The value of antipsychotic medication in preventing relapse in schizophrenia has been apparent since soon after its introduction (National Institute of Mental Health, Psychopharmacology Service Centre Study Group, 1964) but non-compliance remains a problem. Failure to take prescribed medication is a challenge in general medicine but presents special difficulties when treating mental illness; residual symptoms of psychosis and impaired insight after discharge increase the likelihood that a patient will stop taking antipsychotic medication, thereby contributing to higher relapse rates. The development of depot antipsychotic medication that could be administered intramuscularly at intervals of several weeks raised treatment and outcome expectations for patients who were felt to be at higher risk of non-compliance when in the community. The need for regular administration and monitoring of patients receiving depot medication led to depot and maintenance medication clinics. Today, with increasing numbers of patients who would previously have been receiving depot medication now taking atypical oral antipsychotics, is there still a need for the depot clinic?

Offender health is an important part of general mental healthcare. To improve the health of offenders, we need reforms similar to the reforms in community care of the last decade – early intervention, alternatives to the institution and multi-agency community services. Front-line clinicians are in a key position to bring about such reforms. It will be crucial to argue that improvements in offender health will help bring about broader government aims such as reduced reoffending.

In most countries, social or behavioural interventions are recommended for autism. However, in France, psychoanalysis is still used, despite objections by patients, families and mental health experts. Supporters of psychoanalysis maintain that the choice of therapeutic approach is a matter of cultural preference, and that objections to psychoanalysis arise from misunderstandings. We argue that more deep-rooted problems are the lack of an evidence base for psychoanalysis and its focus on sexual relationships between children and adults, which demonises mothers and can put children at risk of abuse. Furthermore, psychoanalysis in France is protected from criticism by powerful educational and political networks.

Psychiatric services for the elderly are evolving rapidly. The Government has recently reiterated that this area needs special attention. The reasons for upheaval are well-known: the changing age structure of the population, the historical neglect of the elderly mentally ill and a growing emphasis on community-based approaches in place of traditional institutional solutions. In the London area and elsewhere, adjustment has been complicated by geographical transplantation from old suburban mental hospitals to locally situated units, often within district general hospitals. New specialist services also suffer from the effects of financial stringency and inadequate recruitment. These and other changes have ensured that the process of restructuring services has been difficult. Planners have had few precedents to fall back on, and have been heavily dependent on available guidelines. There has been comparatively little information available about how effectively services work in practice.

Out-patient clinics are widely used to asssess and treat patients. In psychiatric practice, out-patient clinics are used both to assess new referrals and follow up existing patients. More than three-quarters of psychiatric out-patient attendances are for follow-up (DHSS, 1984). With modern emphasis on community psychiatry, the role of out-patient clinics may become less prominent and more refined. Very little appears to have been published on the subject of psychiatric follow-up clinics.

A significant proportion of patients referred to psychiatric out-patient clinics fail to attend the first appointment. Previous work suggested that typically 30% do not attend (Burgess & Harrington, 1964; Skuse, 1975) and this results in an inefficient utilisation of psychiatrists' time. One solution would be to overbook new patients by 30%. Unfortunately the proportion of non-attendance at each clinic is variable and difficult to estimate in advance. Psychiatrists have been shown to be poor predictors of non-attendance from examining referral letters (Woods, 1992). Overbooking might result in a long waiting time and short time for assessment. Previous research has suggested patients are more likely to attend if they received a personal letter rather than a standard card, had a previous psychiatric history, and if they were seen in a health centre rather than a hospital (Hillis, 1990). Allaying the patient's fears and misconceptions about psychiatry also improved attendance (Skuse, 1975). Work in a child and family setting suggested that sending a family questionnaire prior to the appointment reduced the non-attendance rate (Mathai & Markantonakis, 1990).

With the increasing importance of evidence-based medicine in psychiatry, the recent inclusion of a critical analysis paper in the MRCPsych Part II Examination and the current emphasis on clinical governance, it is now necessary for all psychiatrists to have some degree of training in evidence-based practices.

In 1988, the Cambridge Health Authority commissioned a working party of clinicians and NHS managers to visit a variety of different treatment services which cater for the psychiatric needs of mentally handicapped adults in England and Wales. This survey – part of an ongoing planning exercise – is now complete, new services are being planned in the light of the findings, and the experience may be of general interest to other clinicians and service planners throughout England and Wales.

The British benefit system provides for disabled people. However, disincentives within the existing system reduce uptake of benefit entitlements. The link between mental illness and poverty is now well known. If welfare benefits are essential for mentally ill people to function effectively in the community, then changes may be necessary to the current system. These changes include increasing the availability of accessible literature and information from both health and social services sources, further training for mental health staff, and the automatic evaluation of benefit entitlement by the Department of Social Security.

A questionnaire was completed by 135 of the 161 (83.9%) National Health Service (NHS) trusts who provide specialist health services for people with learning disabilities in England and Wales. From these, cumulative frequencies were calculated to describe the current level of provision of NHS beds. Results vary in different parts of the country, but the majority of NHS trusts provide assessment and treatment admission beds, long-stay beds (including those NHS trusts who have completed their resettlement process) and respite care beds. A half of NHS trusts directly manage NHS day places. The high response to questionnaires indicates the current high level of interest in this issue.

Policy for mental health services in England is based on two straightforward principles. These are, first that care should be provided as locally to where a person lives as is reasonably possible, and secondly that treatment should be available in the least restrictive conditions that are compatible with the safety of the patient, of those looking after him and of the public at large. I make no apology for reviewing the history of policy and practice; it is not possible to understand the mental health services that we are trying to achieve for the future without understanding how the service has developed over the years. I shall use the mental illness service as an example – similar considerations apply to the mental handicap services.

The MARSIPAN (MAnagement of Really SIck Patients with Anorexia Nervosa) project was established in response to reports of patients admitted to medical wards and proving refractory to treatment, sometimes dying on the ward. Psychiatrists, physicians and other clinicians in nutrition and eating disorders were brought together to discuss key issues in the assessment and management of such patients. The resulting guidance report, which applies to adult patients over 18, addresses: assessment of risk, where to treat the patient, specialist support for medical teams, key elements of treatment, namely (a) safe refeeding to avoid refeeding syndrome and underfeeding syndrome, (b) management of problematic behaviours, (c) support for the family, and (d) transfer to a specialist eating disorder unit when appropriate and possible.