While attending a rancorous and ill-tempered meeting of the Hackney Community Health Council in 1985 it was brought home to me that psychiatry was different from other branches of medicine. Not in the sense that it was the only one that dealt with intangibles, we all know that X-rays, scans and the like are far less precise than their purveyors let on. But it seemed that the mental health professionals and the groups that represented the clients, relatives and users of the service couldn't agree on a single thing, not even whether people were ill in the first place. It was difficult to imagine, say, the British Diabetic Association and a group of Endocrine Clinic staff knocking verbal lumps out of each other in this way even though diabetes and schizophrenia have a good deal in common.

In our special article (pp. 439–441, this issue) we have described the structure and function of a 24–hour crisis assessment and treatment team (CATT). Comprehensive, accessible, specialist, out of hours crisis services designed to facilitate community treatment are not new in the UK but they are not currently widespread. Services employing the CATT model have become widespread in Australasia and are considered to be a success there. In this paper we discuss some of the advantages of CATTs and some possible reasons why they are not more commonly employed in the UK.

“And when life has no more meaning in old age, the will to meaning is lost; when life no longer seems to be worth living, some people who have experienced disasters and are unable to cope, may throw their lives away.” (Wilson et al, 1988) There continues to be a great deal of interest among psychiatrists, psychologists and sociologists about post traumatic stress disorder (PTSD) related to war crimes and experiences. Twentieth century studies of Holocaust victims and Far East prisoners of war, Korean and Vietnam veterans and the recent experiences of people in Bosnia have honed the diagnosis and increased awareness of the gradations of these disorders. Almost every conceivable variable has been examined in attempts to explore the motivating and resulting behaviours. Initially most studies dealt with the immediate impact of the event, but more recently articles have focused on the longer-term effects on relatives and the next generations of the earlier events (Sigal, 1998). Time has allowed this. The passage of time has also established that post-traumatic stress symptoms can be reactivated as much as half a century after the original trauma (Krasucki et al, 1995). Reactivation of events from 40 or 50 years previously may occur via current stressors such as social isolation and upheaval. Equally perceived helplessness precipitated by the somatic process of ageing could reactivate previous feelings and a delayed onset or exacerbation of clinical PTSD may emerge during the process of ageing. Institutionalisation itself could re-awaken feelings associated with incarceration or victimisation (Aarts & Op den Velde, 1996; Sadavoy, 1997). Late-life PTSD is more often associated with sleep disturbance, nightmares, intrusive ideation and avoidance of reminders of the original events (Kuch & Cox, 1992).

The recent White paper, Modernising Mental Health Services, recommended the provision of home treatment teams for acute mental illness (Department of Health, 1998). Such services are not widespread in the UK and have been the subject of recent debate (Smyth et al, 2000). In Australia, multi-disciplinary teams providing 24–hour community assessment and treatment of psychiatric emergencies have been in place now for over a decade, and form the cornerstone of the public mental health service.

Shortly after taking up my appointment as National Director for Mental Health, I convened a working group of consultant psychiatrists to consider how to involve psychiatrists more in the current process of changing mental health services. This was in recognition of the fact that, while psychiatrists are central to modernising services, their skills and experience are insufficiently used. It is one of the most frequent complaints that I hear from clinicians.

Our 5-year long campaign to reduce the stigmatisations of and discriminations against people with mental illnesses, launched as an outline endeavour in October 1998, is now in its third year. This update is intended to reveal that since 1998 we have been constructively busy and are poised to go public’ in major ways. We are now therefore appealing to the membership at large to join in the tasks. To this end we have been busy generating a tool kit that you may wish to draw upon and a series of proposed projects, some of which are already underway and some of which you may be able to pick up on or adapt for local purposes, in addition to any of your own initiatives.

The past 5 years have seen dramatically increased interest among users, professionals and the Government in enabling people with mental health problems to gain employment. Many new projects have been started, with a range of different approaches including supported employment, training and placement, transitional employment, social firms and cooperatives. There are a number of reasons for this increased interest.

As part of training for general practice, approximately 40% of junior doctors will undertake a senior house officer (SHO) post in psychiatry (Ratcliffe et al, 1999). The majority of such posts will be within general adult psychiatry. As a result of this general practitioner (GP) trainees often receive little exposure to old age psychiatry or child and adolescent psychiatry. Similarly, although trainees will inevitably gain some experience of substance misuse associated with mental illness, there is little opportunity to develop skills in addressing primary substance misuse disorders and there is a clear need to develop better skills in the recognition and management of psychiatric comorbidity (Commander et al, 1999).