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.

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).

This short review outlines the clinical profile of the selective serotonin re-uptake inhibitors (SSRIs). There has been much recent publicity and promotion of this group of drugs and this review attempts to give a balanced account of their current place in the treatment of depression. Although a large number of preclinical and clinical trials have been carried out many questions and problems remain – it is important to proceed carefully and carry out (and replicate) controlled independent clinical trials. The views of general psychiatrists and GPs about these drugs in normal clinical practice will be the acid test – this will be particularly important in view of their cost.

This is the second in a series of three articles about clinical guidelines in mental health. In the first article (Kendall et al, 2004), we introduced the National Collaborating Centre for Mental Health (NCCMH) and its guidelines work programme commissioned by the National Institute for Clinical Excellence (NICE); the possible uses of clinical guidelines; and the different guideline products generated alongside each NICE guideline.

The Royal College of Psychiatrists has established a Working Group on Choice in Mental Health and held a conference to include service users in formulating a challenging view of the choice agenda for mental health. This is set out here to stimulate wider interest. Choice-based practice develops in a climate of trust and information, and goes beyond simple variety or individual consumerism. For some service users, limited initial areas of choice can be of great importance, but a true culture of choice requires the widespread participation of service users and carers in service improvement. It is important that psychiatrists champion the empowerment of their patients through choice, in policy and training, and in clinical practice.

New psychological services are about to roll out across England. the National Institute for Health and Clinical Excellence clinical guidelines have led to government investment in the Improving Access to Psychological Therapies (IAPT) programme. New IAPT services should cut waiting times for psychological treatment of depression and anxiety disorders from months to days. They are intended to be available for all adults on the basis of need rather than age. It is not currently illegal for patients to be discriminated against by the National Health Service (NHS) because of their age. the government intends to introduce new legislation against age discrimination in the provision of goods, facilities and services by the NHS. Further investment and service development will be needed to counter existing age-related inequalities in mental health services

A group of interested people met for two days last year in order to attempt to reach a consensus on good practice in the management of patients with generalised anxiety. The result of their efforts is published below.

Most patients presenting with anxiety, whether acute or chronic, mild or severe, were until recently treated with tranquillisers. Recognition that these drugs can cause dependence in some patients has prompted a re-evaluation of the pharmacological management of anxiety and the value of non-pharmacological treatments is now recognised. Uncertainty remains among many doctors about the efficacy of the whole range of current therapies and the place of the new classes of drugs for anxiety. However, research findings are now accruing which indicate the relative merits of these various therapies, and clarify the principles on which they are based.

Comorbidity of severe mental illness and substance misuse is now common in general psychiatry (Regier et al, 1990), and perhaps almost standard in forensic psychiatry (Snowden, 2001). It is also reflected in child and adolescent psychiatry (Boys et al, 2003) and even in old age psychiatry (Jolley et al, 2004). The range of hazards associated with substance misuse in people with mental illnesses includes elevated risk of relapse of psychosis (Cantwell & Harrison, 1996), increased frequency of hospitalisation (Bartels et al, 1993), poorer compliance with treatment (Jablensky et al, 1992), higher levels of treatment-resistance (Bowers et al, 1990), impairment of the integrity of therapeutic regimes in hospital settings and in hostels in the community (Sandford, 1995), stress in the community (Drake & Wallach, 1989), higher rates of homelessness (Scheller-Gilkey et al, 1999), increased suicidality (Drake & Wallach, 1989), and increased potential for antisocial behaviour and crime of both an acquisitive and a violent nature (Stewart et al, 2000; Sinha & Easton, 1999). The misuse of substances is therefore a significant obstruction to the effective use of psychiatric treatment, and the financial cost associated with such clinical adversity must run into millions of pounds.

Old age psychiatrists and their teams have a particular responsibility in the identification and prevention of elder abuse and in carefully examining the factors that foster ‘the corruption of care (Wardhaugh & Wilding, 1993).

Despite anti-stigma campaigns in the UK in recent years, the experiences of people with mental health problems indicate that stigma is still a major problem. The stigma of being a member of a socially excluded group, based on socioeconomic, personal or cultural/ethnic characteristics, should be considered alongside the stigma of mental illness. Membership of a stigmatised group (not based on mental illness) is often itself a risk factor for developing mental health problems. This article discusses the experiences of people from Black and minority ethnic and lesbian, gay and bisexual groups to explore how stigma can create more stigma.

Under the 1959 Mental Health Act of England and Wales, it was possible for courts to sentence offenders to hospital provided they had been found guilty of an offence which was punishable by a term of imprisonment. Higher courts could add restrictions to a hospital order if they so wished. This power has been retained in the 1983 Mental Health Act and this paper examines the nature and use of the restricted hospital order.

Traditionally, general practitioners and psychiatrists relate to one another through a system of cross referrals, from primary care to secondary care and back again, the referral being initiated by the GP through a request for a domiciliary visit or more usually for an out-patient assessment of the clinical problem. However, in the mid-1960s, individual psychiatrists began to report a new way of working, which consisted of the psychiatrist going by invitation into GPs' surgeries or health centres to work directly with the general practitioners and with other members of the primary health care team. A survey undertaken by Strathdee & Williams of the General Practice Research Unit of the Institute of Psychiatry, showed that by 1984 in England and Wales, one psychiatric consultant in five, sometimes with, sometimes without, junior staff, spent some time in a general practice setting. At the College meeting in Cambridge (April 1988), Pullen reported that in Scotland a similar survey showed that as many as 40 to 50% of psychiatric consultants spent some time in primary care settings.

Recent changes in the law and mental health policy have forced psychiatrists and other mental health professionals to review the traditional cloak of secrecy that surrounds record keeping and letter writing. This paper establishes what proportion of patients attending a psychiatric out-patient clinic are interested in receiving letters from their psychiatrist. Those who are interested tend to be better educated, whereas those who are not interested are much more likely to have an ICD–10 diagnosis of schizophrenia. Overall, there appear to be high levels of satisfaction with the nature of the letters received. The significance of these findings is discussed in relation to the difficulty of engaging people with the most severe and enduring forms of mental health problems as active participants in the process of care.