Child and adolescent mental health services operate at four tiers. An eating disorders service is a tier 3 function and in the usual absence of specific funding has to operate from within current resources. The operation of an eating disorders team within a wider child and adolescent mental health service has significant advantages. The operation of such a team is explained and the advantages discussed.

The release of the antipsychotic agents risperidone, sertindole and olanzepine forces difficult choices upon clinicians. The new compounds are better tolerated than neuroleptics, expensive and their long-term side-effects unknown. These choices can be made easier by the dose and side-effect minimisation procedure set out below, which aims to produce the greatest benefit and least harm from conventional neuroleptics.

Annual admission rates from the North-East Thames Region to maximum- and medium-secure forensic psychiatry services demonstrated a highly significant correlation with social deprivation measured at district health authority level using the Jarman UPA 8. There were specific associations with the number of unemployed persons, overcrowded households, and persons from ethnic minorities in the districts studied. There was a 10-fold difference in treated prevalence rates across the region, indicating that certain purchasing authorities may be seriously underfunded to meet the needs of their catchment area populations for secure forensic psychiatry services. Further research is required into the nature of the association between admissions to these services and social deprivation. It is readily apparent that a new formula is required for the allocation of resources in the face of such wide disparities in demand from different geographical locations.

This study investigated the links between aspects of cultural life and response to ethnic monitoring questions, and compared parental and adolescents' responses. Questionnaires were given to consecutive attenders at a child and adolescent psychiatry department situated in central London. Forty-seven parents participated, and 24 adolescents (aged 12–16 years) also completed questionnaires. Parents came from many parts of the world and their offspring were mostly born in the UK, but had varied cultural life with respect to language, peer group and diet. Just over half of the offspring were regarded as ‘White British’ by parents but the second largest group was that marked ‘other’, who all had mixed identity. There were differences in how parents described adolescents, especially in relation to peer culture. Since ethnic categories have limitations the data should be used carefully, and for many aspects of health planning and delivery other cultural variables would be useful. Consideration should be given to the need for specifying whether adolescents or their parents should respond to ethnic monitoring questions.

The Royal College of Psychiatrists has published national guidelines for services for those who carry out deliberate self-harm. This study aimed to discover whether these recommendations are being followed. We conducted a semi-structured interview with a professional from the accident and emergency service and one from the specialist service at each of 16 hospitals in the former Yorkshire Regional Health Authority. The findings are that services are not adhering to the guidelines. The production of guidelines without an adequate implementation strategy is ineffective. The Department of Health should endorse the College guidelines, and produce an implementation strategy to secure the involvement of purchasers and providers.

Prescription charts including a prescription for olanzapine were evaluated for 202 patients from 15 National Health Service trusts. In patients prescribed olanzapine for less than six weeks, the mean dose was found to be 12.4mg/day but 56% of patients were prescribed olanzapine as the sole antipsychotic. For patients prescribed olanzapine for longer than six weeks (when dose titration and drug crossovers were assumed to be complete) the mean dose of olanzapine was 15.8mg/day and 64% received olanzapine as the sole antipsychotic. A substantial proportion of patients were prescribed concurrent anticholinergic drugs (but relatively few when on olanzapine alone). Olanzapine was used in doses higher than the standard dose recommended by the manufacturers, often in combination with typical antipsychotics. Such practices increase costs and, at least in the latter case, very probably adversely affect outcome. Studies are needed to evaluate the relative effectiveness of commonly used antipsychotic regimens in naturalistic settings. In the absence of these, olanzapine should be used as the sole antipsychotic and patients should be property assessed on lower doses before dose increases are undertaken.

Respite needs for carers of persons with severe mental illness were assessed using a semi-structured inverview. Very few carers were currently using respite facilities. The need for respite was widespread, although largely unmet. Carers shared clear and definite ideas concerning the layout of a good respite service.

The demand for child and adolescent psychiatric services outstrips the supply of resources, leaving a large unmet demand. One way of managing this is to prioritise referrals. A sample of Norfolk general practitioners were interviewed face to face. They were asked to prioritise child and adolescent mental health problems that might present to them in the surgery. A high response rate was obtained. Anxiety provoking problems were considered to be of the highest priority. Service provision and prioritisation should take cognisance of the wishes of referrers themselves. Mental health care training priorities in general practice include substance misuse and psychiatric emergencies.

Six months after the introduction of the Mental Health (Patients in the Community) Act 1995, this study shows that the new legislation has been implemented in its first six months of existence. Lack of resources and increased paperwork are identified by some doctors as reasons for their reluctance to proceed with implementation of supervised discharge. Patients who were placed on supervised discharge were found to be mostly young, mentally ill patients previously detained under Section 3 of the Mental Health Act 1983, as yet, the 1995 Act does not appear to have been implemented in the after care of ‘forensic’ patients or those with mental impairment.

The extent to which electrical dose exceeds the seizure threshold is an important determinant of the efficacy of electroconvulsive therapy (ECT) but seizure thresholds have not before been evaluated using an ECT machine made in the UK. In this study seizure threshold was empirically titrated at the outset of bilateral ECT given to 100 consecutive depressed patients treated with an Ectron Series 5A ECT machine. No patient received anti-epileptic drugs. Men and women under 30 years of age (n=14) had low thresholds and men of 60 years or more (n=3) had high thresholds. Seizure thresholds varied at least threefold among other groups, suggesting that empirical titration may be desirable for most patients treated by bilateral ECT.

A study of all trusts in England and Wales providing specialist health services for people with learning disabilities attracted an 83.9% response rate. Considerable variation exists with regard to the quantity of services. The relationship between the learning disabilities psychiatrist and National Health Service learning disabilities bed-numbers and learning disabilities health professionals from other disciplines is explored. An appropriate balance needs to be kept in these ratios to reduce stress and burnout.

This retrospective study looks at the outcome of 71 consecutive liaison referrals. Placement was noted at three-month follow-up and further use of medical, psychiatric and social services, compliance with clinical management and recommendations was also measured. Nearly half the patients had dementia and about half had a functional disorder. In 90% of referrals the recommendations were followed. At three-month follow-up 17% had died, 26% had further medical hospital admission, 39% had moved into a continuing care facility (residential/nursing home), and over half had further contact with the old age psychiatry services.

Records were obtained of all suicide and open verdicts in York (n=127) between 1990–1994 inclusive. Those with no past or current contact with psychiatric services were identified (n=67). The extent and nature of this group's general (i.e. non-psychiatric) hospital contact in the months prior to death was established. Thirteen per cent (9/67) of these received general hospital input in the month before death with eight out of the nine aged over 65. Five of the 67 suicides showed evidence of depression. General hospital practitioners are in a position to make a small but important contribution in reducing the suicide rate.

Over the past 20 years, with the closure of psychiatric hospitals, there has been a greater emphasis on treatment of the seriously mentally ill in the community. Recently, there have been untoward incidents involving psychiatric patients leading to increasing public concern over this policy. Steps to reduce this concern have included the care programme approach, the supervision register and the community supervision order. Each requires some form of risk assessment to be carried out prior to their implementation, although there is little guidance on what areas should be covered.

This paper reports a retrospective case note study of all patients with learning disability and challenging behaviour admitted to Kneesworth House Hospital between 1986 and 1991 (n=70), describing their demographic and clinical characteristics. The subjects had high levels of psychiatric morbidity, in addition to learning disability. Patients whose stay was relatively short, or who were discharged to community placements, were not able to be differentiated on clinical grounds, suggesting that the provision of local facilities determined the length of the admission. There is a need for more regional and sub-regional services for this group with multiple long-term problems.