“My whole mental power has disappeared, I have sunk intellectually below the level of a beast”(a patient with schizophrenia, quoted by Kraepelin, 1919, p. 25).

Depression is a frequently occurring symptom in schizophrenia. While today it is often underrecognised and under-treated, historically such symptoms were the focus of much attention. Affective symptoms were used by Kraepelin as an important criterion with which to separate dementia praecox from manic–depressive illness. Kraepelin also recognised the importance of depression as a symptom in schizophrenia and identified several depressive subtypes of the illness. Mayer-Gross emphasised the despair that often occurs as a psychological reaction to acute psychotic episodes and Bleuler considered depression to be one of the core symptoms of schizophrenia.

The purpose of this review is briefly to consider the biological basis of depression and to attempt to illustrate how antidepressants produce their beneficial effects by correcting these abnormalities.

A male farmer in his forties from the Irish Republic was referred for an opinion on his mood swings and their possible relationship with organophosphate exposure. He had been regularly exposed to organophosphorus sheep dips for around 15 years prior to the assessment.

At present, the treatment options for Alzheimer's disease are largely symptomatic giving rise to temporary remissions in cognitive decline or the amelioration of troublesome behavioural and psychological symptoms. However, as more is becoming known about the molecular biology of Alzheimer's disease, there is a clear movement to treatments directed towards disease modification. Disease modification is now a realistic option and its importance is highlighted by the fact that a delay in the progression of the disease by just five years would halve the disease prevalence. Ultimately, however, drug therapy based on the molecular biology of Alzheimer's disease will be preventive. These treatment strategies are still in their infancy, but our understanding of the processes requiring therapeutic manipulation is improving at a dramatic rate.

There is increasing evidence that substance misuse among British adolescents is escalating (Miller & Plant, 1996; Sutherland & Willner, 1998). Swadi (1992) found that, among adolescents aged 12–17 years referred to mental health services, the prevalence of drug use was 13.1% (16.3% among boys and 9.3% among girls). Despite this relatively high prevalence, there are very few organised treatment services for adolescents in the UK. Instead, there is extensive emphasis on prevention even though there is no universal agreement on what prevention can achieve. This approach also overlooks the fact that a significant number of adolescents fail to respond to preventive measures in any form.

Patients with borderline personality disorder (BPD; known in ICD–10 (World Health Organization, 1992) as emotionally unstable personality disorder) pose some of the most difficult management problems facing the clinical psychiatrist. They frequently present in crisis, but are often difficult to engage in any form of treatment. Their behaviour causes considerable anxiety but their ambivalence about treatment often leaves professionals feeling frustrated and resentful. These feelings can all too easily be transformed into therapeutic nihilism. As well as being a significant problem in its own right, comorbid personality disturbance complicates the management of other psychiatric disorders and has a negative effect on their prognosis (Reich & Vasile, 1993).

Anthony Winston reviews and describes current perspectives on the aetiology of borderline personality disorder, covering areas such as the role of traumatic factors, attachment theory and self-psychology. The author links these to the psychopathology of the borderline patient who experiences difficulties such as regulation of affect, impulse control and cognitive capacity to both think and reflect. The psychological function of splitting is considered along with other defence mechanisms as having adaptive potential for the borderline patient. Winston describes in a helpful way the links between human development, psychodynamics and psychopathology as he reveals some of the more recent contributions to the field of BPD. At the beginning of his article, he emphasises the problems encountered when attempting to treat or manage patients with BPD. He centres these difficulties on the counter-transference of the clinician, pointing out how such feelings can “all too easily be transformed into therapeutic nihilism”. His article can easily be read as an attempt to counter such a state of mind and he appears to try to generate a more hopeful if not optimistic outlook. In doing so, I fear that he goes beyond his own account of the research evidence for the effectiveness of treatment. Such enthusiasm or optimism can readily be understood as a reactive polar opposite to nihilism or pessimism. I would like to consider further Winston's statements germane to this aspect of his article and raise for further discussion some other ideas which extend beyond the narrower confines of aetiology and psychological therapy.

The previous article (Rix, 2000) in this series described the process of dispute resolution and litigation under the new Civil Procedure Rules, which have now been implemented in England and Wales following the recommendations of Lord Woolf. The purpose of this article is to provide detail of the provisions of ‘Part 35: Experts and Assessors' and examine the accompanying practice direction, the pre-action protocols, the ‘Draft Protocol of Best Practice in the Instruction and Use of Experts' and the ‘Draft Code of Guidance for Experts and Assessors' as they relate to the role of the medical expert.

“Employers have a key role to play in safeguarding the mental health of their workforce, both by providing a supportive work environment and by encouraging the use of the workplace to provide health education and health promotion activities” (Department of Health (DoH), 1998a, 4.64)

This is a timely and useful start to a major debate that should now be taking place in mental health services. The authors have successfully woven the need for staff support into the themes of clinical governance and the national service framework for mental health and other Government initiatives. While concentrating on the particular stresses of consultants, they recognise that other grades and other disciplines in the field also suffer.