It was a day of quite intemperate heat as into our office in the Department of Applied Management Need burst an individual of some 40 years, perspiring as much, perhaps, from the heat and haste as the layers of clothing he affected. Beneath a pristine white coat he wore a pin-striped waistcoat and trousers, a starched shirt, striped tie and crimson kerchief fountaining from his breast pocket.

This paper by Gray & Fenn (1993) represents the first systematic attempt to put a cost on Alzheimer's disease (AD) in England. At a time when a large proportion of research effort in AD is directed towards the basic biology, it is an interesting and novel avenue for investigation. There are those who would say it is long overdue. The authors introduce the burden of illness analysis which is essentially a comprehensive attempt to cost the impact of a disorder. The analysis takes into consideration differences in the expression of disease – chronic, non life-threatening disorders rank relatively highly in loss of earning and health service costs but relatively low as a contribution to mortality. A number of concepts are explained which will be of interest to the non-expert, such as the difference between real resource costs, (e.g. payment for a service such as Attendance Allowance to a carer) and transfer payment (e.g. paying Income Support to an AD sufferer). Mortality rates (which give an equal weighting to a death independent of the age at which it occurs) are replaced by potential years of life lost – the loss of economic contribution to society being greater the younger the age of death.

The Substance Misuse Committee of the Mental Health Foundation has produced a booklet called Guidelines for the Prevention and Treatment of Benzodiazepine Dependence. The problem addressed is twofold: encouraging and managing withdrawal, and preventing new cases of dependence. There is no room for complacency because although prescriptions for anxiolytics have halved over the past ten years, prescriptions for hypnotics are unchanged – now twice the number for anxiolytics. The average GP can expect to have about 50 long-term benzodiazepine users on his or her list. The long-term safety of these drugs is uncertain and there are side effects, e.g. memory impairment, ataxia and falls in the elderly, and road traffic accidents.

A Confidential Enquiry has been set up to review cases of homicides and suicides by mentally ill people. It is appreciated that those looking after people with psychiatric illnesses have always been alert to the need to protect those in their care. However, the objective of the enquiry is to discover whether some of these distressing deaths might have been prevented by different approaches to clinical management or by different provision of care.

Give or take a few months, it must be 20 years since I led a College Study Tour Group on a tour of Italy, or, to be more exact, of the area north of Rome, economically privileged and steeped in the academic tradition from the Renaissance onwards.

Ann Barker

In the preface to the BNF you state that “comments and constructive criticism will be welcome”. I should like to ask a question. I should like to know how members of the Committee reach a decision on what dose should be considered the upper limit of medication, and in particular psychotropic medication, commonly known as “the BNF maximum”.

As part of winding-down from the Society for Psychotherapy Research's conference in Ravenscar and the Royal College of Psychiatrist's meeting in Cambridge on destruction, I went to see the award winning film Scent of a Woman∗. There was a synchronicity to this choice since in retrospect it seemed to me to reflect much of what was to be gained from the two conferences.

The recent release of British and American hostages held by fundamentalist Islamic groups in Lebanon has received national and international publicity. The Psychiatric Division of the Royal Air Force Medical Service has been involved with the management of released British nationals and others but, in the interests of the hostages and their families, has delayed public discussion of the matter. From the British and American viewpoint the recent hostage crisis in the Lebanon has now resolved. It therefore now seems appropriate to describe in general terms the principles upon which early management was based.

Section 57 of the Mental Health Act 1983 relates to certain forms of medical treatments for mental disorder which require both consent and a second opinion. It applies to any surgical operation for destroying brain tissue or for destroying the functioning of brain tissue; it also applies to the surgical implantation of hormones for the suppression of male sexual drive. These treatments cannot be given unless the patient has consented and three independent people, including a medical practitioner, certify that the patient is capable of understanding the nature of the treatment proposed, has consented to it, and the appointed registered medical practitioner has certified that the treatment is appropriate. This paper examines whether Section 57 is indeed justifiable and whether the current procedure needs amendment.

People's beliefs about illness, distress and disability profoundly influence their experience of, and responses to, such problems. Medical anthropologists have long recognised the importance of explanatory models of physical illness and the impact of these on the provision and use of health services. Similarly, psychological models of physical illness and related behaviour stress the importance of the ways in which people conceptualise or understand their difficulties. These are central in determining emotional responses to illness, help-seeking and illness-related behaviours, attitudes towards and compliance with treatment. Eisenbruch (1990) argues that, “the culturally constructed ideas held by the patient about the cause and nature of disease” are as important in relation to mental distress and disturbance. Help-seeking behaviour, attitudes towards and compliance with treatment are of central concern in psychiatry and all of these are influenced by people's understandings of their difficulties. Yet relatively little attention has been paid to the ways in which people conceptualise their mental distress.