Alzheimer's disease is likely to be one of the challenges for the early part of the 21st century. Better knowledge of the molecular biology, genetics and pathogenesis of the condition have led to a host of psychopharmacological compounds being developed which may help in its the treatment, while epidemiological studies have suggested that existing treatments for other chronic conditions may have an effect on the presentation of Alzheimer's disease.

The clinical assessment and management of suicide risk depends primarily on face to face contact with the individual who presents the risk, and aims to predict behaviour in the very near future. Whether or not clinical intervention prevents suicide depends a great deal on the clinician's skill in reaching out to the individual patient. This poses a dilemma, because much of what has been written about predicting suicide has been based on averaged data concerning long-term outcome in large cohorts of patients.

Childbearing, from the standpoint of psychological medicine, is the most complex event in human experience (Brockington, 1996). Pregnancy and childbirth involve major biological, social and emotional transitions and expose the mother to a range of psychological and medical complications. There are about 20 psychiatric disorders occurring in the post-partum period (see Table 1).

Interest in the relationship between mother-child interactions and mental health has two sources: awareness of the importance of correct parenting in personal development; and the exploration of postnatal mental illness.

The management of patients with depression who have failed to respond to antidepressant medication is a common problem in general and old age psychiatry. It has been estimated that about 20–30% of patients with major depression fail to respond to treatment with a single antidepressant drug given in adequate dosage for an appropriate period of time. At the current time there are many possible ways to pursue pharmacological treatment, but few controlled trials to help us choose between the various options. In addition there are few clinical predictors to help match patients to an appropriate treatment.

The proceedings of a mental health review tribunal involve two psychiatrists – one to be found among its members and the other (having care of the patient) who appears before the tribunal as the responsible medical officer (RMO). Both have a very important role to play and the juxtaposition of two psychiatrists guarantees a lively debate at many tribunal hearings.

This paper has two objectives: to review some aspects of the law of confidentiality in the health care field and to evaluate how the law of confidentiality impacts on the processes of child protection.

Psychological therapies are a necessary component of any mental health service. Psychiatrists will require a working knowledge of different psychological approaches and many will wish to develop clinical skills to practice at least one model of psychotherapy. Historically, most psychiatry training schemes have offered exposure to psychodynamic psychotherapies, while training in other approaches has been less systematic. The expansion of research into brief psychological therapies and a wealth of recent publications on the subject have led to an increasing awareness of the benefits of training in other models of psychotherapy. The most widely practised and researched brief psychological intervention is cognitive-behavioural therapy (CBT). This paper will outline the principles behind providing training in CBT, and the barriers to successful implementation of a training programme.

Family life in Britain is changing daily to include more stepfamilies, which have widely differing structures with varying histories, losses, transitions and economic circumstances. Of the one in five children who currently experience separation before they are 16, over half will live in a stepfamily at some point in their lives. Of the 150 000 couples with children who divorced each year at the end of the 1980s, a further 35 000 had a subsequent divorce. For some children we need to think of step-parenting within wider processes of transition, which include relationship changes of many kinds. The National Stepfamily Association have calculated that if current trends of divorce, cohabitation, remarriage and birth continue, there will be around 2.5 million children and young adults growing up in a stepfamily by the year 2000. The true pattern of re-ordering of partnership and family life is hard to chart, since many couples second or third time around prefer to cohabit rather than to marry.

Competence should be “at the heart” of medical practice to ensure patient confidence in health care (Calman, 1996), but what is competence in relation to medical practice?

It is now well established that children of parents who have psychiatric disorders are at risk of developing disturbances themselves (Rutter, 1989; Garmezy & Masten, 1994). Of particular concern is that these disturbances may persist well after remission of the parental disorder. Eating disorders occur commonly among women of child-bearing age (Szmukler, 1985; Fairburn & Beglin, 1990) and the prevalence seems to be rising (Treasure et al, 1996). Estimates indicate that at least 2% of women aged 16–40 suffer from bulimia nervosa or anorexia nervosa, and up to 4% when other eating disorders are considered (Fairburn & Beglin, 1990; Hoek, 1993). It is therefore surprising that the potential implications for their offspring have received so little attention until recently. Knowledge of whether these children are at risk and the mechanisms underlying any transmission of disturbance is important so that appropriate treatment can be instituted and preventive strategies put in place.

As with most issues in medicine, the prevention and management of a problem is best understood when the origins are known. The term ‘false memory syndrome’ (FMS) came into use in March 1992 with the foundation of the False Memory Syndrome Foundation (FMSF), a non-profit-making organisation established in the USA by a group of families in which one or more of the parents was accused. The parents in these families were reacting to a phenomenon which developed in a characteristic form in the preceding decade and had become common enough by 1991 for a number of them to realise that they were not alone, and to join in setting up the Foundation with a professional and scientific advisory board.

The true incidence and prevalence of sexual abuse against children is difficult to ascertain. Differing sampling methods, definitions of sexual abuse and methods of information-gathering have a significant effect on the rates reported. General population studies (Morrison et al, 1994) in the USA and Europe reveal a rate between 0.7 and 1.83 per 1000 children. Data from prevalence studies (Morrison et al, 1994) highlight large differences, with rates varying from 7 to 62%; meanwhile, only between 2 and 17% of sexual assaults are reported to the police. Many of the reported offenders are not prosecuted because of difficulties with the child's statement. Some offenders are cautioned, others are charged with specimen charges or have their charges downgraded. Despite an increase in the reporting of sexual offences since the 1970s, they account for only approximately 3% of all offenders on probation and 8% of male offenders in prison even though the number and length of prison sentences for sex offenders has increased since the 1970s. Convicted female offenders remain a very small group with only 23 convicted female sex offenders in custody in 1989.

Children, like adults, can directly experience or be witness to interpersonal violence either within or outside the family, on one or repeated occasions. Intra-familial violence may result in the death or serious disablement of a parent or child, or may be experienced as child sexual abuse or chronic domestic violence. Non-familial violence includes urban violence now endemic in some communities, war and civil conflict, and vicarious violence such as in films and on television. Traumatic events can also occur by natural forces, for example, earthquakes, volcanic eruptions, hurricanes. This review will focus mainly on the effects on children of witnessing severe or repeated violence, sometimes resulting in death, occurring to a member of their family, perpetrated either by a parent, step-parent or cohabitee or by a person or persons unrelated to them, although it will draw on studies of other traumatic experiences where relevant.

Victims of child and other forms of sexual abuse receive increasing attention and resources but it is often difficult to extend the same kind of understanding and possibilities of treatment to their perpetrators. Many of the perpetrators have been victims themselves, which is often a major reason for their having developed in such a way; sometimes the offenders are virtually children themselves (Royal College of Psychiatrists, 1994b).

Liaison psychiatrists are frequently asked to see people with chronic, debilitating and unexplained physical symptoms, in particular chronic pain and chronic fatigue. People with these conditions have often seen many doctors and received multiple medical investigations, but rarely have had any effective treatment or even explanation for their symptoms. There are many reasons for focusing on occupational factors in this patient group. First, many people may attribute their symptoms to workplace exposures. For example, back pain may commonly be put down to accidents; upper limb disorders to use of keyboards or repetitive manual tasks; and headaches and fatigue to visual display units or air conditioning. These attributions have prognostic and legal implications, and are likely to affect the course of treatment. Second, for those who have had prolonged sickness absence, it is often necessary to make decisions regarding return to work or to help them negotiate the often lengthy and complex medical retirement process. This may be a major stumbling block in managing such people. Finally, psychiatrists are frequently invited to write medico-legal reports regarding the role of occupational factors in causing unexplained physical symptoms. This article aims to address these issues and provide some practical guidance to clinicians.