The treatment of anxiety is one of the more contentious issues in therapeutics. It is also one of the most important, as pathological anxiety is such a common symptom in the population. The recent Office of Population Censuses and Surveys survey of psychiatric morbidity indicated that one in eight of all those interviewed had an anxiety disorder of sufficient severity to receive a formal diagnostic label in the week before interview (Meltzer et al, 1994). Clearly, only a proportion of these should be treated with drugs, and selection for pharmacotherapy is one of the more difficult issues in clinical practice. It is a matter of some concern that changes in the National Health Service are increasingly shifting the onus of responsibility for treatment from the psychiatrist to the general practitioner. As a consequence, it behoves both disciplines to keep liaison active, so that best practice can be maintained from whatever source it is being provided.

At most, 15% of patients in Western countries remain free of relapse after their first episode of schizophrenia (Crow et al, 1986). Like many chronic illnesses, schizophrenia can be controlled by appropriate treatment, but there may be a gradual deterioration over time. This encompasses problems such as loss of self-care, communication and community skills; negative symptoms of poverty of affect and ideation; cognitive impairment; behaviour problems such as aggression; and poorly controlled positive symptoms.

The number of beds available in the UK for the treatment of mental illness has fallen by over two-thirds since its peak in the mid-1950s. There is a worldwide trend of closure of large mental hospitals and integration of services for the mentally ill in their own local community. Community surveys have shown that an overwhelming majority of mentally ill people are treated in primary care or by specialists, but without being admitted to a hospital. This is now the preferred clinical practice (Shepherd et al, 1981).

The purpose of this review is to outline current knowledge on the life expectation of people suffering from organic brain disease, the techniques available for describing and comparing life expectation in populations, factors which are associated with longer and shorter life expectation, and the causes of death among patients with this condition.

This paper will concentrate on some of the practical contributions that consultant psychiatrists can make in the prevention and treatment of psychiatric impairment in doctors. We will illustrate this with case material from programmes in which there has been a good deal of psychiatrist participation.

This study is presented to encourage recognition of the contribution mental health practitioners can make to the care of head-injured people.

‘Educational supervisor’ is the term now used by the General Medical Council for a consultant who has junior doctors working with him/her, whether employed by the National Health Service or a university. This paper represents our views of the role of the educational supervisor, rather than official College policy.

Although police surgeons (or forensic medical examiners; FMEs) usually assess fitness to be interviewed by the police (Norfolk, 1996), psychiatrists may also be asked for an opinion (Protheroe & Roney, 1996).

The role of the general practitioner (GP) in the care of individuals with mental health problems has long been recognised. Goldberg & Huxleys' (1980) pioneering work on the pathways to mental health care demonstrated that only a fraction of identified mental health problems are referred on to psychiatrists. Goldberg & Bridges (1987) estimated that between 20 and 25% of a GP's workload concerns mental health, with only about 5% referred on to psychiatrists. Shepherd (1991) insisted that the only real hope for significant improvement in mental health care lay in the improvement of GP provision – there will simply never be enough psychiatrists.

Anxiety is a very common and disabling condition which has serious consequences for patients, their families and society in general. The past decade has witnessed an increase in the recognition and understanding of the problem but considerable confusion and debate remains over attitudes towards treatment. The background to this controversy dates from the late 1980s when widespread and vehement criticism of doctors and drug companies over the use of benzodiazepines began. Although the litigation was unsuccessful, it resulted in a pervading feeling of uncertainty (both within the medical profession and among patients) about prescribing or taking any drug as a treatment for anxiety. The situation has been further confounded by the split that has occurred between the proponents of pharmacological and psychological approaches to management. These controversies have left the practising clinician in an unenviable position, with few practical or relevant guidelines to follow. Developments over recent years, however, should put an end to this confusion; new pharmacotherapies such as the selective serotonin reuptake inhibitors (SSRIs) and buspirone, and older ones such as the tricyclic antidepressants (TCAs), have emerged as effective alternatives to the benzodiazepines and have been paralleled by a similar growth in effective and available psychological treatments, particularly cognitive and cognitive–behavioural therapy. This progress seems set to continue with the rapid expansion of knowledge about the brain circuits and transmitters regulating anxiety that is now emerging from imaging studies.

Until 50 years ago chronic pain was not considered to be a medical condition that required special evaluation and treatment facilities. Pain was considered to be an indicator of tissue damage and appropriate medical or surgical treatment was prescribed for this. The many patients who had continuing pain because of the results of disease or trauma or because acute treatment was unable to relieve the condition were not seen as suffering from a recognised pathological entity. It was not until a doctor, Sicilian-born John J. Bonica, had to pay his debts as a medical student through wrestling professionally, and later suffered persistent pain as a result, that chronic pain became a recognised condition in its own right. Bonica started a pain clinic in Tacoma, Washington State, in 1949 and wrote the first textbook on pain treatment, The Management of Pain, in 1953. There are now 2000–3000 pain clinics in the USA and almost 5000 worldwide.

The most taxing behavioural complications of severe head injury for relatives include irritability and aggression, as illustrated by J. B. Longitudinal studies show an increase over time in the frequency and severity of temper outbursts (Brooks et al, 1986; Hall et al, 1994), which take the form of explosive or impulsive aggression. I will comment on the nature and treatment of impulsive aggression as illustrated in case J. B., emphasising the interaction of neurobiology with motivational, situational and personality factors.

This paper will focus primarily on the most recent research studies involving doctors in the UK. We will not discuss the treatment of doctors who are psychiatrically unwell as this is covered in other papers elsewhere in this issue. Before reviewing specific studies, we will consider the measurement of psychiatric disorder, stress and burn-out.

Of all the controversies over the different medications used in psychiatry, there is probably least dispute about the effectiveness of antidepressants in controlling depressive illness. However, the choice of which antidepressant to use is bedevilled by the spectre of potential toxicity from adverse effects, interactions and overdose. The unwanted effects may vary from mild and tolerable to potentially lethal. At one time it was relatively easy to become familiar with the problems surrounding the original two main groups of antidepressants – the tricyclic antidepressants (TCAs) and the monoamine oxidase inhibitors (MAOIs). Recent years have seen the introduction of a number of newer drugs, with a wide range of chemical structures and differing pharmacological activities. They also have a new spectrum of adverse effects and interactions. It is worth reviewing the major differences between old and new antidepressants, and to identify the areas in which clinical caution must be exercised in order to avoid pitfalls and maximise clinical benefit.

Seasonal affective disorder (SAD) is a recurrent depressive disorder in which episodes occur at a particular time of year. The most frequent variant is winter SAD in which patients become depressed during the autumn or early winter, with remission or conversion to hypomania the following spring. Recognition of winter SAD is important because the diagnosis predicts a good response to the novel treatment of phototherapy. One other variant, summer SAD, has also been described and we will discuss this condition separately. Otherwise, we will confine our discussion to the winter variant which we will refer to as SAD.

The Government White Paper ‘Working for Patients' (1989) incorporated the idea of general practitioners (GPs) managing funds in order to purchase health services for the patients under their care. The aim was for decisions about purchasing and providing health care to be taken as close to the patient as possible, by their own GP. It has meant that two forms of purchasing have grown side by side – health authority and GP fundholding. Subsequent policy changes have made fundholding accessible to more practices, and have extended the fundholders' areas of purchasing. More than 50% of the population in England are now covered by fundholding GPs. The proportion of GPs who are fundholders varies enormously geographically, with high levels in the West Midlands, Trent, South Thames, Oxford and Anglia regions, where the collective purchasing function of GP fundholders is now very considerable.

The development of the first effective antidepressants in the late 1950s marked a turning point in the treatment of depressive illness. In 1957 the monoamine oxidase inhibitor (MAOI) iproniazid was discovered by chance, while searching for new antituberculous drugs. One year later the tricyclic antidepressant (TCA) imipramine was introduced, having been developed originally as an antipsychotic. A number of other drugs were subsequently added to these two groups of antidepressants, which dominated the field for the next three decades.

Autism is a pervasive and life-long disorder that is characterised by profound deficits in communication and social understanding, together with ritualistic and obsessional behaviours and a general resistance to change. Although usually associated with additional cognitive impairments (approximately 50% of those affected have an IQ below 50) the condition can occur in individuals of all levels of ability, and around 20% of cases have an IQ within the normal range. Estimates of prevalence vary from 3.3 to 16.0 per 10 000 and rates may be even higher if children within the autistic wider spectrum are included (Wing, 1993, 1996). Understanding of causation is still limited, although genetic factors are now known to play a major role (Lord & Rutter, 1994).

Clinical management of patients across cultures challenges the clinician's familiar tried and tested strategies. The relationship between the patient and the psychiatrist is often examined in isolation from a number of premises which both patient and professional bring to the encounter: previous experience of other cultures, contact with less familiar cultures, past experiences and socioeconomic status are some of the determinant influences. There are a number of ways in which the clinician can facilitate therapeutic effectiveness. However, a trusting relationship must first emerge such that the patient has faith in the treatment recommendations. Special difficulties can arise in the context of pharmacological, social, psychotherapeutic and psychological interventions. Community, out-patient, in-patient and emergency settings each require that consideration be given to the context of the assessment and treatment process, as well as the content and immediate outcome. The clinician must plan the assessment and intervention carefully. The rationale and goals of treatment should be discussed and agreed by participants in the therapeutic interaction. Special groups have unique cultural and historical obstacles to receiving health care. Potential problems are highlighted in this paper and suggestions made for managing conflicts when they arise.

It has been estimated that every year 8 per 100 000 of the population suffer severe head injury, 18 per 100 000 suffer moderate head injury and 250–300 per 100 000 suffer mild head injury (Medical Disability Society, 1988). It is likely that 100–150 per 100 000 of the population have significant disability as the result of head injury (Department of Health, 1994).