A substantial body of research indicates that, for people from Black and Asian ethnic minorities, access to, utilisation of and treatments prescribed by mental health services differ from those for White people (Lloyd & Moodley, 1992; for a review see Bhui, 1997). Pathways to mental health care are important, and the widely varying pathways taken in various societies may reflect many factors: the attractiveness and cultural appropriateness of services; attitudes towards services; previous experiences; and culturally defined lay referral systems (Goldberg, 1999). Contact with mental health care services may be imposed on the individual, but people who choose to engage with services usually do so only if they think that their changed state of functioning is health-related and potentially remediable through these services. In such cases, they will contact whoever they perceive to be the most appropriate carer, and these carers are often not part of a national health care network.

Humans have attempted and successfully committed suicide since time immemorial. The reasons for killing or harming oneself vary with cultures and societies and in urban or rural settings.

The Patron of the Royal College of Psychiatrists has pointed out the irony involved in recording patients' religion, without seeking to discover that all this means to them in terms of understanding and coping with their illness (HRH The Prince of Wales, 1991). One College past-President (Sims, 1994) firmly recommends evaluating the religious and spiritual experiences of our patients in assessing aetiology, diagnosis, prognosis and planning treatment. Across the water, an American Journal of Psychiatry editorial (Andreasen, 1996) has it that, ‘We must practice and preach the fact that psychiatrists are physicians to the soul as well as the body.’

Cognitive–behavioural therapy (CBT) is a shortterm, problem-focused psychosocial intervention. Evidence from randomised controlled trials and metaanalyses shows that it is an effective intervention for depression, panic disorder, generalised anxiety and obsessive–compulsive disorder (Department of Health, 2001). Increasing evidence indicates its usefulness in a growing range of other psychiatric disorders such as health anxiety/hypochondriasis, social phobia, schizophrenia and bipolar disorders. CBT is also of proven benefit to patients who attend psychiatric clinics (Paykel et al, 1999). The model is fully compatible with the use of medication, and studies examining depression have tended to confirm that CBT used together with antidepressant medication is more effective than either treatment alone (Blackburn et al, 1981) and that CBT treatment may lead to a reduction in future relapse (Evans et al, 1992). Generic CBT skills provide a readily accessible model for patient assessment and management and can usefully inform general clinical skills in everyday practice.

Simulated or standardised patients have been used in medical education and other medical settings for some 30 years (Box 1). Their use encompasses undergraduate and postgraduate learning, the monitoring of doctors' performance and standardisation of clinical examinations. Simulation has been used for instruction in industry and the military for much longer (Jason et al, 1971) but the first known effective use of simulated patients was by Barrows & Abrahamson (1964), who used them to appraise students' performance in clinical neurology examinations.

Culliford (2002, this issue) has given us a valuable tour of what is involved in an appraisal of a patient's spirituality and its relevance to the assessment of mental state and prognosis. My task here is to provide some commentary from the perspective of a Buddhist. What immediately confronts me, therefore, is whether the teachings and practices of Buddhism do, in fact, find a place upon the map here set out. This is not a straightforward question, and this alone illustrates the fact that this is a subject within which one has to be willing to encompass, or at least allow for, differences of basic paradigm. However, what strikes me particularly is the fact that the Buddhist paradigm actually may be less at odds with the medical model than many might imagine.

‘In some few jails are confined idiots and lunatics, –many of the bridewells are crowded and offensive, because the rooms which were designed for prisoners are occupied by lunatics. The insane, when they are not kept separate, disturb and terrify other prisoners. No care is taken of them, although it is probable that by medicines, and proper regimen, some of them might be restored to their senses, and usefulness in life’ (Howard, 1784: pp. 10–11).

Group psychotherapy is one of the most widely practised treatment methods in psychiatry, with an extensive literature, but it has long been regarded as the poor relation to individual therapy. Nineteenth-century ideas about the primacy of the individual, taken up by psychoanalysis, continue to dominate Western culture. Mrs Thatcher's famous remark “I don't believe in society. There is no such thing, only individual people, and there are families” (Women's Own, 31 October 1987) typifies the extreme view in which the self and the individual's needs are paramount and are set above those of the group. Foulkes in the 1950s had put forward the opposite position, arguing that there is no such thing as an individual that exists apart from and outside the social (Foulkes, 1948; Foulkes & Anthony, 1957).

Reform of mental health legislation has been under consideration for several years in England and Wales (Department of Health, 2000a), where the Mental Health Act 1983 is in force, and in Scotland (Millan Committee Secretariat, 2001), which is governed by the Mental Health (Scotland) Act 1984. The Mental Health (Northern Ireland) Order 1986 is also under review, although the findings have yet to be published.

It is a sign of the progress we have made in the field of learning disability that it is possible to consider three previously taboo subjects in one paper. Before 1979, there was no published English clinical or theoretical paper which looked at either talking treatments for people with learning disabilities, treatment for those who survived physical and sexual abuse or, specifically, talking treatment for survivors of abuse who also have learning disabilities. Such steps forward bring hope for the future, but also pain concerning the past. How often have emotional and behavioural communications of betrayal and violation been ascribed to ‘disability’ and not been properly considered because there was no social intellectual context to help us to consider that there might be a reason for them? This also illustrates the need for continuing professional humility and toleration of uncertainty. What painful experiences and communications of our patients are we missing today because of internal and external taboos? How will we feel when we become aware of them in another 10 or 20 years' time?

I read Culliford's article (2002, this issue) with keen interest. I am pleased to comment on some of the aspects from the traditional view of my Islamic faith. Let me begin with the terminology. In Islam, the term spirituality is inseparable from the awareness of the One, of Allah (God), and a life lived according to His Will. This principle of Oneness (Al-tawheed –unity) must be taken into consideration in any study of Islamic spirituality. In the Qur'an, God has manifested that which is within the soul of man. He has ‘breathed into man’ His own spirit. The word that Muslims use for spirituality is ruhaniyyah. Ruh, which means spirit, is mentioned in the Qur'an; ‘The Spirit is from the command of my Lord’ (Chapter 17, verse 85).

Most of the excitatory neurotransmission in the central nervous system (CNS) is mediated by the endogenous excitatory amino acids (EAAs) glutamate, aspartate and homocysteine. Most of the endogenous inhibitory neurotransmission is mediated by gamma-aminobutyric acid (GABA). EAAs modulate the firing of almost all neurons in the CNS, as excitatory neurotransmission can result in both neuronal inhibition and excitation. The glutamate system is the best characterised of the EAA systems (Box 1).

It is estimated that 29% of adults in the UK smoke (Office for National Statistics, 2000). Each year smoking kills 120 000 people (13 deaths per hour), making it the single most common preventable cause of death in Britain (Callum, 1998). Around half of all smokers will die prematurely because of their addiction (Peto et al, 1994). Their overall life expectancy is, on average, 8 years less than for non-smokers (Callum, 1998). Smoking also costs the National Health Service (NHS) £1500 million, with around 1000 admissions every day for smoking-related illnesses (Parrott et al, 1998). (However, the UK treasury earns £8 billion in tax on tobacco sold in the UK alone, in addition to the enormous revenue from overseas markets.)

Man can change and go on changing as long as he lives (Horney, 1942)

There is widespread support for a positive and lasting relationship between participation in regular exercise and various indices of mental health, and several consensus documents and reviews (e.g. Biddle et al, 2000; Craft & Landers, 1998) have been published in this field. The evidence for psychological benefits, although impressive for mentally healthy individuals, is even stronger for psychiatric populations (Martinsen & Stephens, 1994). For example, a number of studies have demonstrated a positive relationship between exercise and mental health in people with alcohol misuse problems (Donaghy et al, 1991), people with schizophrenia (Chamove, 1986; Faulkner & Sparkes, 1999) and those with clinical depression (Mutrie, 1988; Martinsen, 1993; 1994; Martinsen et al, 1989a, b).

The National Health Service (NHS) spent £10 billion (40%) of its total budget on people aged 65 and over in 1998/1999. The profile of the health and social care of older people has been raised recently by the publication of the National Service Framework (NSF) for Older People (Department of Health, 2001). The NSF contains standards that older people can expect when they receive health and social care (Box 1). The document also discusses in detail medication management issues in older people. Its two aims in this area are to ensure that older people gain the maximum benefit from their medication in order to maintain or improve quality and duration of life, and do not suffer unnecessarily from illness caused by excessive, inappropriate or inadequate consumption of medicines.

The syllabus for higher training in forensic psychiatry requires knowledge of the therapeutic uses of security, although there are no references to this in standard texts. Similarly, the process of mapping a mental health service is an essential first step in planning, audit and needs assessment. All mental health services, not just forensic services, are organised to stratify patients according to the risk they present so that they can be cared for in an environment that is safe but imposes the minimum necessary restrictions and intrusions. Forensic mental health services differ from other mental health services mainly by including subsystems which are at higher levels of security than those necessary in local services. Although they have a general orientation towards risk awareness and risk management, they remain integral parts of the mental health services for the populations they serve.