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.

The integration of medical/‘biologial’ and psychological approaches to the human mind is unique to psychiatric training. There have been past tensions between the two views, but the ability to integrate them is increasingly recognised as an indispensable contribution of our profession to mental health care as a whole.

The lack of official consideration of the legal and contractual implications of the informal admission of psychiatric patients has resulted in a situation in which individual hospitals and mental nursing homes have generated their own mistaken assumptions about the nature of this form of admission, often to the detriment of patients.

It is important to explore and interpret the dynamics of cultural differences and racism in clinical work. Race and culture often play a significant role in any psychotherapeutic relationship. Vignettes and clinical narratives are used to illustrate that they can be a useful vehicle for the expression of transferences, demonstrating how basic concepts of psychotherapy apply to cross-cultural interactions.

Managed care is a phrase on the lips of every US psychiatrist. Some believe that this revolution in health care has brought US doctors kicking and screaming into the age of ‘cost-effective’, ‘evidence-based medicine’ (Mechanic, 1997). But most psychiatrists I interviewed from Boston, San Francisco and New York, thought it had transformed them from autonomous professionals to automatons.

This article summarises the findings of a National Health Service Executive, Royal College of Psychiatrists', National Association of Health Authorities and Trusts, and Trust Federation working group on medical staffing in mental health, which reported to ministers in summer 1996 and was launched at a conference in November 1996 jointly with the College. Although primarily focused on England and Wales, it is clear that similar problems exist in other parts of the United Kingdom and the Republic of Ireland.

This family blockbuster film is about aliens given asylum on earth on condition they follow certain rules. Basically these are to live in a stated place, to allow access to the Men in Black and to remain in human disguise while in public places so as to not frighten the natives. The heroes are human secret agents who monitor the well-being of the aliens and ensure that they abide by their conditions of residence. Striking parallels with recent mental health developments are evident, particularly to at-risk registers and supervised discharge orders. This paper discusses these similarities and their possible consequences referring to events in the film to illustrate relevant points.

Palliative care is a growing speciality. The terminally ill suffer high levels of psychiatric morbidity. The involvement of one senior registrar in setting up a liaison psychiatry service to a Marie Curie Hospice in special interest sessions is described. A liaison-consultation model developed and 29 referrals are described over six months.

Recommended changes in services for adults with mild learning disabilities are likely to have training implications. A case vignette study examined the effect of coexistent mental illness and learning disability on trainees' clinical assessment and management. Mental illness was more likely to be diagnosed in those with a mild learning disability than in a control group who had no learning disability. Despite this, the learning disability group was less likely to receive treatment. Service and training issues are discussed.

Dutch forensic psychiatry provides services for mentally disordered offenders which centre around a legal measure called the TBS order. Specialised units deal separately with assessment and treatment. The system appears to work in the context of a small and wealthy country and a criminal justice system which differs from the English system. This paper describes the key features of the secure units, examines the conceptual issues and complications of the Dutch system, and considers lessons for psychiatric and legal approaches to the problem of psychopathy in Britain, in particular the new hybrid order.

The study of fatal suicides in York, 1990–1994, by Elwood & De Silva (1998) is valuable confirmation that other people than general practitioners (GPs) and psychiatrists have responsibilities in averting such deaths, but does not go far enough. It is assumed that the GP or general hospital doctor has failed to recognise the suicidal risk, and better teaching would have increased their diagnostic awareness and so saved lives. But examining the detailed sequence of events leading up to death (medical audit) will show that in a number of cases medical diagnosis was not lacking, and the problem lay elsewhere.

In our evidence-based journal club we appraised an article investigating the use of the CAGE questions in screening psychiatric populations for alcohol misuse. We calculated a likelihood ratio of four for a score of two or more positive CAGE questions, suggesting the CAGE is a moderately useful screening instrument.

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.