The closure of Britain's large psychiatric hospitals, long foreseen, is now rapidly becoming a reality. Surprisingly little is known about the process and outcome of the relocation of long-stay hospital residents. One area of particular concern is the fate of ‘elderly graduate’ patients, who are by convention defined as long-stay patients aged over 65 years who came into continuous psychiatric contact before the age of 65. (More cynically they might be defined as those elderly patients whom our colleagues specialising in the psychiatry of the elderly choose not to take over). This paper documents the experience of a specialist resettlement team working within a declining mental hospital attempting to place ‘elderly graduate’ hospital residents into community provision.

Since developing an interest in the use of electroconvulsive therapy (ECT) in late life, I have received correspondence from psychiatrists describing difficulties in obtaining anaesthetics for elderly patients who are perceived as frail or physically unwell. Nevertheless, Pippard & Ellam (1981) found in their survey of the use of ECT in 1980 that 37% of courses were given to people aged 60 years and over. I decided to survey old age psychiatrists' views on ECT, and to look at difficulties encountered in obtaining anaesthetics. Old age psychiatrists specialise in the care of mentally ill elderly people and are dealing with patients who are particularly likely to have physical problems in addition to mental illnesses. Their experience of ECT is therefore of wider relevance to all who prescribe ECT for elderly or physically ill people.

Patients discharged after acute psychiatric admission are vulnerable, and need continuing care in the community. For these people and their families, the first two weeks after discharge is a critical time. This is when problems arise, support is needed, drugs run out, and default most likely. Care may be shared between psychiatrist, community psychiatric nurse, general practitioner and other health personnel. It is therefore essential to identify the roles and responsibilities of all involved in follow-up care. Studies have shown that information needed by general practitioners includes differential diagnosis, management, treatment on discharge, prognosis, what patient and relatives were told, future plans which specify the roles and responsibilities of all involved, as well as the date of any follow-up appointment. Moreover this information is needed within two weeks of discharge. Without this information effective follow-up is unlikely to occur. The early discharge summary provides this vital information in the immediate post-discharge period. This is quite distinct from the final report which usually takes a few weeks to be sent. It is therefore important to identify current psychiatric practice relating to the initial discharge summary.

For more than 20 years, in parallel with moves towards community care, psychiatric teams have been trying to develop closer links with general practice. Many styles of working with GPs have been developed, five of which are described by Mitchell (1989). The literature contains numerous reports of most of these, particularly the shifted out-patient model (see for example Tyrer, Seivewright & Wollerton, 1984). In this paper we describe a liaison project which is closest to Mitchell's (1989) ‘joint team consultation’ and report the results of a simple survey of GP satisfaction with this scheme.

Little is known about those patients who bypass their GP and self-refer directly to hospital. There have been studies of referrals to emergency clinics (Lim, 1983; Haw et al, 1987; Kehoe & Newton, 1990) and to community centres (Hutton, 1983; Boardman & Bouras, 1989). All these studies found that more men self-referred than women. Hutton (1985), Boardman & Bouras (1989) and Kehoe & Newton (1990) found that self-referrals often had a non-psychiatric precipitant and rarely required acute psychiatric intervention.

As more health authorities close large psychiatric hospitals the provision of small local facilities in which former residents of such hospitals are housed is increasing. Such houses tend to share many common characteristics dictated both by practical necessity and by deliberate policy – they tend to be large Victorian houses chosen because they have a larger number of bedrooms and they tend to be run in a much less formal manner than hospital wards (Goldberg, 1985).

For almost 20 years planning for the mentally ill and mentally handicapped has focused on a shift of care from hospital to community, the advantages and difficulties of this process generating much discussion and interest. The hospital population of the mentally handicapped is currently at the forefront of this change, planning impetus now being propelled by alterations in funding with budgets being transferred from NHS to local and social services. One consequence is the closure, or planned closure, of large mental handicap hospitals situated at the periphery of urban centres, with residents being moved to small group homes and hostels within the towns and cities the hospitals once served. The change should prove beneficial for a majority of residents although the process continues to generate debate.

Clozapine is an atypical antipsychotic drug with relatively weak D2 and D1 blocking properties and strong 5HT and cholinergic blockade. Its potency as an antipsychotic drug is surprising considering the ratio of receptor blockade and it represents a true advance in treatment of schizophrenia. The efficacy of clozapine calls for revision of the seemingly over simplistic dopamine theory of schizophrenia. Now clozapine is available in the UK to consultant psychiatrists who register with the Clozaril Patient Monitoring Service (CPMS).

The new syllabus for both general and psychiatric nurses, Project 2000, is a manifestation of the gradual revolution taking place in nursing. It attempts to address some long-standing issues which have concerned the profession in several countries. The resolution of these issues will determine the role of nurses as members of the multidisciplinary team and effect cooperation and interactions therein.

Guardianship can offer a measure of control and support in the community to individuals suffering from any type of mental disorder, be it mental illness or mental handicap, yet there were only 14 new guardianship cases in Scotland in 1989, compared with 3,604 episodes of detention under the Mental Health (Scotland) Act 1984 (MWC Annual Report 1989), and out of an estimated total of mentally disordered people in Scotland of more than half a million (Titterton, personal communication).

In discussions of the psychopathology of the double, acknowledgement is usually given to the various literary accounts of the subject by Dostoevsky, De Maupassant and Stevenson (Christodoulou, 1986). Curiously, mention is never made of the work that has been described by Karl Miller (1985) as “the cardinal text” in the literature of the double. James Hogg's The Private Memoirs and Confessions of a Justified Sinner, published in 1824 and since recognised as a Scottish literary classic, represents the most detailed and complex exploration of the theme of the double.

Becoming demented is something people dread most about growing old; the image of a confused and wandering elderly person is a powerful and distressing one. Alzheimer's disease is the commonest cause of dementia, affecting 500,000 people in Britain alone. It is a progressive and presently incurable brain disease, causing great suffering and imposing an enormous burden on health resources. As a result, a large research effort is under way to find out what causes the disease, since a cure is only likely to emerge once the disease is understood. This research is wide-ranging and diverse, as the complexity of Alzheimer's disease requires many lines of enquiry if the puzzle is to be solved. At one extreme, the research focus is upon large groups of elderly people who are being followed up to see what features predict and herald the onset of dementia. At the other, individual genes, molecules and brain cells are under detailed investigation. Some of the latter studies have given important clues as to the cause of Alzheimer's disease, and these are briefly mentioned here.

Psychiatrists are frequently invited to give expert opinions to Courts about children's emotional welfare, their parents' capacity to care for them and issues of placement and access. Previous child abuse/neglect may have been suspected or confirmed or the parents might suffer from psychiatric symptoms. Assessment may be required of parents' mental state with a guide to prognosis, but, in addition, factors in parent–child relationships will be crucial to overall assessments of parenting.

Music therapy is a non-analytic therapy concerned with the creative process in which an attempt is made to reach the emotions of the patient without recourse to verbal means. It should in theory be suitable for chronic psychotic patients and all whose verbal ability is minimal. The ability to appreciate music may persist despite psychotic disintegration and provides one way, maybe the only way, into a patient's inner life. Music is one aspect of the aesthetic or creative experience that neurotic patients often lack and for this group music may provide a broader view of emotional life than their own more narrow previous experience.

The Royal College of Psychiatrists (1989) has recently produced its own preliminary report on medical audit. It defines medical audit as: “The systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patients.” This definition is in essence similar to that of the Royal College of Physicians.

Productivity in research is now an almost mandatory requirement for trainee psychiatrists. There is an increasing awareness among psychiatric trainees of the necessity to participate in and indeed publish research in order to ensure career progression (Junaid & Staines, 1990). This paper describes the research activity of psychiatrists in the training grades, during the year October 1988 to September 1989.