Electroconvulsive therapy (ECT) has long been recognised as an important method of treatment in adult psychiatric disorders, especially severe depression. However, in spite of increasing concern about the occurrence of depressive disorders among the young (Klerman, 1988), very little is known about the use of ECT in children and adolescents. Indeed the published literature on ECT in this age group consists almost entirely of case reports (Bertagnoli & Borchardt, 1990). This paper is concerned with an important determinant of such practice, the attitudes of child and adolescent psychiatrists.

Following the introduction of a 24 hour Emergency Clinic at the Maudsley Hospital in 1952, psychiatric hospitals across the UK have come to offer a similar but often smaller service.

In a rapidly changing NHS, there is a great awareness of the need to consult with general practitioners about their expectations of a service. A number of studies have looked at GPs' perceptions of psychological and psychiatric services (e.g. Eastman & McPherson, 1982; Whitfield & Winter, 1980) but to date little is known about how GPs view psychotherapy services. About 40% of the referrals to the Leicestershire psychotherapy department come directly from GPs and the present study aimed to ascertain local GPs' perceptions of the service. This was timely for the purpose of planning local development but clearly has important implications for psychotherapy services in general.

Increasing concern has been expressed in the psychiatric literature and general press about the use of neuroleptic medication for the treatment of behaviour disturbance in the mentally handicapped (Buck & Sprague, 1989). The issue was highlighted in a television documentary (Public Eye, BBC2, 1 May 1992) which reported a number of cases of tardive dyskinesia in mentally handicapped people who had been treated with neuroleptics. The programme, although taking a characteristically slanted view, will have made an impression on relatives, patients and the general public. It was also intimated that British families may be preparing to test the legal grounds for prescribing these drugs to the mentally handicapped, particularly where there is no formal psychiatric diagnosis.

A survey of Scottish psychiatric rehabilitation and support services, carried out in 1983 (McCreadie et al, 1985), found that although there were wide between-hospital differences, the National Health Service in Scotland was making considerable efforts to provide services for the long-term mentally ill. However, services provided by local authorities were seriously deficient.

Registers on people with learning disability are widely held (Cubbon & Malin, 1985). They have been set up in a variety of ways, hold differing types of data, and are put to various uses. Service planning and management is a common function for which register data may be required. However, a literature search revealed that no accuracy studies had been undertaken on such registers, apart from a reliability study on the Wessex Mental Handicap Register developed by Kushlick et al (May et al, 1982). In Wandsworth, an inner city health authority, the Register for People with Learning Difficulties is jointly funded and managed by the health authority and local social service department. The register holds data on just under 1,000 people who use services for people with learning disabilities, and the data are updated annually by questionnaires sent out by the register organiser. The questionnaire includes enquiry into demographic information, functional ability and service use. It also notes the presence or absence of additional complications, including psychiatric disorder and behaviours presenting specific management problems. This article describes a pilot study of the accuracy of the psychiatric and behaviour problem data held on the Wandsworth Register.

Psychotherapy is recognised as an integral part of general psychiatric education at the level of preparation for the membership exam. Guidelines were first published over 20 years ago by the Royal Medico-Psychological Association (RMPA, 1971). In 1986 these guidelines were reviewed and clarified amid some pessimism about how widely the previous recommendations were being met (Royal College of Psychiatrists, 1986). The shortage of consultant psychotherapists and the competing demands of other service and training commitments were suggested as explanations for this.

In view of concern regarding rising youth suicide rates, suicide being a critical event in increasing emphasis on clinical accountability, I conducted a quality assurance exercise in relation to casualty department assessments of parasuicides. While much has been written in the area of suicide assessment and rating scales, I found nothing adequate for my purpose. Accordingly, I present a format for conducting such an exercise with the aim of providing suggestions as to which clinical assessment items might usefully be emphasised in future clinical assessments. It has been designed solely to guide this process with no attempts to estimate reliability or validity.

The role of the accident and emergency department in the care of psychiatric patients has been long recognised. Mindham et al (1973) reported that many psychiatric patients, at their first or subsequent contact, present themselves as emergencies, and therefore a suitable service must be provided for them. It is interesting that a large number of reports describe various aspects of one particular service in London, namely the Maudsley Emergency Clinic. Several recent reports describe emergency psychiatric services in different district general hospitals in the United Kingdom.

The Access to Health Records Act came into force on 1 November 1991. This legislation allows patients access to their written medical records (access to computerised records is covered by separate legislation). Concerns have been expressed about the implications of this Act for staff and patients, particularly in psychiatry. These concerns have included detrimental effects on patients exposed to their notes and the restrictions it could place upon staff in recording speculation or subjective opinion. We report the following findings: staff attitudes to the new legislation including awareness of the Act, evaluation of the Act as useful or detrimental and the Act's implications on clinical practice.

With the implementation of community care and resettlement programmes, the extent, frequency and the management of emergencies in the mentally handicapped population have attracted a good deal of attention. Among the issues of importance are crisis in the community and unnecessary and repeated hospital admission; inappropriate emergency referrals leading to abuse of services; the need for emergency services and the importance of short term admission facilities (Nolan et al, 1992). While the number of psychiatric emergencies in people with mental handicap is not large, the trend towards living in the community has brought the need to monitor such referrals.

For almost four decades social policy has been directed at the closure of old mental hospitals and the resettlement in the community of large numbers of patients. Research into resettlement shows that, on the whole, individual needs are recognised, service responses are reasonably well planned, and that individual welfare has not deteriorated, at least in the short-term (Knapp et al, 1992; TAPS, 1993). Furthermore, those who receive services under the resettlement schemes are said to be better served than those who receive routine care on discharge from hospital (Allen et al, 1992).

The report of the Standing Medical Advisory Committee to the Department of Health, The Quality of Medical Care (1990), states that outcome is the most relevant indicator of quality of medical care. In addition to providing information about the appropriateness of treatments, there are important ethical and resource implications if activities are found to be unjustified. However, measuring outcome is difficult if there is no quantifiable change in symptoms or function following treatment. In child psychiatry this is a relatively common dilemma and outcome studies, while agreed to be essential, are frequently abandoned at an early stage or fail to get off the ground because of the complexity of the problems they generate. In a review of the ways in which child mental health services attempt to measure outcome (Pound & Cottrell, 1989) the authors acknowledge these difficulties and conclude that a start should be made by “Asking the customer's opinion” about the treatment they have received. In other words, “Are they satisfied?”.

The relatives of people with schizophrenia are a group who have much to offer professional carers and other relatives. They have a huge store of knowledge, often gained painfully by trial and error, about the problems involved in caring for sufferers from schizophrenia.

Electro-convulsive therapy (ECT) is a safe and effective treatment for some psychiatric disorders, but its mechanisms of action remain unclear. In the last decade ECT seems to have enjoyed a resurgence of research interest and some recent findings have raised exciting possibilities of making it a more rational and targeted treatment.

This paper reports the results of a nationwide survey of social services responses to psychiatric emergencies. The survey is a companion to that by Johnson & Thornicroft (1991) (J&T) who reviewed the emergency service options available in psychiatry, including the emergency clinic, general hospital services, the emergency ward, acute day hospital and crisis intervention and residential services, as well as considering the role of sectorised services, and community mental health centres (CMHCs). For the purposes of our respective surveys of health and social services in England and Wales, we have defined a psychiatric emergency as “occurring when someone (patient, friend, relative or professional) requests urgent intervention on behalf of someone in the community who is suffering from a mental disorder”.

Letters from psychiatrists to general practitioners (GPs) should provide an appropriate content in a format which is easy to write and assimilate. For content, GPs have requested “key items” (diagnosis, suicide risk, treatment, prognosis and follow-up), and an explanation which is educational (Williams & Wallace, 1974; Pullen & Yellowlees, 1985; Margo, 1982). For format, GPs preferred a one page letter with two or three sub-headings in a survey based on one fictitious case (Yellowless & Pullen, 1984). Real letters from psychiatrists in one district averaged one and three quarter pages with four subheadings (Prasher et al, 1992). GPs' opinions about actual changes in the format and content of letters sent to them have not been reported.

In spite of the moves over the last 20 years towards community care, there remain substantial numbers of elderly people with both physical and mental illness who require residential, nursing home and hospital care. There is evidence to suggest that health service provision of long term care for the mentally ill has been, and continues to be, reduced. In addition there has been reduction in beds for long term care by geriatric physicians and while the nursing home and residential care sectors have expanded, this expansion has been entirely within the ‘independent’ private and voluntary sector, with considerable contraction of local authority provision. Representations have been made about this to the Old Age Section of the Royal College of Psychiatrists and they have reported on this (Benbow & Jolley, 1992). Concern has not been confined to the profession. Over the last year, there has been considerable media publicity about the long term care of elderly people in institutions. Some of this has been very critical [Panorama, 20.1.92] and has provoked debate on the pages of the national papers.

Few clinical decisions are more difficult than whether or not to withhold treatment from patients who are unable to make this choice for themselves. This is because they bring into conflict a number of principles central to clinical practice, such as the duty to save life, the duty to relieve suffering, and the duty to heed patients' wishes. In North America, advance directives (‘living wills’) from patients, made when they are fully competent, have achieved considerable popularity in recent years as a possible way out of these dilemmas (La Puma et al, 1991; Molloy et al, 1991); unfortunately, it is by no means clear whether these can in fact provide a workable solution to the problem of treating incompetent patients (Hope, 1992). For the time being, decisions about withholding treatment will continue to be made by the health professionals immediately involved at the time, often junior staff with little experience or training, and there is a need for a professional consensus as to the factors that should be properly taken into consideration. This study investigates the current attitudes and approaches of psychiatrists and psychiatric nurses in one health district to this problem. It examines the criteria used, and the conditions under which decisions about administering or withholding treatments are being made.

Many mental disorders are associated with an increased risk of fire setting. As a result, its assessment and management is an important part of the management of people with psychiatric disorders. As more patients are managed in the community, away from the protection of high levels of hospital staff and fire regulations, such assessments are vital to ensure appropriate and safe placement. The presence of fire regulations in hostels offers only limited protection. Further, as residences with four people or less are not subject to fire regulations, assessment by psychiatric staff may have to extend to the fabric of the placement. Despite psychiatric hostels tending not to accept patients who are ‘a fire risk’, figures suggest that fires in hostels are common. One health authority reported 26 fires in hostels over 12 months (Moxom, personal communication).