discover if higher doses of venlafaxine used in the trust were related to prior failure to respond to antidepressant treatment. Hospital in-patients being treated with venlafaxine during a 1-week period in October 2001 were identified and case notes were reviewed to determine patient demographic data and prior history of antidepressant therapy.

There were 38 patients identified as being prescribed venlafaxine (18 of whom had a primary diagnosis of depression). Twenty-five were classed as non-treatment-resistant and 13 were classed as treatment-resistant. Doses of venlafaxine were statistically significantly higher in patients considered treatment-resistant (245 mg v. 180 mg daily, P=0.03). All other recorded patient characteristics were similar.

Higher doses of venlafaxine were prescribed to patients who were retrospectively defined as treatment-refractory. Further studies should address the reasons for this prescribing practice.