Policy and practice in the cart of people with a mental Illness has been changing radically for many years. This article draws attention to the Important role doctors can play in Influencing the development of central policies and to the need for leadership, including leadership by doctors, in developing a mental health service for the next century.

People with learning disability and behavioural disturbance can be difficult to treat in the community, frequently requiring specialist in-patient assessment. The impact which a new community-based ‘challenging behaviour service’ has had on a district's in-patient bed use is described.

Clinical Practice Guidelines (CPGs) are systematically developed statements to assist practitioner and patient in clinical decisions about appropriate health care for specific clinical circumstances. The Royal College of Psychiatrists CPG Programme aims to develop clinical guidelines which are scientifically valid and acceptable to those affected by them. At the same time, CPGs must be responsive to advances in knowledge, and versatile enough for the demands of routine practice. Their development involves a number of stages and a variety of methods, built into a cycle of evaluation and review. The Programme has established priorities for clinical topics for CPG development through consultation with the mental health community. Well-developed CPGs would benefit clinicians, patients and purchasers of care. It Is now important to appraise their ability to change clinical practice, the associated direct and indirect costs, and their value as a medical technology. The clinical professions are in the strongest position to co-ordinate their development, and guide their evaluation.

One hundred and nine consultant psychiatrists completed an anonymous questionnaire on the suicide of patients In their care. A patient suicide was reported by 82%, of whom 47% had experienced their first patient suicide within five years of entering psychiatric practice. A formal review of the suicide had occurred in 24% of cases. The study examines the perceived effects of their first patient suicide on the professional practice of the respondents, and measures the personal stress related to it, using the Impact of Event Scale. We discuss the implications of this common experience for psychiatric training programmes.

There has been a great deal of debate and uncertainty about the role of day hospitals. The current emphasis is on their use as an alternative to acute-in-patient care. There are, however, difficulties with this approach. This paper looks at developments in service provision in a day hospital in Northern Ireland, where the focus is on multidisciplinary assessment and group and sessional treatment, rather than day care.

To avoid identifying patients with a class while classifying disorders, DSM-IV specifies that it will not use such expressions as a schizophrenic but instead will use the designation an Individual with schizophrenia. This review aims to explore the sociolinguistic connotations of various designations used for patients suffering from schizophrenia. An analysis of these designations from six perspectives, using conceptually different sociolinguistic paradigms, systematically supports the DSM-IV comment. Further research is required into the social impact of the language of psychiatry.

Actual and perceived safety of male and female in-patients in an inner-city psychiatric hospital were examined. Using semi-structured interviews, 59 inpatients were asked to report on their direct experiences of physical or sexually threatening behaviour towards them during their admission. Of the sample, 75% reported unwanted physical or sexual experiences: female patients were significantly more likely than males to report sexual harassment. Most incidents were not reported to staff and both staff and patients appeared to perceive the ward environment as safe despite fairly high levels of verbal and physical aggression. This study has implications for the way that ‘violent incidents' in psychiatric hospitals are defined and recorded and raises questions about the provision of women-only space in hospitals.

The coils of operating a psychiatric intensive care unit (PICU) were recorded for a six-month period. There were 110 admissions and 99 discharges. Mean length of stay was 12.3 days. Total costs were £346,516 over the study period, £283.56 per patient-day. Fixed costs comprised 93% of the total, inducing nursing staff ($169,447), overheads ($77,017), medical staff ($48,819), hotel costs (£24,160) and miscellaneous (£1,750). Variable costs included special nursing, (£19,405), treatment of major self-harm (£3,024), drugs (£1,707) and staff time to manage aggressive incidents (£1,188). Reduction of the incidence of aggression could result in valuable cost savings.

Community mental health teams are handicapped by long-standing ambiguities about responsibility and accountability. Professional responsibilities need to be separated from practitioner's responsibilities as employees, and clear lines of accountability established accordingly. This requires stronger delegated operational management responsibility at team level. Greater attention should be paid to defining shared, core responsibilities among team practitioners employed by health and social services. These are here defined as ‘care coordinating’ responsibilities and provide a means of reconciling the care programme approach and care management into coherent practice.

We surveyed 119 psychiatrists to see how they would act with a patient who has taken a potentially lethal overdose, has no mental illness, and is refusing treatment. There was substantial disagreement. There may be a risk of action under civil law whether the psychiatrist decides to treat the patient without his or her consent or not. The Law Commission are examining whether mental disorder, as defined in the Mental Health Act 1983, should be used as a test of Incapacity to give consent to medical treatment. Such legislation would help doctors but may encourage a wide interpretation of the definition of mental disorder.

Clozapine is effective in treatment resistant schizophrenia, but unfortunately is associated with a 3% incidence of neutropenia. Regular haematological monitoring is mandatory for all patients. We asked forty patients who had been taking clozapine for more than six months why they thought they had to have regular blood tests. Almost half did not know and only a small proportion were subject to a Mental Health Act (MHA) second opinion for consent to treatment. Initial explanations of the potentially serious side effects of clozapine may not be understood or retained. Ongoing education of patients is essential. The wider use of MHA second opinion doctors should also be considered.

This paper puts the case for accessible multidisciplinary mental health services for children and young people to managers, purchasers and GPs, in a framework of national and international statutes and guidance. The essential differences between the disciplines are explained, based on detailed advice from mental health colleagues in nursing, teaching, social work, psychology, child psychotherapy and child and adolescent psychiatry.

The shift of power from specialist services to the primary care teams has forced the former to examine the value of their hallowed traditions. In psychiatry, and geriatric medicine, the catchment area is a favoured restrictive practice, enabling demand to be regulated to suit the resources of each team. It is time to decide whether this is a practice to be defended and retained or whether, like many other restrictive practices, it is harmful to the consumer.

We describe the problems encountered in dealing with a ‘discharge refuser’ in the context of recent government guidelines on good practice in the discharge of mentally disordered people.

Over nine months, 57 consecutive newly referred and previous out-patient attenders to two community psychiatric out-patient clinics located in a deprived inner city area of London were interviewed to elicit demographic information, psychiatric details and obtain their views about their preferred location for the out-patient clinic. The majority (94%) preferred a community out-patient setting to a hospital out-patient clinic, with 76% preferring a community out-patient setting to a home assessment. The overall attendance rate was 89%. A 10% higher rate of attendance was found at the community mental health centre compared with the general practice and 15% higher rate for new referrals. Patients preferred to attend a psychiatric out-patient clinic based in the community. This suggests that introducing community-based psychiatric clinics would make a substantial improvement on the current high rates of non-attendance at hospital psychiatric out-patient clinics.

There has been little published on the use of Guardianship Orders in mental handicap (the term ‘mental handicap’ is used rather than ‘people with learning disability’ to avoid ambiguity). Its use in the mental handicap services in four health districts in the Mersey region was surveyed. The study was retrospective, covering a five year period ending August 1994. Guardianship was used on ten occasions. Health professionals have been divided over the interpretation of the definition of “mental impairment” in the Mental Health Act (MHA) 1983. They have tended to exclude many mentally handicapped adults who do not, in their opinion, exhibit “abnormally aggressive or seriously irresponsible conduct”. It is clearly shown by our study that some health professionals are willing to classify self-neglect and vulnerability as “seriously irresponsible conduct”, thererefore allowing wider usage of the order.

Prediction of in-patient psychiatric violence is difficult: longitudinal appraisal during environmental change may identify Influential factors. Incidents on a secure ward fell substantially in number and severity over 31 months during which staff were trained in control and restraint techniques (CAR) and a monthly audit of incidents was carried out. A few patients caused many incidents. Women were disproportionately violent: both sexes preferred a victim of the same gender. Most incidents occurred in clusters by the same patient. Perceived antecedents were patients' psychosis, inadequate CAR and other staff. Increasing C&R staff was the only factor associated with reducing violence. Patients attacked each other rather than nurses as violence decreased.

Services for deliberate self-harm patients in the general hospital are unsatisfactory in many respects. A survey of activity and quality in a district general hospital confirmed recent trends observed elsewhere and highlights areas in which service provision can be improved.

High rates of deliberate self-harm (DSH) are a public health problem. A study in Oxford showed rising rates among young women during the late 1980s, and a threefold increase in the proportion due to paracetamol poisoning between 1976 and 1990 (Hawton & Fagg, 1992). A multicentre European study found a trend of increasing peak age, a declining female to male ratio, and unexplained differences between regions (Platt, 1992). In the year following DSH, 9% repeat (Hawton & Fagg, 1992); and suicide rates reach 1.1 to 1.3% of patients in the three years following an episode of DSH (Owens et al. 1991).

In order to investigate bias in history taking among psychiatric trainees, a retrospective study of case-notes was undertaken in an emergency psychiatric clinic in a teaching district. Two hundred and twenty-seven consecutive new patient assessments were assessed for quality of alcohol, substance use and forensic histories. Trainees were more likely to take alcohol, substance use and forensic histories from men, and more likely to take substance use histories from younger patients. It is concluded that trainees make sexist and ageist assumptions when they assess patients. There is a need for the education of doctors in this area.

We reviewed all 112 suicides and self-harm open verdicts in Central Nottinghamshire between 1987 and 1991. The rate of consultation with general practitioners of completed suicides was similar to control patients a year before death. It then increased during the succeeding months, particularly in the month before death, when 41% consulted their general practitioner. A further 12% saw another doctor in their last month. Those who did not consult were more likely to be middle-aged, male, divorced or separated, to have experienced a recent broken relationship, and to show evidence of planning the suicide. Better awareness may have detected and possibly prevented some suicides in consulters. Those who did not consult a doctor had different characteristics. Additional strategies would be needed to prevent these deaths.