The unregulated market for medicines has evolved in different ways and exists in different forms in different parts of the world. Given this wide variation, the phrase ‘unregulated market for drugs’ is commonly used in a generic sense and encompasses the sale of medicines that have been licitly manufactured but diverted from legitimate sales routes as well as the illicit manufacture and sale of (counterfeit) pharmaceuticals. Also within this unregulated environment, prescription-only drugs are sold (illegally) without prescription.

With the extraordinarily large movements of populations from some of the former Soviet Union states into Western Europe, since their recent membership of the European Union, attention has been focused in recent years on how easy or otherwise it has been for these people to adjust to life in very different economic and social circumstances. It has been estimated that the UK has absorbed up to a million immigrants from Eastern European states since 2004, and an equivalent picture is seen elsewhere; for example, in Switzerland immigrants now comprise nearly a quarter of the population. We consider here the mental health issues faced by those moving to work in other countries, some of whom aim to become citizens, others to gain temporary economic advantage, and yet others to escape persecution and threats to their personal safety in their countries of origin.

Several European states such as Sweden have become transit countries for migrants, as well as reception countries for an increasing number of young migrants, not only asylum seekers and refugees from beyond Europe but also from the European Union's new members, after the dissolution of the Soviet bloc in 1989 and then the Soviet Union itself in 1991. Over 110000 immigrants from Eastern Europe and the former Soviet Union resided in Sweden in 2002, although the exact figure is difficult to estimate because of the varied legal status of the migrants. International migration is not a new phenomenon in this part of the world, of course: people have always moved in the search of greater personal safety, among other reasons. However, new groups with new psychosocial needs and demands on the healthcare systems of the host countries will be a challenge. The aim of this article is to give an overview of three sets of empirical data:

1. • the prevalence of mental disorders among recent immigrants to Sweden from Eastern Europe and the former Soviet Union

2. • their access to mental health and social care facilities arising from their legal status

3. • their utilisation of health and social services

Canada admits more than 220 000 immigrants every year and this is reflected in the statistic that 18% of the population was born abroad (Beiser, 2005). However, government policy emphasises the admission of healthy immigrants rather than their subsequent health. Immigrants do not show a consistently elevated rate of psychiatric illness, and morbidity is related to an interaction between predisposition and socio-environmental factors, rather than immigration per se. These factors include forced migration and circumstances after arrival, such as poverty, limited recognition of qualifications, discrimination and isolation from the immigrant's own community. For instance, in Canada more than 30% of immigrant families live below the official poverty line in the first 10 years of settlement (Beiser, 2005).

Interest in the psychological well-being of refugees and asylum seekers has steadily grown in recent years. Latest estimates indicate there are 32.9 million people of concern to the United Nations High Commissioner for Refugees (2006). A refugee is defined as being in that position because of a well-founded fear of persecution due to race, religion, nationality, social group or political opinion, and who is consequently outside and unable to return to his or her country. The status of ‘refugee’ is contrasted with that of a person seeking asylum, whose experiences may be similar but who is not formally determined in the same way.

Estonia is a small country (45 000 km2) with a population of 1.3 million people. It has undergone rapid change since it gained independence from the Soviet Union in 1991. It has achieved some economic success, although there is a suggestion that this has been at the expense of the mental health and general emotional well-being of the people. In the Estonian Health Interview Survey, depressive symptoms were observed in 11.1% of respondents and their presence was strongly correlated with socio-economic status (Aluoja et al, 2004).

The following view was espoused in a 1903 Lancet editorial describing psychiatric services in the East: ‘The treatment of lunatics in the East has not yet fully emerged from the clouds of ignorance and barbarism which have surrounded it for ages.’ One of the first reformers was ‘Mr. Theophilus Waldmeier, a gentleman resident in Syria, who commenced in the spring of 1896 the work of helping and providing for the numerous sufferers from mental disease in Syria and Palestine.’ He attempted to introduce the methods of humanity and science in this field. In 1939 Bernstein described his visit to the Maristan Arghoum, a psychiatric hospital, in the city of Aleppo. He observed the complete lack of medical supervision, ‘bad’ patients being chained and the despotic rule of the ‘keeper’ of the hospital.

Slovenia, with an area of 20 000 km2 and a population of 2 million, is one of the smallest members of the European Union. It gained its independence from Yugoslavia in 1991. The country has a gross domestic product (GDP) of US$27 300 per capita. (Largely because of its historical links with Western Europe, Slovenia has a higher GPD compared with other countries in transition in Central Europe.) The health budget represents 8.4% of GDP. Slovenia has a low birth rate and an ageing population. It is divided into 210 municipalities; however, the re organisation of government into several separate regions with more administrative and economic autonomy is in progress. The prevalence of mental illness is comparable to that in other European countries, although there are high levels of alcoholism and suicide.

The World Health Report 2001, dedicated to mental health, identified several important factors for improving mental health services (World Health Organization, 2001): the policy and legislative framework; community mental health services; provision of mental healthcare within primary care; human resources; public education; links with other sectors; and monitoring and research. Moreover, national mental health policies and national implementation programmes for these policies are vital for the improvement of mental health services (World Health Organization, 2004; Jacob et al, 2007).

Schizophrenia is a chronic illness with a lifetime prevalence of 1% and with serious physical, social and economic consequences. Over the past decade, atypical antipsychotic medications have become the first-line treatment for schizophrenia (Breier et al, 2005).

The use of complementary and alternative medicine is increasing among psychiatric populations. Herbal medications are a form of alternative and complementary medicine whose use has increased over the last decade. Two studies done among Western out-patient groups have reported rates of use of herbal medicine at 15% (‘current use’; Matthews et al, 2003) and 24% (Knaudt et al, 1999).

Sir: We read the article by Pi & Zhu (2007) with interest, as this topic is particularly important to psychiatrists practising in countries like Sri Lanka, where, because of the lack of local prescribing guidelines, the dosing of medication is generally determined by guidelines developed for patients in the West, such as those from the National Institute for Health and Clinical Excellence (NICE) and the British National Formulary.

Sir: The editorial by George Christodoulou et al (2008) on ‘Psychiatry for the person’ and the response by Jeremy Holmes (2008) have been read with avid interest on this side of the globe. Listening to previous presentations on this topic at Asian meetings of the World Psychiatric Association (WPA), we were often left with a sinking feeling that they resonate well with our work but could be better. For the Institutional Programme on Psychiatry for the Person (IPPP) to succeed, there should be more participation from developing countries. The marketplace of ideas should not be confined to academics in Europe and North America and ignoring the rich experience of clinicians in Chennai, Singapore or Batu Pahat.

Sir: At its 2006 annual forum in Riga, the European Federation for Psychiatric Trainees (EFPT) issued its first statement on competency-based training and assessment in psychiatry. The EFPT, which represents national associations of psychiatric trainees from across Europe, is broadly in favour of competency-based training if it improves the standard of psychiatric education and is not overly bureaucratic.

Sir: Your readers may be interested to know that the Association of European Psychiatrists (AEP) held its 16th Annual Congress in Nice, France, 5-9 April 2008. There were almost 3000 delegates from 57 countries. The theme was ‘Pathways to Integrative Care.’