In this lecture I will ask: is morale poor among doctors? If it is (and let us for a moment assume that it might be), why is it that? If it is worse recently then is the deterioration an inevitable part of the process of rapid change in the National Health Service (NHS)? Is it, on the other hand, remediable?

A questionnaire on attitudes to the supervision register, about one year after its introduction, was sent to all consultant psychiatrists identified as working in the National Health Service South Thames Region. A response rate of 72.3% was obtained. Half of the respondents felt that the supervision register was not likely to reduce the risk of violence to the public by mentally disordered people and a quarter was unsure. Just over half felt confident in predicting violence, and over half felt that they had been reasonably trained to do so. Most had not changed their practice in admitting or discharging patients, or in the use of the Mental Health Act. There were criticisms of the register, for example: lack of resources needed to implement it, increased paperwork, stigmatisation of patients and the lack of a formal appeal mechanism. Fifty per cent felt the register should be abolished, only 25.5% felt it should not be.

A sample of 19 consultant psychiatrists and 28 keyworkers were interviewed to determine their views on using the supervision register and to see whether it was affecting their practice. The majority felt that the supervision register was politically motivated and had little effect on direct clinical practice. However, there was a slight increase in indirect patient activities such as administration and meetings and some keyworkers were more vigorous in their outreach work. Most patients did not challenge their registration and the use of advocates in Care Programme Approach meetings may be needed. There was also a need for improved training and supervision for keyworkers.

From 1 April 1996 mental health legislation was expanded to include provision for “supervised discharge” under the Mental Health (Patients in the Community) Act 1995. However, the use off Section 17 (s17) off the Mental Health Act has always provided an option for an extended leave. This retrospective case note study examines 10 years of practice off s17 use and focuses on characteristics off those patients recalled. Increases in s17 applications represented equivalent increases in admissions and overall sections, although numbers off patients actually recalled had fallen significantly. Patients recalled after discharge were generally middle-aged men with a long history of schizophrenia, on s3, who relapse quickly due to treatment non-compliance.

Information was collected from responsible medical officers (RMOs) in the South and West Region who had used the new supervised discharge order (SDO) (Section 25a) during the first year of its operation. Twenty-nine patients were placed on a SDO by 19 consultants. Most patients suffered from schizophrenia. In a third of cases, medication was stipulated as a requirement, although this is not legally permissible. RMOs commented on the time-consuming process of applying for a SDO and felt it had limited value because of the lack of sanctions.

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.

Those who attempt suicide by jumping often have a history of major psychiatric disorder, are left with a high level of physical and psychological morbidity and have a poor outcome. Services are failing this group in that national statistics may underestimate its size, and even when patients are in contact and are symptomatic and expressing suicidal intent before the incident many go on to jump. Care in hospital and preparation for follow up is uncoordinated.

All personnel within one UK emergency service who had been identified during a six-month period as having been on sick leave for eight consecutive weeks or more were identified. Those consenting were interviewed once using both a semi-structured questionnaire and standardised instruments. There were three main objectives: to discover the nature of the presenting problem in terms of illness or injury, the extent to which psychological problems presented and the relative importance of general and/or traumatic stressors. The resulting sample of 17 people accounted for 2–3% of the workforce. Fifteen agreed to take part and 13 to full interview. of the 14 who completed the Hilton Drinking Behaviour Questionnaire 10 exceeded the threshold consistent with problem drinking. The reason for sick leave in all these cases was recorded as physical injury only.

This is a retrospective study of 173 consecutive admissions to a general psychiatric hospital. The aim was to establish the frequency and adequacy with which alcohol and tobacco use were recorded. Regarding alcohol, in 41% of the notes there was no adequate quantitative history, in 29.5% there was a descriptive mention and in 29.5% no history was recorded. Female patients were less likely to have an alcohol history taken than male patients. With tobacco, in 64% of the notes there was an adequate quantitative history, in 6.4% there was a descriptive comment and in 28.9% no history was recorded. It is to be stressed to all doctors that an assessment of alcohol and tobacco use should be made for every patient, whatever their age, gender or ethnic origin.

A study of 41 families who failed to attend their first appointment at a child psychiatric clinic is described. The study was prospective over a period of one year and the families were interviewed personally; 14.9% failed their first appointment. Improvement of the child's symptoms during the waiting period, anxiety about seeing a psychiatrist/social worker, financial difficulties and the invitation to the family to attend were common reasons given for non-attendance. Another important factor was that families were ill-prepared by the referrers.

Sexual dysfunction is a widely recognised adverse effect of many psychotropic agents. Older antidepressants such as monoamine oxidase inhibitors and tricycles, particularly clomipramine, are known to engender sexual adverse effects. In depression, this problem is exacerbated by the occurrence of impotence and lowered libido as part of depressive illness itself. We examined evidence relating to more recently introduced antidepressants: selective serotonin reuptake inhibitors, moclobemide, venlafaxine, nefazodone, mirtazapine and reboxetine. We reviewed published trials and case reports collated from searches of Medline, PsychLit and Micromedex from 1985 to December 1997, and contacted manufacturers of new antidepressants and requested information from them.

Prompted by a clinical question, an article on prognosis in anorexia nervosa was appraised using evidence-based guidelines. Although problems with the validity and generalisability of the study were identified, this article yielded useful information. We conclude that it is not possible to address all clinical questions using the evidence-based framework.

An audit of case notes and a survey of in-patients was carried out to evaluate risk assessment on an in-patient ward. We found considerable inconsistencies between the risk assessment records in medical and nursing notes. A systematic survey found higher levels of risk than either set of notes, but combining the notes improved the quality of risk assessment compared to the survey. We suggest three key areas for action to improve risk assessment.

Since 1978, Members and Fellows of the College have met once or twice annually at meetings of the American and Canadian Psychiatric Association. Although small in numbers, the meetings off the North American Group have served to maintain contact with the College. The College President, Immediate Past President and Registrar have attended recent meetings. There are over 500 Fellows and Members in the USA and Canada, and with increased awareness off the existence of the North American Group, which was officially recognised by the College in 1996, expansion of activities to include educational programmes is expected. For this to occur, the membership would need to respond in greater numbers than heretofore.

In Scotland's National Portrait Gallery, there hangs the only portrait of a 20th century Scottish psychiatrist to have been commissioned by this pantheon to the country's great and good. The subject of the painting is, of course, R. D. Laing, who was not only Scotland's most famous psychiatrist, but, for a brief period in the 1960s and early 1970s, the most famous psychiatrist in the world. He was the world's first media psychiatrist, and his books sold in millions and were translated into more than 20 languages.