It is appropriate to be writing about psychiatric training in Europe as the joint meeting between the Royal College of Psychiatrists and the Association of European Psychiatrists is being planned for July 1996.

The last 20 years have witnessed a surge of interest in assertive community treatment (ACT) for the severely mentally ill (Drake & Burns, 1995). ACT aims to help people who would otherwise be in and out of hospital on a ‘revolving door’ basis live in the community and enjoy the best possible quality of life. Services based on the ACT model seek to replace the total support of the hospital with comprehensive, intensive and flexible support in the community, delivered by an individual key worker or core services team. They are organised in a way that optimises continuity of care across different functional areas and across time.

It is difficult not to be won over by the description of assertive community treatment that promises nearly total caring for the most chronically disabled mentally ill, including “the material essentials of life such as food, clothing and shelter, coping skills necessary to meet the demands of community living and motivation to persevere in the face of life's adversity”. If we keep in mind that this approach is for patients who in previous decades would have spent their life in a mental institution, one can readily justify the transfer of expense and resources to this hopefully more humane form of treatment which allows patients to live within the context of open society, a preference they inevitably opt for when surveyed after a move from hospitalisation to community care.

Although a rare form of ‘lethal’ catatonia, involving high temperature and rigidity, was first described long before the advent of neuroleptic drugs, Delay's description of a syndrome malin in 1960 is usually regarded as the first recognition of this syndrome. Over the next 20 years the number of case reports grew and the appearance of reviews such as Caroff's in 1980 marked the birth of the neuroleptic malignant syndrome (NMS). Reports of its incidence give variation rates of up to fiftyfold, possibly due to differences in diagnostic criteria, and mortality reports are similarly variable. Although it is debatable whether it is a rare, severe idiosyncrasy or one of many neuromuscular side-effects of dopamine antagonists (Levinson & Simpson, 1986), most clinicians nowadays regard it as a serious but recognisable risk of neuroleptic treatment which merits further attention.

People with mental illness have always been marginalised and economically disadvantaged. Warner (1987) has shown that this is particularly true in times of high unemployment. Poor inner-city areas have excessive rates of severe mental illness, usually without the health, housing and social service provisions necessary to deal with them (Faris & Dunham, 1959). The majority of those who suffer major mental illness live in impoverished circumstances somewhere along the continuum of poverty. Homelessness, however defined, is the extreme and most marginalised end of this continuum, and it is here that we find disproportionate numbers of the mentally ill.

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.

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).

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.