I had acquainted myself with the psychiatric services in New Zealand some years ago during my student elective. I wanted to return to experience further a system which was both similar and different to the NHS. The New Zealand hospital system was funded in a similar way to the NHS. One organisational difference was the managerial layer, which was still filled by medical superintendents. Another difference was the extensive no-fault accident compensation scheme through which settlements were made without resort to lawsuits. Thus doctors paid low medical defence fees and were rarely sued, but the Government had regularly to meet a large bill. The psychiatric services were in the process of moving from hospital-based to community-based, in line with prevailing clinical and public attitudes. This was fuelled by some headline-making scandals over patient care in the asylums. One cause for general alarm was the poor health of ethnic minorities, especially the indigenous Maori. This issue resonated with racial and political overtones.

Professionals dealing with young drug misusers, those providing mental health services for children, and those providing services for adult misusers have roles that converge and overlap (though occasionally diverge). While services for adult misusers may have been developing at a reasonable (though not to everyone's satisfaction) pace, those for adolescent misusers have not.

The structure of mental illness services is changing rapidly. Large hospitals are closing or preparing to close and the service will be provided in other ways, partly by smaller units, partly by increased care in the community outside hospital and partly by amalgamations of two or more large hospitals. Smaller units allow closer working relationships with GPs, social workers and other professionals.

With growing concern – both professional and lay (Ashton, 1986; Lacey & Woodward, 1985) – about the adverse effects of long-term benzodiazepine use, many GPs are wondering how best to tackle the problem. In this paper, I describe a strategy adopted by a GP, CPN and psychiatrist (the author). This strategy centred around a meeting of all patients who had been taking benzodiazepines for over six months.

The term ‘liaison psychiatry’ is becoming increasingly popular. Indeed, the Royal College of Psychiatrists has set up a special interest group, the Liaison Psychiatry Group, which has a growing membership. There appear to be developments in training and in service provision but it is difficult to assess their clinical impact. Ongoing research is required to quantify the actual level of service provided to general hospitals.

Before commencing work on the Daily Living Programme at the Maudsley Hospital, in London, to compare the benefits of community care with standard hospital admission for patients with serious mental illness, a visit to Madison was arranged, where some ten years ago a similar study had been carried out (Stein & Test, 1980). We had the impression from the substantial literature which has appeared on the mental health service in Madison (Stein & Test, 1985) that they have implemented in practice their positive research findings on community care. It was felt that their lengthy experience with such a service could be beneficial to the UK, where such services are now being developed. This visit included PACT (Program for Assertive Community Treatment); a research programme investigating the long-term prognosis of mainly schizophrenic patients, and the various units of the mental health services in Madison.

There are two medical schools in Hong Kong, that of the University of Hong Kong and that of the Chinese University of Hong Kong. The former has a history of more than 100 years whereas the latter admitted its first batch of students only in 1981. Both use English as the teaching medium and both are recognised by the GMC. I received my undergraduate medical education in the former but have been teaching in the latter for seven years.

The nature, management and disposal of patients who present to casualty departments and receive psychiatric diagnoses by the assessing doctor are areas that have received scant attention by psychiatric researchers. The aim of this study was to analyse the records of such patients to see how they had been managed, in particular to document the degree of psychiatric intervention provided or offered, and to see what follow-up arrangements, if any, had been made.

The expression primary health care (PHC) gives the impression of an ensemble of control of communicable diseases, infant care, avoidance of insanitary personal habits and curbing environmental pollution. These indeed constitute the main elements of the scheme but are not exclusive to it. An integral but often ignored aspect is the community dimension of mental health whose importance is underscored by the fact that a significant majority of people in the third world live in rural areas with minimal or no access to formal psychiatric facilities. In this paper, I shall review the conceptual framework and practicality of primary health care with special reference to community mental health, highlight some notable limitations to policy execution and finally propose an organisational model structure for the community mental health services within the primary health care system.

The Community Psychiatry Research Unit at Hackney Hospital have established a support team for the care of people disabled by long-term mental illness living in the community. The work of the support team in coordinating and managing the care of their clients in supportive accommodation using a review system and an information package is described.

A method for estimating the psychiatric manpower needs of a district has been described in the Bulletin (Watson, 1986), and while the data presented in that article were for general psychiatry the approach to this issue can be modified for specialist services.

There is increasing recognition that people with a mental handicap who also suffer from psychiatric disorder will need specialised services. Those with major psychiatric disorders may need periods of hospital in-patient care but treatment as out-patients or day-patients may be more appropriate for those with neurotic disorders, behaviour or conduct disorders, problems of adjustment or personality problems. Many such psychiatric difficulties are amenable to treatment by therapies commonly used in general psychiatry. However, the treatment process can be prolonged and may need modifying so that there is always a ‘concrete’ or ‘practice’ base for handicapped persons who may have limited or no ability to conceptualise abstract ideas, although able to gain insight and modify their behaviour when taught appropriate skills and strategies.

In recognition of the fact that schizophrenia disorders remain a major public health problem presenting a severe limitation to the success of community-based approaches to mental health care, a programme was started in 1985 with the goal of developing family care of schizophrenia within the NHS.

There is now an extensive literature on benzodiazepines (over 18,400 publications since 1966), particularly regarding their addictive potential (Feely, 1988). The importance of this finding lies in prescribing as well as in the treatment of existing addiction. However, psychological factors are also important in the maintenance of addictive behaviour and one should not assume that all are recognised. For example, it is known that drugs are used to reward children employed by the pornographic industry and that sexually abused children can develop drug addiction (Burgess et al., 1984). There are now over 300 publications on child sexual abuse but none linking it with benzodiazepine addiction specifically. This is the first one.

The Mental Health Act brought a number of signficant changes to psychiatric practice. Among the most important were changes in the process of compulsory admissions. Other notable alterations have been a change in the definition of the nearest relative; a reduction in duration of treatment section by a half; a right to appeal against their detention by all patients; the observation section becoming an assessment and treatment section; the introduction of nurses holding power; the removal of age limits for admission of patients with psychopathic disorder and mental impairment, and the introduction of the treatability clause. These and other important differences could be expected to interact with social work and psychiatric practice to influence the number of compulsory admissions. Previous correspondence has examined this question, to which we add our findings.

With the increasing emphasis on community care (Turner, 1986) the psychiatric day hospital has been seen as an alternative (Tantam, 1985) or as a complement (Tyrer, 1985) to in-patient care. Associated with this is the development of new styles of working with patients such as the ‘multidisciplinary team’ with those looking after individual patients being referred to as ‘key workers’ (Watts & Bennett, 1983). In our day hospital the keyworker has considerable responsibility for history-taking, organising a treatment programme and communicating with other professionals, including writing the discharge summary.

There are national differences relating to compulsory admission to mental hospitals. As a visitor from Thailand, it was of interest to me (PK) to compare procedures relating to admission, treatment and aftercare of the mentally ill in England and Thailand. In Thailand there is no equivalent of the Mental Health Act 1983. Although there are some legal provisions affecting patients' rights in Thai law, there are no legal provisions concerning ‘detained’ patients in mental hospitals.

It was decided to plan the introduction of a benzodiazepine policy in North East Essex when the result of a health authority survey of all local general practitioners in 1986 revealed a substantial dependence problem among patients in the area.

To have been external examiner for the Masters Degree in Psychiatry (M Med) of the University of Nairobi for the last three years was an unusually stimulating opportunity, not only for a ‘busman's holiday’ (as my registrar called it) and a ‘good enough’ reason for a return to Africa, but it also enabled me to contribute again to training East African psychiatrists – a task which I first undertook in 1972 when a lecturer at Makerere University in Uganda. Because of the civil wars in Uganda, however, the Department of Psychiatry in neighbouring Kenya has now flourished and become one of the most substantial Departments in Central and Southern Africa. The Department, which includes one ‘full’ professor, two associate professors, four lecturers, two tutorial fellows, will soon have its own teaching in Kenyatta National Hospital as well as accommodation at the Mathari Mental Hospital, made famous by the pioneer observations of Carothers. In addition to its commitment to postgraduate training the Department provides three months teaching for other doctors taking an M Med in Medicine and Paediatrics and also teaches 150 medical students each year.