By the 1980s, one-fifth of all general psychiatrists in England and Wales (Strathdee & Williams, 1984) and one-half in Scotland (Pullen & Yellowlees, 1988) were spending some proportion of their time working in primary care. Rather than limit this process, the growth of general practice fundholding fostered it and developments in general practice total purchasing and extended fundholding have encouraged it further (Lee et al, 1999). At the same time, nationally there has been a gradual increase in referrals directly from general practitioners (GPs) to community psychiatric nurses (CPNs). Referrals from GPs constituted 37% of all referrals to CPNs in 1990 and 46% in 1996 (Brooker & White, 1997: further details available from L.G. upon request), even though there has been a trend away from the primary care service base (21% in 1990 compared with 14% in 1996).

“Appropriately controlled and structured clinical trials have not yet revealed any pharmacological approach for rehabilitation of stimulant dependent individuals for which the risks have been shown to outweigh the assets.” (Schuckit, 1994)

In the sometimes sensational world of illicit drug reportage, there is one unsung villain. While heroin misuse remains the bête noir of tabloid journalism, ecstasy the demon of the dance floors and cocaine caricatured as the choice of the rich and famous, amphetamine misuse has lurked the shadows. Its use defies such simple categorisation and spans several groups in society. Bruce has provided a timely reminder of this neglected area in substance misuse literature and, in the process, has highlighted the relevance of basic information gathering as the most important tool in the armamentorium of drug misuse workers. The lack of prominence given to what they describe as a “hidden epidemic” is striking. Could this be because amphetamine misuse is a less prevalent problem than that of other illicit drugs? Evidence suggests otherwise. Amphetamine is the second most common illicit drug seized in the UK (after cannabis). It is easily produced and used in a variety of modes, and recent research confirms a high prevalence of misuse in this country reflecting that found in North American and Australian literature.

Anorexia nervosa is often a chronic, severe disorder in which morbidity and mortality are high. After 20 years, as many as 20% of clinical series have died (Patton, 1988) and another 20% have experienced poor outcome (Tolstrup et al, 1985).

Post-modernism is a term that is omnipresent in the media, academic circles and contemporary culture. It is also a term that has caused substantial consternation among systemic family therapists. Systemic family therapy traces its origins from the 1950s, and there are currently several different models contained within the systemic paradigm. A unifying feature of systemic therapy is the importance placed on understanding psychological difficulties in the context of social relationships. Another point of agreement among systemic therapists is the significance of drawing distinctions and marking ‘difference’ as an aspect of creating change. A third common feature is the practice of working in teams, where one therapist conducts the interview, while a small number of others comment on their observations. The degree to which these models and practices have been influenced by postmodernism varies.

Neuropsychological assessment, in the broader sense, is common clinical practice with older adults because of the widespread use of mental status examinations and dementia rating scales. In the more narrow sense, a neuropsychological assessment conducted by a clinical psychologist or clinical neuropsychologist is used less frequently and for more specific purposes. This paper outlines these uses and provides a brief overview of the different types of test that might be used, with a clinical example to illustrate the type of information gained. This review is designed not to be comprehensive, but to provide a pointer towards the latest trends in test development.

Anthony Winston reviews and describes current perspectives on the aetiology of borderline personality disorder, covering areas such as the role of traumatic factors, attachment theory and self-psychology. The author links these to the psychopathology of the borderline patient who experiences difficulties such as regulation of affect, impulse control and cognitive capacity to both think and reflect. The psychological function of splitting is considered along with other defence mechanisms as having adaptive potential for the borderline patient. Winston describes in a helpful way the links between human development, psychodynamics and psychopathology as he reveals some of the more recent contributions to the field of BPD. At the beginning of his article, he emphasises the problems encountered when attempting to treat or manage patients with BPD. He centres these difficulties on the counter-transference of the clinician, pointing out how such feelings can “all too easily be transformed into therapeutic nihilism”. His article can easily be read as an attempt to counter such a state of mind and he appears to try to generate a more hopeful if not optimistic outlook. In doing so, I fear that he goes beyond his own account of the research evidence for the effectiveness of treatment. Such enthusiasm or optimism can readily be understood as a reactive polar opposite to nihilism or pessimism. I would like to consider further Winston's statements germane to this aspect of his article and raise for further discussion some other ideas which extend beyond the narrower confines of aetiology and psychological therapy.

I am certain this review by Hall is welcomed by psychiatrists working across a number of specialities, who in the course of their work are asked to assess a young offender with a learning disability. The main difficulty the paper highlights is how little research has been undertaken in this area, leaving clinicians to rely on their experience and that of a handful of colleagues specialising in this area. The literature on the more able population is a useful source of information, as there is considerable overlap between the two groups.

Epidemiological research has revealed that psychiatric disorders in children and adolescents are common, persistent and handicapping. Only 1 in 10 of those with a disorder is seen in specialist mental health services. However, the majority of children and adolescents see their general practitioner (GP) every year. Although the majority present with physical complaints, there are indications that rates of psychiatric disorder in those attending are increased and that psychiatric disorder is associated with increased consulting. These findings raise questions about the role of primary care in the promotion and management of mental health in young people.

Certain areas of child and adolescent mental health generate a degree of polarised debate, both within and outside the profession. Media attention, the development of self-help groups and the Internet lead to the publishing of papers and opinion, which exist alongside peer-reviewed research and evidence-based medicine. Parents reading such material may find it hard to know what advice is best. One area that falls into this category is chronic fatigue syndrome (CFS).

The majority of people with learning disabilities in the UK live at home with their families, usually with their parents (Mental Health Foundation, 1996) or – more commonly in later life – with one parent, usually their mother. Nowadays, people with learning disabilities live much longer than they did in the past, with the result that there is also an expanding population of elderly parents who are continuing to care for a son or daughter well into old age.

The previous article (Rix, 2000) in this series described the process of dispute resolution and litigation under the new Civil Procedure Rules, which have now been implemented in England and Wales following the recommendations of Lord Woolf. The purpose of this article is to provide detail of the provisions of ‘Part 35: Experts and Assessors' and examine the accompanying practice direction, the pre-action protocols, the ‘Draft Protocol of Best Practice in the Instruction and Use of Experts' and the ‘Draft Code of Guidance for Experts and Assessors' as they relate to the role of the medical expert.

The recent film Boys Don't Cry illustrates in a highly dramatised form the problems that the phenomenon of gender identity disorder can create in an extreme situation. The film is based on the true story of a young person, Brandon, with a female body who perceived himself as a male. In the film we do not know when the issue of his male gender identity first appeared, but we see him living in a male role as a teenager trying to conceal, to his peers, the reality of his female body. (I refer to Brandon as ‘he’ because this is how Brandon presents himself in the film. The dilemma about using ‘he’ or ‘she’ typically confronts professionals in the management of teenagers like Brandon.) The struggles of these concealments are well portrayed, as in the scene when he steals tampons from a shop. He joins in male activities and displays of physical strength as a confirmation of his male role. He is well accepted as a boy within a troubled and troublesome group of young people. He falls passionately in love with a girl, Lana, who accepts him as he is without much questioning, and a close intimate relationship develops, which the peer group seems to accept. The reality of his body is eventually revealed. His girlfriend can accept the new situation, but had she really not known or had she turned a blind eye? Unfortunately, two young men become more and more disturbed by this realisation. It stirs a primitive violence in them, which leads first to Brandon's rape and then to his murder.

“Employers have a key role to play in safeguarding the mental health of their workforce, both by providing a supportive work environment and by encouraging the use of the workplace to provide health education and health promotion activities” (Department of Health (DoH), 1998a, 4.64)

In the second of my previous two articles on the role of the expert witness, I anticipated the implementation of Lord Woolf's proposed reforms to the civil justice system in England and Wales (Rix, 1999). These changes came into effect on 26 April 1999 and they represent the most radical changes to the civil justice system for a hundred years. In the previous article, it was not possible to do more than list a few of the key points relevant to experts. The purpose of this article is to describe the changes in detail and show how they will, or can be expected to, affect the role of the expert.

Depression in old age is a pathological process, not a normal reaction to growing older. The majority of people cope with ageing, and many feel happy and fulfilled. However, there is a bias among health professionals and the community in general to accept lower functioning and more symptoms in older people (Alexopoulos, 1992). Depression tends to be denied by the current generation of elderly people, many of whom were raised in an atmosphere where showing feelings was discouraged, and this adds to diagnostic difficulties. Comorbid medical conditions, the tendency of patients to somatise, cognitive deterioration, and multiple life events, often of loss (e.g. bereavement, retirement, moving to smaller housing), all further complicate the diagnostic process.

It is Government policy that increased attention should be given to the quality (as well as the quantity/efficiency) of clinical care. To achieve this, it has set national standards through the National Service Framework for Mental Health (NSF–MH; Department of Health, 1999a) and the National Institute for Clinical Excellence (NICE).

With the arrival of clinical governance, psychiatrists working for the National Health Service (NHS) can no longer work in isolation, and commitment to both clinical effectiveness and continuing professional development (CPD) is expected and likely to become mandatory. Clinical governance gives clinical effectiveness a high priority within NHS organisations, both at primary and secondary care levels, together with clearer lines of accountability.

When asked for advice about a survivor of torture (or of some other form of organised state violence), there are at least two people to consider. In addition to the needs of the patient, those of the person asking for advice – the health professional – must be taken into account. There are some forms of violence which can damage others, even in the controlled circumstance of a consulting room. There is a context, often a community or a family, in which the person exists. This paper will first address some of these broader issues before going on to consider some of the narrower, more technical, matters of best available treatment.