Supervision is a key feature of professional development in a wide range of professions. The Royal College of Psychiatrists, in its ‘Statement on approval of training schemes for basic specialist training for the MRCPsych’ (available on request from the Postgraduate Educational Services Department of the Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG) dictates that each basic specialist trainee should have a “protected hour per week” with his or her educational supervisor. This time should belong “exclusively” to the trainee and be “for the benefit of the trainee”. The Higher Specialist Training Handbook (Royal College of Psychiatrists, 1998) also emphasises the central importance of supervision as part of higher training for specialist registrars. Training consultants are expected to be “readily available” to trainees, and to provide a “regular, weekly, timetabled supervision session”. Supervision is obviously perceived by those responsible for standard-setting in psychiatry as a key activity. However, there is a marked lack of clarity as to what constitutes good and effective supervision and there are often few opportunities for learning how to supervise. Hayes (1996) writes about research supervision but his comments are equally applicable to other forms of supervision. He suggests that quality supervision, where it exists, is often by accident rather than by design. It is likely to have been acquired experientially and not without some past hurt to either supervisor or supervised or both. He argues that too much attention has been paid to the quality control of supervision and not enough to quality assurance, with insufficient attention paid to all the possible roles of a supervisor and the key personal attributes necessary to fulfil these roles.

Barring a few exceptions (such as rauwolfia), most of the psychiatric medications have been developed in the West, especially the USA, the UK and Europe. Their safety trials have been conducted in the populations living in these parts of the world. Although these drugs are used all over the world there is a limited research to determine accurate pharmacodynamic and pharmacokinetic profiles across different ethnic groups. Hence, clinicians usually adopt a ‘universalist style’ (seeing every condition and treatment as similar) of managing psychiatric illnesses, but this appears to neglect the information from the emerging literature which advocates a relativist approach to pharmacotherapy (see Lin et al 1995 for review). Anthropologists have encountered ‘phenomenological absolutism’ in a general tendency of people from one culture to perceive and value other cultures in terms unconsciously based upon their own, but phenomenologically experienced as absolute and universally applicable (also known as ethnocentrism). In addition to ethno-biological determinants of drug response, there are significant cultural factors: the concurrent use of pluralistic health systems, alternative therapies and folk remedies which might support, hinder or complicate pharmacotherapy and treatment adherence. In this paper we highlight some key factors of which clinicians need to be aware. These include pharmacodynamic and pharmacokinetic principles, and application of these principles in pharmacological management of psychiatric conditions. Ethnic differences in pharmacodynamics are most clearly demonstrated in the greater sensitivity to a variety of drugs in Caucasians than in Asians or in African–Caribbeans.

Recent research has highlighted the fact that a significant number of patients with bipolar affective disorder have a poor outcome (Cole et al, 1993). The most common poor outcome is the development of rapid or ultra-rapid cycling, but mixed states, prolonged depression and severe mania are also associated with poor outcome. It is estimated that approximately one-third of patients with bipolar affective disorder do not respond fully to lithium and a significant number of patients discontinue lithium (Post, 1990) which may itself cause further problems.

The January 1997 issue of this journal contained four reviews that compared tricyclic antidepressants with selective serotonin reuptake inhibitors (SSRIs) and other newer antidepressants in terms of their pharmacology (Palazidou, 1997), adverse effects, potential drug interactions and toxicity (Henry, 1997), efficacy in the prevention of relapse and recurrence (Edwards, 1997), and findings from meta-analyses (Anderson, 1997). In July 1997 reboxetine was promoted as the first selective noradrenaline reuptake inhibitor (NARI), and in October of the same year mirtazapine was promoted as the first noradrenergic and specific serotonergic antidepressant (NaSSA). Milnacipran is presently being registered by the manufacturers, after which it will be the second antidepressant drug promoted as a specific serotonin and noradrenaline reuptake inhibitor (SNRI).

Attention-deficit hyperactivity disorder (ADHD) and hyperkinetic disorder are well-established diagnoses in children, with estimates of prevalence in pre-adolescent children from 3 to 5%. Until recently ADHD was not thought to persist beyond adolescence, but results from long-term prospective outcome studies indicate that 30–70% of children with ADHD exhibit some symptoms as adults. Recognition of this disorder is important as the persistence of ADHD symptoms has been shown to be associated with academic and occupational failure and high rates of psychiatric comorbidity. With the establishment of a UK support group (LADDER) and increasing media attention highlighting this problem it is likely that there will be an increased demand for psychiatric assessment of adult ADHD in the next few years.

Eye movement desensitisation and reprocessing (EMDR) was described by Shapiro (1989a,b) as a new method for treating post-traumatic stress disorder (PTSD). In May 1987, while walking in the park, Shapiro noticed that her own disturbing thoughts changed then disappeared “without any conscious effort” (Shapiro, 1995) when they had been temporally paired with diagonal upward to and fro eye movements. Over the next six months Shapiro worked with approximately 70 people to develop a procedure based on the temporal pairing of distressing images and thoughts with various eye movements. Shapiro began to develop strategies to unblock stalled emotional processing, which was initiated by EMDR in non-patients. She successfully tried the method on a Vietnam veteran suffering from severe PTSD and then embarked upon a trial of EMDR on a mixed group of victims of rape, molestation and Vietnam combat trauma. Initially, EMDR achieved wide recognition as a new breakthrough treatment for PTSD. This was, in part, because of very positive early reports (e.g. Wolpe & Abrams, 1991), but also because the EMDR effect appeared to occur with unprecedented speed, often in cases of PTSD that had previously resisted treatment by many other methods over a long period.

Hormones are widely considered to cause powerful psychological effects and because of this psychiatrists may be asked to advise general practitioners, consultants in other specialities or patients about the relationship between hormones (including sex hormones) and psychiatric disorder. Sex hormones may be relevant to psychiatry in three ways:

(a) Sex hormones may play a role in the pathophysiology of psychiatric disorders.

(b) These agents may be utilised for treatment of psychiatric disorder.

(c) Administration of sex hormones may cause psychiatric side-effects.

The dramatic development of cognitive–behavioural therapy (CBT) over the past 30 years, with associated high-quality research into the evaluation of its treatment effects, is to be welcomed and applauded. This form of therapy is now a recognised psychological treatment of choice for a wide variety of psychological disorders. The role of cognitive processes in the development and prolongation of psychological symptoms has been studied, and resulted in the development of coherent and effective treatment models.

Twenty-four-hour nursed care refers to a model of psychiatric care which in fact varies quite significantly from unit to another. This sort of residential care unit has also been called the “hospital hostel” (Goldberg et al, 1985), “ward in a house” (Wykes & Wing, 1982), “psychiatric nursing home” and in some cases “staffed group home”. Although the unit size, staffing structures and ratios, and the degree of direct management within the National Health Service (NHS) vary, this model of care has some quite specific characteristics, which have been summarised by Shepherd et al (1994) as follows:

In response to what are regarded as the two principal evils of the civil justice system, costs and delay, Lord Woolf, now Master of the Rolls, has presided over an inquiry which has resulted in some proposed reforms which should change radically the administration of civil justice. The implications for experts are best considered against the background of a brief overview of the proposed reforms. This paper then considers the role of the expert witness organisations and the medical version of ‘the model expert report’.