Somatising disorders, characterised by complaints of unexplained physical symptoms, are common presentations in children and adolescents, both in primary and secondary care settings. They have significant impact on the children themselves and on health care resources: as in adults, there is a wide range of severity and resulting handicaps.

With progressive deinstitutionalisation in many countries, the general psychiatrist is now more frequently requested to provide assistance with behavioural problems in people with learning disabilities. There are a range of challenges in providing quality care for these people. There are challenges in assessment and diagnosis, in coordinating behavioural and social interventions with pharmacotherapy, and in the lack of psychopharmacological research in this population, which results in a diminished evidence base. In addition, there are numerous factors beyond the patient. These include legal consent requirements and the complex system of carers surrounding those with disabilities with whom the practitioner may need to interact.

At present, the elderly constitute 18% of our population but receive 45% of prescribed drugs (Royal College of Physicians, 1997). Many patients (78%) receive medication via a repeat prescription system and for approximately a quarter of prescriptions written for this age group, patients have not seen their doctor for over a year. A substantial proportion of the elderly live not in their own homes but in residential or nursing homes, and a small number live hospital. Prescribing and administering medicines poses different problems in each of these settings.

The term ‘therapeutic community’ is usually used in the UK to describe small cohesive communities where patients (often referred to as residents) have a significant involvement in decision-making and the practicalities of running the unit. Based on ideas of collective responsibility, citizenship and empowerment, therapeutic communities are deliberately structured in a way that encourages personal responsibility and avoids unhelpful dependency on professionals. Patients are seen as bringing strengths and creative energy into the therapeutic setting, and the peer group is seen as all-important in establishing a strong therapeutic alliance. The flattened hierarchy and delegated decision-making are sometimes misunderstood as anarchy by outsiders. However, staff in modern therapeutic communities are deeply aware of the need for strong leadership and their responsibility to provide a safe ‘frame’ for therapeutic work (Association of Therapeutic Communities, 1999).

In March 1997 APT published two reviews of the use of benzodiazepines, buspirone, beta-blocking drugs and antidepressants in the treatment of anxiety disorders (Cowen, 1997; Tyrer, 1997). These were followed by a paper on the practical pharmacotherapy of anxiety (Nutt & Bell, 1997). The present review was originally prompted for several reasons. A number of large-scale investigations of the use of antidepressants in anxiety disorders have been completed since those papers were published. Indeed, several antidepressant drugs have since been licensed to treat anxiety disorders, and more applications are being considered. El-Khayat & Baldwin (1998) found that the prescription of antipsychotic drugs for anxiety disorders was widespread, but concluded there was no methodologically sound evidence to support their prescription. They suggested that this use of antipsychotic drugs reflected the fears of practitioners about the risks associated with benzodiazepines. There is no reason why the prescription of antidepressant drugs should arouse such fears, and it seemed timely to produce an up-to-date review of their efficacy in the treatment of anxiety disorders. This view was reinforced while this manuscript was in preparation, when the Committee on Safety of Medicines issued a statement in December 2000 that restricted the indications for the prescription of thioridazine because of concerns about rare but serious cardiotoxicity; thioridazine was no longer to be indicated for the treatment of anxiety or psychomotor agitation.

Over the past 20–30 years psychiatry has gradually moved from predominantly hospital-based care to care in the community. Community psychiatry embraces a variety of definitions: it may describe the practice setting, the population served or the philosophy of illness and treatment (Johnston et al, 1995). In discussing the training implications of this shift towards community models of psychiatric care, we will not consider a separate discipline of ‘adult community psychiatry’. We believe that nearly all psychiatric specialities now involve substantial elements of work outside the hospital, and we therefore contend that the new skills, knowledge and attitudes required to meet the challenge of providing both hospital- and community-based care are pertinent to all trainees. Furthermore, the development of these are essential if the consultant of the future is to provide the safe, effective and sustainable service to those with complex mental health needs detailed in the recent National Service Framework (NSF) for Mental Health (Department of Health, 1999). We will also not attempt specifically to assess the merits of the move to community psychiatry, which may be subject to a separate debate.

The term ‘challenging behaviour’ was introduced in North America in the 1980s, and was originally used to describe problematic behaviours in people with ‘mental retardation’ (learning disabilities). Challenging behaviour can, however, occur across the intellectual spectrum, being particularly prevalent in populations with psychiatric disorder.

Creutzfeldt–Jakob disease (CJD) is a devastating illness that is rare and notorious in equal measures. In 1996 a ‘new variant’ (vCJD) was identified (Will et al, 1996), which is likely to be caused by humans eating beef infected with bovine spongiform encephalopathy (BSE). Although the number of new cases of vCJD has not started rising, the long incubation period means that it will be many years before a major epidemic in humans can be ruled out. In the meantime, representatives of patients with vCJD have expressed concerns about the care that sufferers receive. In particular, patients often present with psychiatric symptoms, but there is some delay before the correct diagnosis is made.

Depression, in its severest forms, causes severe morbidity, has a high incidence of mortality and requires emergency treatment. In a previous article in this journal (Porter & Ferrier, 1999), we discussed the emergency treatment of severe depression by pharmacological means and electroconvulsive therapy (ECT). Here, we will discuss the contribution of non-pharmacological aspects of management to fast, effective and safe treatment of severe depression. We will also complete our review of this subject by examining the efficacy of some emerging therapeutic interventions for severe depression.

The epidemiology and management of schizophrenia have been well studied over the past few decades. In the UK, key findings that have emerged time and again are the excess prevalence and incidence rates of schizophrenia among people of African–Caribbean origin. The reasons for this excess and the implications of this finding are many. The findings may reflect a true excess or a methodological artefact related to errors in the estimation of numerator and denominator data. The findings have been increasingly accepted as better designed studies have emerged, but these still do not fully address concerns about the nature of schizophrenia in other cultural groups and in societies in which industrialisation and economic productivity of the individual are not considered to be as crucial for an individual's sense of belonging in a community.

An editorial in The Lancet two decades ago (Lancet, 1981) described the contemporary practice of electroconvulsive therapy (ECT) in Britain as “a shameful state of affairs”. It concluded that, “if ECT is ever legislated against or falls into disuse it will not be because it is an ineffective or dangerous treatment; it will be because psychiatrists have failed to supervise and monitor its use adequately”.

The practice of brief psychotherapy is a distillate of the active ingredients in longer-term work but with the addition of two special elements: limited time and therapist activity in formulating a focus and focusing on it. Typically, patient and therapist work together over 10 to 25 sessions in weekly meetings. In very brief dynamic psychotherapy (VBDT), the time frame is shrunk to fewer than 10 sessions, sometimes just a single session; the constraint means that there is less room for corrective manoeuvre in order to achieve the therapeutic task of maximum benefit and minimum harm in the time available. To do this well requires knowledge, skill and sensitivity. In this paper, special attention is paid to a ‘three-plusone’ intervention (brief intervention and followup (BRF)) that has been tested in a randomised controlled trial (RCT).

Human beings have moved from place to place since time immemorial. The reasons for and the duration of these migrations put extraordinary stress on individuals and their families. Such stress may not be related to an increase in mental illness for all conditions or to the same extent across all migrant groups. In this paper, we provide an overview of some observations in the field of migration and mental health, hypothesise why some individuals and groups are more vulnerable to psychiatric conditions, and consider the impact of migration experiences on provision of services and care.

Every year one in ten women in the UK is subjected to physical abuse from a partner or ex-partner, while one in four experiences such abuse at some point in their lives (Mooney, 1993; Morley & Mullender, 1994a). Domestic violence is one of the most pervasive of all social problems, affecting most of the population directly or indirectly (Box 1). I cannot think of a single close friend or colleague whose life has not been touched by this largely hidden problem.

What does it mean to respect autonomy and encourage meaningful consent to treatment in the case of patients who have dementia or are otherwise incompetent? This question has been thrown into sharp relief by the Law Lords' decision in R.v Bournewood Community and Mental Health NHS Trust, ex parte L (1998). The effect of the Law Lords' ruling in the Bournewood judgment is to reinforce problematic and serious anomalies in the way we view patients whose competence is in doubt because of their mental disorder. Others, such as relatives and informal carers, are frequently allowed to decide on behalf of adults whose competence is doubtful in a way that English law generally abhors, even for totally incompetent patients in a persistent vegetative state. This raises profound questions about autonomy. And incompetent adults' consent to treatment is not required to be of the same quality as it is for the rest of us: mere absence of resistance will do. This paper will explore the philosophical, jurisprudential and legal implications of this difference. Throughout I will be more concerned with the ramifications of a finding of incapacity than with how such a finding is made (for the latter, see such classic texts as Applebaum & Roth (1982), Grisso & Applebaum (1998) and Bellhouse et al (2001)).

The DSM–IV classification of body dysmorphic disorder (BDD) refers to an individual's preoccupation with an ‘imagined’ defect in his or her appearance or markedly excessive concern with a slight physical anomaly (American Psychiatric Association, 1994). An Italian psychiatrist, Morselli, first used the term ‘dysmorphophobia’ in 1886, although it is now falling into disuse, probably because ICD–10 (World Health Organization, 1992) has discarded it, subsuming the condition under hypochondriacal disorder.

Part-time training and working have become popular acceptable options for both male and female psychiatrists, regardless of age. There are a number of reasons for this, the most common being family commitments such as those to children or elderly relatives, but also including personal ill health, wanting to reduce stress and prevent burn-out, wanting to pursue different priorities, portfolioworking or simply trying to achieve a better quality of life. The importance of providing flexible working patterns has been emphasised by the Department of Health (1998) in Working Together – Securing a Quality Workforce for the NHS.