Although relatively neglected in Britain, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has been widely adopted in both Western and non-Western countries (Spitzer, Williams & Skrodol, 1983). The descriptive and multiaxial approach used in DSM-III (1980) and in its revised edition DSM-III-R (1987), together with the introduction of specific criteria for allocating each diagnosis, would seem particularly useful when comparing psychopathologies across societies. In addition to Axes I, II and III (Clinical Syndromes, Developmental and Personality Disorders, Physical Disorders and Conditions), the Manual has two more obviously ‘social’ axes – (IV) Severity of Psychosocial Stressors and (V) Global Assessment of Functioning.

In 1984, the Department of Health and Social Security issued guidelines, based upon the recommendations of a working party of the Royal College of Psychiatrists, on the management of patients admitted to hospital following acts of deliberate self-harm (DSH). Unlike the 1968 Hill report (which recommended that all such patients should be assessed by a psychiatrist before discharge) the new guidelines placed the responsibility for psychosocial assessments on the admitting medical team.

Over the past three decades there has been a shift in emphasis from hospital based to community care of psychiatric patients. Central to this change has been the development of the community psychiatric nursing services and an increase in its numbers. Until recently community psychiatric nurses (CPNs) were almost entirely hospital based, working as members of a multidisciplinary team and providing follow-up for psychiatric patients.

Consent for operation/treatment of a mentally handicapped person has been an issue stimulating much discussion. Generally, in the past, relatives or consultants responsible for their care have given ‘consent’ for treatment when mentally handicapped people were unable to do so. It was appreciated that legally this was not valid once the person was over the age of 16 and so we felt that the ‘consent’ procedure operating at our hospital should be reviewed. We were unsure of the practices in other areas, apart from Lothian Area where we knew new ‘consent’ forms had been devised, and felt that a good starting point would be to contact mental handicap hospitals in Scotland to gather information regarding the present ‘consent’ practices overall.

Mental disorders may seriously impair insight and therefore cause some patients to refuse potentially life-saving treatment which they would otherwise accept. Opinion on the ethics of current legislation regarding compulsory admission and treatment varies with open debates leading to heated and emotive exchanges. During the reading of the 1982 Mental Health Amendment Bill intense lobbying of MPs took place (Bluglass, 1984). Some argued against compulsory detention because of its infringement on personal liberty while others argued that it was necessary for the adequate treatment of mental disorders which impair insight. They pointed out one's right to receive appropriate treatment whether or not insight is impaired.

In the current climate of interest in audit (Standing Medical Advisory Committee, 1990) and a desire at our hospital to embark on criterion based projects, we set out to undertake a simple audit project surveying the practice of ECT. The aim was to audit the treatment facilities, the treatment procedure and the supervision and training. It was hoped that the full cycle of audit – setting goals, measuring activity, and then effecting change – would be achieved (Shaw & Costain, 1989)

At the Department of Psychiatry, Royal South Hants Hospital, an Audit Committee of two consultant psychiatrists and the three senior registrars working in the department meet every two to three weeks to plan and execute audit projects.

Working for Patients (DOH, 1989) has provided considerable impetus to the development of medical audit. The Royal College of Psychiatrists (1989) Preliminary Report on Medical Audit defined and distinguished between clinical audit, peer review and performance indicators, and referred to some of the particular problems affecting the development of audit in psychiatric practice. There are special concerns for child and adolescent psychiatrists developing medical audit programmes because of the wide diversity of child and adolescent practice and the considerable variability of resources in the subspecialty. Nicol (1989) has described the initial concern of the National Child Psychiatry Section's Working Group on audit with the Korner Report (HMSO, 1982) and the proposals on performance indicators outlined by the DHSS in 1987.

This paper discusses the concept of Psychiatric Register Integrated Support Modules (PRISM). It addresses issues around the linkage of longitudinal data held on individual patients in case register systems to expert and other decision support systems. The paper describes two developed systems which link to the SafetyNet case register system, an inexpensive and comprehensive Mental Health Information System which runs on single or networked computers and which was previously described in detail (Taylor & Bhumgara, 1989). The merits of the two approaches in aiding clinical decision making on anti-psychotic medication are discussed as are the medico-legal implications of using expert systems.

As part of an ongoing educational audit of the process, content, and outcome of higher training in the Mersey Region, the Senior Registrar Tutor (MA-S) and the Psychotherapy Speciality Tutor (MG) organised a whole-day workshop for the senior registrars, involving them in internal audit as well as providing an experience of strategic thinking on the impact of NHS changes on higher training. We modified a package used in industry for strategic planning called the Quick Environmental Scanning Technique (QUEST) (Nanus, 1984). The QUEST process involves two whole-day meetings usually separated by a month which we condensed and adapted to one day, alternating large group discussion with small group work.

The Royal College of Psychiatrists' Guidelines for Training in Liaison Psychiatry (1988) recommend that trainee psychiatrists have the opportunity of working closely with an individual ward or department. Such an attachment may involve the trainee psychiatrist in staff support. This paper describes the involvement of a psychiatric trainee in the development of support structures in a hospice during a liaison attachment. The project not only shed light on the causes of staff strain in palliative care settings, but also provided an opportunity to participate in management.

Since the 1970s there has been a growing trend for psychiatrists to establish formal attachments to primary care and these now form an important component of community psychiatry (Strathdee & Williams, 1984). In this paper a six stage plan for the establishment of a psychiatric attachment is proposed. The framework outlined may be modified in the light of local service, training and research needs.

We decided to set up a short-term, closed group of mothers attending our local clinic, with the following questions in mind.

Population movements away from large cities and congestion in urban areas create problems for the delivery of psychiatric care which are compounded by the move towards greater care in the community. These developing service patterns require adequate methods of communication between service components. There is a proliferation of new technology offering opportunities for improved national and international communication in psychiatry as in other branches of medicine. It will be important to decide which technological innovations will improve the efficiency of service delivery rather than end up as expensive ‘gadgets’, or solutions looking for problems to solve. In this paper the use of interactive television in psychiatry is reviewed and the implications for the evaluation of new communications technology are discussed.

Guardianship Orders (GOs) are being applied more often in care of people suffering from mental illness (Hughes, 1991) and the elderly may have problems particularly suited to their use. Since many individual psychiatrists have little experience of GOs, we decided to examine our use of them. One of us had been involved in six orders over seven years working as a full-time consultant in the psychiatry of old age.

Two theoretical positions in psychiatry, the psychodynamic and the biological are explored, as seen in a discussion at the conference mentioned. It is argued that they form part of a wider philosophical debate between idealism and materialism, which is explored with reference to ideas about substance and then using psychodynamic and biological theories of depression. Double aspect theory is presented as a pragmatic solution adopted by the profession.