The occurrence of depression in people with learning disability is not a late-20th century phenomenon. Reports were first published in the 1800s describing the existence of depression in individuals with intellectual impairment (Clouston, 1883). However, as we enter a new millennium, the appropriate diagnosis, assessment and treatment of depression, and indeed all forms of mental illness in people with learning disability, will become the focus of considerable concern for all professionals working in this field. With recent national trends towards de-institutionalisation, referral of individuals with learning disability to psychiatrists to ‘rule out a possible depressive illness' and to ‘advise about further treatment’ will increase. It remains essential for all psychiatrists in learning disability to continue to improve their diagnostic skills to better manage depressive episodes and, where possible, to learn how to prevent a future relapse. This review highlights the important presentation and management issues relating to depression in the field of learning disability. Depression in this review implies a single major depressive episode, irrespective of whether or not it conforms to any given classification system.

The concept of computer addiction is examined and the importance of conceptual and nosological clarity emphasised. The risk of tautology in the construction of such conditions is raised, as is the issue of whether it would be better to classify many affected individuals in terms of the end behaviour rather than the mediating mechanism. Definitional difficulties and sociocultural contexts are explored.

This paper considers how death and dying are presented in literature. A wide range of texts, principally but not exclusively from the English language tradition, is used to illustrate themes. Broad categories are suggested for the study of death: some authors give personal accounts of their impending death or their sense of bereavement; some use literature to structure and order our thoughts about death; and some treat death as a literary device, using it, for example, as a symbolic representation of the decay of society. It concludes that the biggest obstacles that health professionals and patients face as they attempt to understand death in literature are concerned not with a lack of appropriate emotional depth, but with difficulties either in understanding the conventions of literature or in coming to terms with the cultural gaps imposed by time and place.

A classification system can benefit disturbed children enormously by bringing to bear a wealth of knowledge and experience. This can make all the difference between an inadequate consultation and a precise formulation of the nature and extent of a child's difficulties, their cause, the likely outcome and a realistic treatment plan. However, inappropriate application of a diagnostic label that has little validity could do more harm than good, and classification systems can be misused. This paper discusses, with examples, issues particular to childhood and adolescence that diagnostic systems need to address if they are to be useful. It considers different solutions applied by the two most widely used schemes, the International Classification of Diseases (ICD–10; World Heath Organization, 1992) and the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV; American Psychiatric Association, 1994). Finally, the types of criteria used to validate categories are discussed.

Assessment and management of the risk of violence in psychiatry inevitably and appropriately draws on emotionally laden ‘intuitive’ modes of thought, as well as deliberative analytic thinking. This article discusses the concept of ‘intuition’ and proposes a brief set of guidelines, derived from work by the cognitive psychologist Robin Hogarth, by which intuitive thinking may be applied by clinicians when undertaking risk assessment work. The guidelines are: consider the learning structure relevant to the risk assessment task; use your own emotions as a source of data; impose ‘circuit breakers' such as cost–benefit analyses and validated structured risk assessment tools; and use a narrative approach to develop formulations. The guidelines are intended to provide a framework for ongoing reflective practice in assessing and managing risk.

Home treatment as an alternative to acute adult in-patient care is part of the National Health Service's Plan for mental health services in the UK. As a form of crisis intervention, it benefits from an understanding of, and ways of working with, the social systems relevant to the patient in crisis. This article describes the social systems intervention process as an alternative to admission and also considers its application in achieving early in-patient discharge.

The role that carers play in supporting older people with mental health needs in the community is well recognised by professionals and in current government policy. This article promotes the view that a systematic planned approach that engages the carer as an integral part of the system of care has potential benefits for patients, carers and services. Ways of working in partnership are outlined and evidence that psychosocial interventions with carers are effective is briefly reviewed. Examples of individual and group interventions for dementia carers are given, drawing on clinical experience and research literature. Areas for further development are highlighted, including greater partnerships with carers in primary and continuing care, as well as at the level of planning and service development.

In the 1960s, most people with severe mental illness were treated in large mental hospitals, receiving all their care under one roof, ensuring its continuity and accountability. Deinstitutionalisation resulted in discharge into the community, where care was fragmented between many agencies, making continuity and accountability very difficult. Countless individual programs were developed with few links between them. Not surprisingly, deinstitutionalised patients, in an unfamiliar environment and with poor coping skills to navigate services, did not receive the care they needed.

Suicide may be defined as intentional self-killing, although the definition has been the subject of critical review (Fairbairn, 1995). As the determination of whether intent was present at the time of death by suicide can be difficult, coroner's inquests tend to underestimate the number of suicides. At the time of suicide, the vast majority of people are suffering from some form of mental disorder, although there may, exceptionally, be a few rational suicides. Suicide is a relatively uncommon event, but the possibility of suicide by those with mental disorders is always a potential hazard faced by health and allied professionals responsible for their care. Detention of a patient in hospital under mental health legislation is often precipitated by concern regarding risk of self-harm and/or risk of harm to others and potential for absconding and, at times, admission to a locked or secure facility is necessary. Detained patients in secure facilities include both offender patients, admitted through the courts or transferred during sentence from prison, and patients on civil orders under sections 2 or 3 of the Mental Health Act 1983. The relationship between suicidal behaviour and that which is violent or homicidal is complex but relevant to an understanding of the phenomenon of suicide in secure conditions.

The treatment of acutely disturbed patients is a stressful area of psychiatric practice. Castle et al (1994) found that MRCPsych Part II trainees expressed a general dissatisfaction with training in the management of violence, and in our experience junior trainees are even less confident in the treatment of the disturbed patient. A survey by Cunnane (1994) found that no consensus exists among consultant psychiatrists on which drug treatment is most appropriate for the management of the aggressive, acutely disturbed psychotic patient. There was uncertainty as to optimal management, low expectation of quick results, unwillingness to express an opinion and the use of drug cocktails of dubious rationale.

As psychiatrists, we are responsible for large numbers of patients who require follow-up over years, and often lifelong. Usually these patients suffer from chronic psychotic illnesses, and their psychiatrist may be their main point of contact with the medical profession. As a group they face a whole range of problems – not only from the psychiatric condition itself, with its associated stigma and psychosocial stresses, but also from unemployment, poverty, poor housing and worse physical health.

This review will look at the evidence that patients in continuing care have increased morbidity and mortality. The types of illness excess will be examined and explanations suggested as to why such an increase exists. Finally, we present practical steps that might usefully be taken to reduce physical illness and premature death in this vulnerable group.

Many psychiatric in-patients report boredom. Such complaints may appear trivial, but this literature review by a clinical librarian suggests that boredom is more complex than may initially appear and relates to wider areas of importance for in-patient psychiatric teams. Boredom may relate to the internal experience of meaning, which itself encompasses meaningful relationships and roles and a sense of control. Although meaningful therapeutic activities are vital, mental health professionals should focus on the internal as well as the external dimensions of boredom. Medications, particularly dopamine antagonist antipsychotics, may be a contributing factor. This article highlights the benefits of the clinical librarian role in synthesising research in mental health. Research can illuminate psychiatric practice in a more holistic way than purely by applying 'scientific' evidence in the practice of ‘biological’ psychiatry.

The General Medical Council suggests that leadership skills are a core requirement for all doctors. The NHS Institute for Innovation and Improvement goes further, stating that doctors have not only an intrinsic leadership role but also a responsibility to contribute to the effective running of healthcare organisations. The Medical Leadership Competency Framework (MLCF) outlines a structure with domains, elements and competency outcomes, all of which are clearly spelled out with examples and methods of learning for different stages of a medical career. The revised curriculum for postgraduate training in psychiatry contains many aspects of the MLCF, both complementing and supplementing its emphasis on the development of personal qualities and skills. This article highlights this approach and describes how the development of leadership and management skills fits with the current structures for training in psychiatry.

Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. We discuss how conflicting emotions and perspectives within teams acquire ethical significance and how negotiation and reflection are essential for good-quality ethical reasoning to take place.

Almost all current research into developing new pharmacological treatment for depression and schizophrenia is focused directly on modulating neurotransmitter receptors in the brain. This approach was stimulated by the chance discovery of the prototype psychotropic drugs such as chlorpromazine and imipramine and the subsequent development of hypotheses based on the presumed mode of action of these drugs. Even clozapine was first introduced as yet another dopamine receptor blocker, and it was only after it was recognised that clozapine shows improved efficacy that hypotheses were developed as to its possible mode of action. Subsequent research based on the receptor approach has led to improved side-effect profiles for modern psychotropic agents, but has not resulted in any improvement of efficacy over and above that of the drugs discovered by good fortune rather than by hypotheses.

The management of patients with depression who have failed to respond to antidepressant medication is a common problem in general and old age psychiatry. It has been estimated that about 20–30% of patients with major depression fail to respond to treatment with a single antidepressant drug given in adequate dosage for an appropriate period of time. At the current time there are many possible ways to pursue pharmacological treatment, but few controlled trials to help us choose between the various options. In addition there are few clinical predictors to help match patients to an appropriate treatment.

This article discusses the aetiology of both simple and complex post-traumatic stress disorders (PTSDs) in terms of attachment theory, and points out the similarities between the diagnosis of complex PTSD and of borderline personality disorder. Case vignettes illustrate an outline of the assessment and treatment of the psychobiological symptoms of PTSD informed by attachment research.

Benzodiazepines are still widely prescribed in psychiatry, mainly for the treatment of anxiety-related disorders. This is not because they are only taken by a hard core component of patients who are addicted and do not need them; it is because they remain the most effective and rapid acting of all drug treatments. Strategies for practitioners to use them more confidently are described.

There is evidence pointing to a bias in the application of the Mental Health Act 1983 (which is in force in England and Wales). One study found that Black people on in-patient units were four times more likely to have been compulsorily admitted than White people. Furthermore, it has been shown that compulsory admissions to secure units are 2.9–5.6 times higher for Black than for White patients. Any understanding of this bias necessitates an examination of the attitudes of mental health professionals towards Africans and African–Caribbeans. Here we discuss possible contributory factors and examine a number of initiatives that have been instituted in order to tackle this problem.

Recent work suggests that a broad clinical spectrum of bipolar disorder is more common than previously thought and that the disorder may affect up to 5% of the population. The correct definition and diagnosis of hypomania is central to the identification of bipolar disorder. In this review we focus on recent diagnostic and clinical advances relating to bipolar disorder, with particular reference to hypomanic states. We also highlight some of the controversies in this field and discuss ways in which clinicians might improve their detection of bipolar disorders.