Over the past few years, numerous articles have highlighted the strain on (and drain of staff from) our specialty. Many general adult psychiatrists are developing bleak views of themselves, the world and the future. Encouragingly, consultants such as Hampson (2003) are structuring their roles with some success. However, we are going through a major overhaul of the model of delivery of care and need to adapt our roles accordingly. Although tuning a Triumph Spitfire might make it run more smoothly for a while, it is still an inferior beast compared with a modern car and might be better on the scrap heap. A more radical approach is needed, which we outline in this article. One of the authors (G.I.) has experience of working as a consultant psychiatrist in Australia, where the state of Victoria changed the model of delivery of general adult psychiatric services to adopt a superior American model, leading to improved patient and carer satisfaction (Joy et al, 2001). The same model has been adopted by the UK government (Department of Health, 2001) through the creation of crisis assessment and treatment services (CATS), assertive outreach teams, and specialist community and in-patient services. Consultant psychiatrists are challenged to adapt their practice accordingly. The Royal College of Psychiatrists has recently set up a Working Group to address this issue (Royal College of Psychiatrists, 2004).

Using a case note study, this paper presents a longitudinal survey of the effect of psychiatric inpatient care on benzodiazepine prescribing. Standards were proposed to assess the quality of this prescribing. Based on these standards, the study shows inappropriate use of benzodiazepines. Following admission, there was an increase in the number of patients prescribed benzodiazepines and in the number of benzodiazepines prescribed. Of the benzodiazepines withdrawn, most were contrary to the proposed standard. The quality of drug history showed little emphasis being placed on rationalising benzodiazepine prescribing. The issue of how benzodiazepines should be handled during psychiatric admission is discussed.

We have evaluated the effects of providing a ‘roving’ psychiatric clinic to local authority residential homes for the elderly. The clinic was well received by the staff in the homes, reduced the need for urgent domiciliary consultations and hospital admission and appeared to be highly cost-effective.

The development of forensic psychiatry provision in Scotland lags behind that in other parts of the United Kingdom. Until recently, there were no medium secure units in the country and mentally disordered offenders (MDOs) requiring such care had to be managed in intensive psychiatric care unit (IPCU) settings. In November 2000, The Orchard Clinic, a medium secure unit sited at the Royal Edinburgh Hospital, was opened. This paper discusses the background to this development, the government policies setting out plans for the care, services and support of MDOs in Scotland, progress and work of the new unit to date and plans for developments in other parts of Scotland.

This study examined the impact of caring on women who were primary care-givers to those with schizophrenia. From the 46 women and 21 men carers assessed for the study, women were considered primary care-givers more often than men (83% v. 57%). Higher levels of burden among women primary carers were associated with living with patients, and more hours in contact with them. Worse perception of patients' social functioning was associated with higher levels of burden. The findings of the study showed that women primary carers have particular needs, and services should consider how to provide support for them in their multiple roles, and over longer periods of time.

The profession awaits the Government's White Paper on a new Mental Health Act (MHA) with trepidation. At the time of writing, the closing date for consultation on the Green Paper (Department of Health, 1999a) has passed. None the less, discussion and lobbying must continue.

“The therapist can cite Bertrand Russell's observation that the degree of certainty with which one holds a belief is inversely related to the truth of that belief. Fanatics are true believers, scientists are sceptics”. (Beck et al, 1979)

I propose to describe the evolution of behavioural treatments, and the more recent leap forward made by cognitive therapy. Exciting new treatments are now available that did not exist when I was a trainee. The accepted term for these treatments is “behavioural-cognitive psychotherapy’ (BCPT). They are behavioural in the sense that emphasis is on observable behaviour, e.g. avoidance of supermarkets in agoraphobia. They are cognitive because many approaches involve working with patients' thoughts, e.g. the negative thinking of depressed patients. The treatment is psychotherapy as it is therapy that works at the mind level, rather than at say the synaptic level as pharmacotherapy does. BCPT combines well with pharmacotherapy, and other therapeutic methods such as social therapy, and so is suitable for a multidisciplinary approach to a psychiatric problem, as well as offering specific techniques for identified disorders.

The Department of Health and National Institute for Mental Health in England have undertaken a programme of research and policy development since spring 2004 in partnership with the Home Office which has important implications for the practice of psychiatry. This article looks at the Victims of Violence and Abuse Prevention Programme (VVAPP) guide ‘Tackling the Health and Mental Health Effects of Domestic and Sexual Violence and Abuse’ launched in 2006, supported by Department of Health and Home Office ministers and national clinical directors.

Rates of developmental delay, autism and mental illness in deaf children are higher than in hearing children. Early language acquisition (signed or spoken) is a protective factor against mental disorder. Deaf children and their families are often given conflicting messages and advice about their upbringing and many are unable to access generic child and adolescent mental health services (CAMHS). We describe the National Deaf CAMHS, a service that has been set up to answer the needs of this group of patients. It uses specialist intervention which incorporates some aspects of Deaf awareness to empower deaf children and reduce the burden of mental health problems that are likely to accompany them into and throughout their adulthood.

The management of mentally handicapped offenders has long been problematic. Three misconceptions of the relationship between mental handicap and criminality have been widely held since the turn of the century, despite there being no conclusive evidence in their support (Jackson, 1983). These are: that mentally handicapped people are more likely than others to commit antisocial acts in general; that they have a particular predisposition to commit serious crime, especially sexual crime (Robertson, 1981); and that they are unlikely to be deterred by normal sanctions. Misunderstanding breeds misapprehension. Sadly, in the past, many mentally handicapped people were admitted to hospital after committing only trivial offences. Moreover, one Special Hospital study (Parker, 1974) found that most “severely subnormal and subnormal” detained patients actually had IQs above the category to which they had been assigned.

Electroconvulsive therapy (ECT) is an effective treatment in severe depressive illness (Kendell, 1981). It is unusual in being administered predominantly by junior doctors, although prescribed by consultants. Pippard (1988) has drawn attention to a tendency for practice to depend on established custom rather than research evidence, and to a lack of consultant involvement in ECT teaching.