Violent behaviour in people with a psychiatric disorder causes great public concern and leads to stigma for people with mental illness. There is good evidence for a correlation between schizophrenia and increased rates of violence but any association between mood disorders and violence has been comparatively overlooked. It appears that there may be more evidence relating mood disorders and violence than many clinicians realise. This article highlights the difficulties in assessing this, summarises what is known and discusses what this means for clinical practice.

Different cultures vary in their perceptions of mental illness (Karno & Edgerton, 1969), which can affect their utilisation of orthodox psychiatric facilities (Padilla et al, 1975; Sue, 1977). Mental health services may be seen by ethnic minorities as challenging the value of traditional support systems, reflecting dominant Western cultural values and harbouring implicitly racist psychological formulations. The clinician-patient interaction may become fraught with misunderstandings if the two parties come from different cultural backgrounds and bring distinct cultural expectations to the encounter.

The authors describe the main forms of supported accommodation available to people with mental health problems in the UK. They address the questions of who needs supported accommodation and how people may be selected for the differing types of unit. Historical trends and policy in this area are reviewed and the general research evidence and evidence of cost-effectiveness are considered. A ‘total system’ approach to assessing accommodation need in a locality is advocated. The authors also consider key quality issues that should be addressed for supported accommodation to be effective.

Sequenced (stepped) treatment approaches are widely endorsed in the management of depression. Combining antidepressants is a recognised step for those failing to respond to monotherapy. Despite the limited evidence base, this strategy is widely used by clinicians in practice. Not every combination used clinically has a sound neuropharmacological rationale and the use of such combinations may increase the side-effect burden without any additional advantage to the patient. Efficacy of various antidepressant combinations along with the data on side-effect profile and toxicity of such combined treatments are reviewed here. The different combinations are considered by each class of antidepressant available in the UK.

Use of both licit and illicit drugs can lead to a range of medical, psychiatric and social problems, and the situation becomes further complicated if the user is pregnant. Prescribed and non-prescribed substances can affect a pregnancy, and substances are seldom used in isolation. In this review we focus on users of illicit drugs (including prescribed drugs used illicitly) during pregnancy and describe some of the issues in managing such cases. We consider the impact of subtance use on the foetus, the mother and the newborn child, and highlight the importance of multidisciplinary working in this area. Space precludes a detailed account of the issues surrounding the use of legal substances such as alcohol and tobacco during pregnancy, but we note their significant impact in this group.

Routine outcome measures are essential to chart individual patient progress and evaluate models of service provision. The Health of the Nation Outcome Scales (HoNOS) were commissioned by the Royal College of Psychiatrists as a simple, brief measure for this purpose. It is one of the most widely used outcome measures in mental health services globally and has been translated into at least seven languages. Its use has broadened beyond its original purpose and in several countries collection of HoNOS data is mandatory. We review 585 potential articles to chart the development and evolution of HoNOS, as well as its psychometric properties, qualitative attributes and uses in clinical practice and research. The potential barriers to implementation of HoNOS on a wide scale are considered and its future role in evaluating effectiveness and benchmarking of services are discussed.

Social phobia (or social anxiety disorder) manifests as a marked and persistent fear of negative evaluation in social or performance situations. The epidemiology, diagnosis and psychopathology are reviewed, including clinical presentation, cultural aspects and the differences between agoraphobia and social phobia. Behavioural treatments, including graded self-exposure and cognitive restructuring, are considered. A cognitive model of the maintenance of social phobia is discussed. It is hypothesised that attentional shifting towards imagery, safety behaviours and ‘post-mortem’ analyses play a key role in symptom maintenance. The implications of this for treatment are described, and guidelines for pharmacological treatment are summarised.

Acquired brain damage in children is not uncommon, head injuries being the most frequent cause. Brain injury may also occur during the very vulnerable periods of rapid growth of the foetal brain from prenatal trauma/strokes, during a difficult birth, or postnatally from strokes, infections (e.g. meningitis and encephalitis), metabolic disturbances (e.g. phenylketonuria), treatment (e.g. central nervous system (CNS) surgery or radiotherapy for leukaemia) or toxins (e.g. alcohol and valproate). This paper concentrates on the assessment of and interventions following acquired brain injury sustained after the first 2 years of life, that is, after a period of relatively normal development when there has been an expectation that a child will follow the usual trajectory in development and learning throughout childhood and adolescence. Acquired brain injury in younger children tends to have global and profound effects, for instance, from CNS radiation (Said et al, 1989) or head injury (Levin et al, 1995). Injury in older children may result in more specific or focal problems depending on the mechanism of injury.

A male farmer in his forties from the Irish Republic was referred for an opinion on his mood swings and their possible relationship with organophosphate exposure. He had been regularly exposed to organophosphorus sheep dips for around 15 years prior to the assessment.

Barring a few exceptions (such as rauwolfia), most of the psychiatric medications have been developed in the West, especially the USA, the UK and Europe. Their safety trials have been conducted in the populations living in these parts of the world. Although these drugs are used all over the world there is a limited research to determine accurate pharmacodynamic and pharmacokinetic profiles across different ethnic groups. Hence, clinicians usually adopt a ‘universalist style’ (seeing every condition and treatment as similar) of managing psychiatric illnesses, but this appears to neglect the information from the emerging literature which advocates a relativist approach to pharmacotherapy (see Lin et al 1995 for review). Anthropologists have encountered ‘phenomenological absolutism’ in a general tendency of people from one culture to perceive and value other cultures in terms unconsciously based upon their own, but phenomenologically experienced as absolute and universally applicable (also known as ethnocentrism). In addition to ethno-biological determinants of drug response, there are significant cultural factors: the concurrent use of pluralistic health systems, alternative therapies and folk remedies which might support, hinder or complicate pharmacotherapy and treatment adherence. In this paper we highlight some key factors of which clinicians need to be aware. These include pharmacodynamic and pharmacokinetic principles, and application of these principles in pharmacological management of psychiatric conditions. Ethnic differences in pharmacodynamics are most clearly demonstrated in the greater sensitivity to a variety of drugs in Caucasians than in Asians or in African–Caribbeans.

Benzodiazepines still play an important role in the management of anxiety disorders but dependence is associated with their therapeutic use. The key to effective and safe long-term use of benzodiazepines is: the careful selection of patients who might benefit from them; administration in clinical situations in which they are more likely to be beneficial; use of lower doses and in conjunction with an antidepressant, if possible; monitoring and managing their side-effects; and minimising the risk of withdrawal symptoms and relapse, mainly through tapering the dose and/or combining with effective psychological interventions.

Treatment of alcohol use disorders typically involves a combination of pharmacotherapy and psychosocial interventions. About one-quarter of people with alcohol dependence (‘alcoholics’) who seek treatment remain abstinent over 1 year. Research has consistently shown that less intensive, community treatment (particularly brief interventions) is just as effective as intense, residential treatment. Many psychosocial treatments are probably equally effective. Techniques for medically assisted detoxification are widespread and effective. More recent evidence provides some support for the use of drugs such as acamprosate to prevent relapse in the medium to long term.

From the 1991 census (Office of Population Censuses and Surveys, 1993) it is estimated that 5.9% of the total population of England and Wales belong to an ethnic minority, and that 3% of this ethnic minority population are aged 65 years and older. This compares with 17% aged 65 years and older in the indigenous population. Although the numbers of elderly people from ethnic minorities are small in absolute terms, these groups are growing rapidly, and mental health professionals working with elderly patients will increasingly need to be equipped with the necessary services and skills to meet their specific needs. The elderly ethnic minority population of the UK is extremely diverse; the largest groups originate from the Indian subcontinent and the Caribbean, but there are also significant communities of Chinese, Somali, Vietnamese, Eastern European, Mediterranean and Irish origin, all of which require consideration when planning and providing services, whatever their numbers. This diversity is also important when considering the various factors that influence the presentation and diagnosis of mental disorders in these groups.

This article summarises internet-mediated approaches to conducting quantitative and qualitative cross-sectional mental health research, and describes aspects of research design to consider for optimising scientific rigour and validity as well as response. Rapid adoption of internet-mediated approaches risks compromising the quality of the methods used. Not only can it cause distress to participants, but methodological problems may lead to inappropriate inferences being made from research findings. In this article the advantages of using internet communication for research purposes are balanced against the disadvantages, using examples of recent internet-mediated research (IMR) studies to illustrate good practice.

Pathological gambling has so far received scant attention in the psychiatric literature. It has a prevalence rate of about 1% in most countries, and with the deregulation of gambling in the UK the prevalence is set to rise here. Pathological gambling can adversely affect the individual, family and society, and also carries high rates of psychiatric comorbidity. Early identification and appropriate treatment can limit the long-term adverse consequences and improve outcome. This article reviews assessment techniques and tools, and treatment strategies for pathological gambling.

Herbal remedies are used by many people suffering from anxiety or depression. It is therefore important to know whether they generate more good than harm. A systematic review of the published literature revealed trial data for Ginkgo biloba, Lavandula angustifolia, Hypericum perforatum, Valeriana officinalis, Crataegus oxyacantha, Eschscholzia californica, Matricaria recutita, Melissa officinalis, Passiflora incarnate and Piper methysticum. Only two of these herbal remedies are supported by sound evidence: Hypericum perforatum (St John's wort) for mild to moderate depression and Piper methysticum (kava) for anxiety. Neither is free of risks. Our knowledge of herbal remedies is incomplete and the subject merits rigorous study.

Knowledge management sounds superficially like yet another of those topical expressions describing something that has been developed outside medicine and is possibly ill-suited for application within the field, but offering an excuse for yet more change. However, one of the distinguishing features of every profession is that it applies a body of specialist knowledge and skills to a defined purpose. Knowledge in medicine is growing exponentially. In a recent survey of just 22 general practices, the practice guidelines identified weighed 28 kg (Hibble et al, 1998)! In psychiatry, about 5500 papers which potentially have clinical relevance are published annually. Keeping pace with knowledge as it grows is a major challenge for all clinicians. This is reflected in the National Health Service (NHS) information strategy, which identifies three specific needs of clinicians (NHS Executive, 1998). These are:

1. • fast, reliable and accurate information about patients in their care;

2. • access to knowledge to inform clinical practice;

3. • access to information to underpin evaluation of clinical practice, planning and research, clinical governance and continuing professional development.

Ketamine, a synthetic derivative of phencyclidine, is a commonly misused party drug that is restricted in high-income countries because of its addictive potential. Ketamine is also used as an anaesthetic in human and veterinary medicine. In the 1990s, research using ketamine to study the pathophysiology of schizophrenia was terminated owing to ethical concerns. Recently, controversy surrounding the drug has returned, as researchers have demonstrated that intravenous ketamine infusion has a rapid antidepressant effect and have therefore proposed ketamine as a novel antidepressant. This article debates the question of ketamine as an antidepressant, considering the drug's addictive potential, ethical concerns about prescribing a hallucinogen, the evidence base and motives behind ketamine trials.

The history of the concept of the placebo effect and research into its quantification and mechanisms are reviewed, particularly in relation to psychiatry. Research has demonstrated a notable placebo effect in depression: a large proportion of the clinical effect of antidepressant medication is attributable to the effect. Various mechanisms have been hypothesised: anxiety relief, expectation, transference, ‘meaning effects' and conditioning. Recent research from neuroimaging has unveiled that the effect is associated with biological correlates in the brain. Despite the renewal of research into the placebo effect, many questions remain unanswered. This partly reflects philosophical obstacles such as the mind/body dichotomy, which are inherent in conceptualising the effect. However, it also demonstrates the vast scope for further research into this area. Ultimately, an understanding of the processes that underlie the placebo effect should allow a rationalised therapeutic approach to be developed to maximise the clinical benefit of the therapeutic encounter.

Cognitive dysfunction is one of the major contributors to the burden of epilepsy. It can significantly disrupt intellectual development in children and functional status and quality of life in adults. Epilepsy affects cognition through a number of mechanisms in complex interrelationship. Cognitive deficits in epilepsy may be treated indirectly through aggressive seizure control using anti-epileptic drugs or surgery, and by treating comorbid conditions such as depression. The beneficial effects of reducing seizures may offset the adverse cognitive side-effects of these therapies. Direct treatment of cognitive impairment in epilepsy mainly involves memory rehabilitation. Other direct treatments are mostly experimental and their evidence base is currently poor.