Rigorous studies of community alternatives to hospitalisation show that they are feasible and effective but have spawned considerable debate about their methodology, replicability, and appropriateness for normal clinical practice. In Britain, many demonstration projects have been centrally funded and evaluated initially by the Personal Social Services Research Unit at the University of Kent and latterly by Good Practices in Mental Health (Renshaw et al, 1988). Such community-based projects have attempted to avoid the problems of community mental health centres in the United States which have, with some important exceptions, failed to offer a comprehensive service that would allow closure or a significant drop in bed numbers at state hospitals (Dowell & Ciarlo, 1983). In practice, the design of community services is very dependent on local circumstances, including the demography of the population, existing service provision and attitudes. For this reason, planners and practitioners need to be aware of many practical options for service delivery.

For young people with emerging psychosis, early weight gain and its potential cardiac and metabolic consequences amplify worrying UK public health trends for young people in general. This paper will argue that if clinicians dismiss these changes as of secondary concern in psychiatric treatment for their young patients, they may be inadvertently condoning a first critical step on a path towards physical health inequalities. Greater recognition is needed for this patient population in their 20s and 30s, at ages not normally considered for active primary or secondary cardiovascular prevention, who are at high risk of dying prematurely. The early phase of psychosis presents an important treatment window for protecting cardiometabolic health.

In the Oxford Community Treatment Order Evaluation Trial (OCTET), patients were randomised either to be made subject to a community treatment order (CTO) or to be managed with Section 17 leave and discharge. No differences in outcome between the two groups were observed. Here it is argued that the patients studied were not those who might have benefited from a CTO and that the psychiatrists involved were unlikely to have used the provisions of a CTO assertively. Consideration of the lengths of time for which both Section 17 leave and CTOs were used supports the notion that CTOs were not used appropriately for a group of patients who might have benefited from them. Hence the results of this study should not be taken to provide any evidence as to the effectiveness or otherwise of CTOs.

There is an inexorable drive in psychiatric services in the UK, including forensic services, towards organising and delivering care based on the principles of the recovery model. Hence recovery, and its subjective and objective measures, is the goal of these services and the standard by which the quality of the service is evaluated. At the same time, all psychiatric services are expected to practise evidence-based risk assessment and management practices and can be subject to severe criticism or sanctions if they do not do so. In this paper I set out the view that the values that underlie the recovery approach and the clinical risk assessment approach appear to be polar opposites. However, an understanding of human behaviour using a humanneeds model is an explanatory paradigm that underlies both the recovery model and the understanding of risk behaviour, and can thus unify these two approaches. Therefore a more explicit integration of this model into forensic care would be beneficial and there should be more research directed to the correlates of recovery-oriented measures and risk-related measures.

Memory clinics have been in existence in the UK for over 15 years. Initially set up for research purposes, these clinics have been transformed by the advent of treatments for Alzheimer's disease. Clinics increasingly provide for early diagnosis, information dissemination, initiation and monitoring of treatment, and education and training. There are variations in clinic design, and availability nationally. There continue to be significant demands on existing services, which have traditionally offered domiciliary care. The valuable contribution of these traditional services deserves greater recognition, as do the benefits provided by memory clinics, which are often not fully appreciated by health care professionals or the public.

The challenge facing services for people with learning disabilities is to create the environment in which clients have the best quality of life without preconception. The heterogenous nature of people with learning disabilities requires diversity of care provisions sensitive to their individual needs. The different demonstration and presentation of their mental health needs has influenced the development of services and different models of specialist services have emerged with local variations. There is still, however, a great deal of confusion on both ideological and service delivery level. Although services for people with learning disabilities have succeeded in resettling people in the community and supporting them in developing adaptive skills, unfortunately these successes are not matched by equally effective and efficient services to those with mental health needs.

This paper argues for the inclusion of religion and spirituality in psychiatric care. After discussing the antagonism of psychiatrists and psychologists to religion, I present a critical overview of studies examining the relationships between spirituality, religion and diverse aspects of mental health: depression, suicide, anxiety, delinquency, drug abuse and schizophrenia. The need to assesses the impact of religion in different faith groups is discussed. Measures of religious coping, both positive and negative, may provide a more accurate portrayal as to how individuals deploy religion in their lives than global measures such as belief and attendance. I highlight the fact that there is a dearth of research on ritual, prayer and other aspects of religious experience. While many studies demonstrate positive effects of religion on mental health, others find detrimental effects. Finally I examine the clinical implications of these findings.

Can delusions, in the context of psychosis, enhance a person’s sense of meaningfulness? The case described here suggests that, in some circumstances, they can. This prompts further questions into the complexities of delusion as a lived phenomenon, with important implications for the clinical encounter. While assumptions of meaninglessness are often associated with concepts of ‘disorder’, ‘harm’ and ‘dysfunction’, we suggest that meaning can nonetheless be found within what is commonly taken to be incomprehensible or even meaningless. A phenomenological and value-based approach appears indispensable for clinicians facing the seemingly paradoxical coexistence of harmfulness and meaningfulness.

In this paper the ethical concept of competence is explored in the context of a very challenging child psychiatry case. Both mental disorder and immaturity may impair a child's competence. However, It is emphasised that competence Is not a generic quality but one that should be applied to specific decisions, even when working with children.

The Health of the Nation – A Strategy for England is a national response to WHO'S Health for All by the Year 2000 initiative. It has great importance both because it focuses on health outcomes and because it selects mental illness as one of five priority areas. This article traces the historical background to the development of the White Paper, summarises the content of the mental illness key area and current progress in improving information and understanding and developing comprehensive services, and improving good practice. It draws out the implications for individual practitioners, users and cares, and for the working arrangements between purchasers and providers.