Dr Hughes raises an important issue which would be of concern to most psychiatrists (Psychiatric Bulletin (Correspondence), May 2004, 28, 183). In addition to changing the letters to patients, I wondered if patients opting to receive them belonged, predominantly, to a specific diagnostic group.

I therefore obtained a list of 100 patients who had indicated a choice of whether to receive these letters. The uptake was 76%, which was higher than we expected and their diagnoses were spread out across most diagnostic categories. The majority belonged to the depressive disorder and the neurotic and stress related categories. A higher uptake might have been because other staff members rather than doctors or community psychiatric nurses (associated with poorer uptake) handed out opt-in forms.

A pilot study showed 83% of patients wanted to continue to receive these letters though 18% initially found them to be distressing (Harpal Nandhara et al, Psychiatric Bulletin, February 2004, 28, 40-42). An appropriate selection of patients to possibly exclude the latter group is thus crucial. Patients who lack capacity and those who present some risk may be considered not suitable to receive these letters (Reference DaleDale et al, 2003). I now make patients more aware of what is actually written down in their case-notes in the course of the consultation. This hopefully reduces any future surprises when they eventually receive a copy of the letter.

This initiative may alter the relationship between psychiatrists and their patients and thus necessitate a review of this process in future. I will re-survey this group in future to ascertain if their wishes to receive these letters change.