Nicaragua is celebrating ten years of revolution since the overthrow of the 45 year long Somoza dictatorship∗. In this time, the Sandinista government has attempted to construct a more democratic society with considerable achievements in the area of health, welfare and education. Indeed, health care has been a priority in spite of severe economic difficulties caused by the United States economic blockade and by the need for defence against the war waged by the counter-revolutionaries (the Contra).

In the medical profession a consultant is a doctor who has attained the capacity for totally independent practice, otherwise known as clinical freedom. Consultants differ from other doctors in the important respect that they have full clinical responsibility (BMA, 1984). The work of the consultant may be audited by his peers, with his full participation, but may not be supervised by one (DoH, 1989a). Thus, whereas the consultant is accountable, administratively, to his employers, in the clinical area, he is not accountable to any other doctors or managers: he is accountable to the General Medical Council for his professional conduct, and, with respect to the diagnosis and treatment of illness, to the patients directly, the patients' relatives, and the law of the land.

The issue of crime and insanity in Victorian Britain is dominated by the 1843 case of Daniel McNaughton. Hounded by paranoid delusions, about which he was relatively unforthcoming despite detailed questioning, he succeeded in shooting Henry Drummond, private secretary to the Prime Minister, Robert Peel. Thinking that it was Peel himself he had shot, McNaughton is quoted by the arresting policeman as stating “he shall break my peace of mind no longer”. The furore over his trial and non-execution filtered down the century, via the McNaughton rules. Daniel himself mouldered in Bethlem and Broadmoor for the rest of his days (West & Walk, 1977, esp. p. 93). But much more prevalent in the public's eye were the seven (at least) serious assaults on the Queen. Not only did they bring about a new criminal charge (vide infra) – but their recurrence tended to promote pro-royalist sympathies as well as pro-custodial attitudes towards “the insane”.

In everyday life we all make choices and decisions with regard to ourselves and our environment. Such decisions may be quite trivial, for example which pair of trousers we should wear, or major, for example to move home. The freedom to make such decisions may be called the right to self-determination or autonomy. For adults, such a right is recognised by the law, either explicitly as in USA or more implicitly as here in the United Kingdom. Such a right is also partially acknowledged in children although if the child or young person is not capable of making a reasoned decision then the parent or guardian may make the decision on their behalf. Some adults through mental disability (mental illness, mental handicap) have a diminished ability to make reasoned decisions. However, it is important to recognise that in any given situation there should be an assessment of the person's ability to make a reasoned decision and assumptions not made for convenience's sake. Even people with substantial intellectual impairment are capable of making some decisions.

Drilling holes in someone's skull and destroying parts of the brain is the kind of scenario dreamt up by anti-psychiatrists. That it can happen in practice - and once happened on a fairly large scale - remains a matter of sensitivity for the public image of psychiatry, notwithstanding that there are still cogent reasons to retain leucotomy in its armamentarium. So any presentation of this subject on the mass media needs to be done with the greatest responsibility, and should convey an accurate message.

Bereavement counselling is one of the few examples of preventive psychiatry to have proved its worth in well conducted random allocation studies (Raphael, 1977; Parkes, 1981). If, as the work of Paykel (1974) and Brown & Harris (1978) suggests, major losses are the life events most often associated with the onset of clinical depression, then psychiatrists would do well to involve themselves in the work of any organisation which aims to meet the psychological needs of the bereaved.

Because of the problem of diagnostic unreliability in psychiatry, there has been a trend over recent years to create explicit diagnostic criteria, such as the Research Diagnostic Criteria and DSM–III. This movement has been called neo-Kraepelinian (Klerman, 1978) as it promotes many of the ideas associated with the views of Kraepelin, regarded as the founder of modern psychiatry. It favours a biological approach and arose partially as a response to attacks on the ‘medical model’ in psychiatry.

During registrar training I had the privilege of working in the interim secure unit at Friern Hospital in London. To gain further experience in the field of forensic psychiatry, I secured (if that is an appropriate term), a post as trainee psychiatrist at James Nash House, centre for forensic psychiatry, Adelaide, South Australia. This article compares the legal and health care frameworks in England and South Australia relevant to mentally abnormal offenders. The two units are described and differences in facilities, patient populations and working practices are discussed.

In the wee midnight hours, long ‘fore the break of day In the wee midnight hours, long before the break of day When the blues creep upon you and carry your mind away.

The post of Emergency and Liaison Registrar in the Bloomsbury Rotation was created in 1988 to provide a psychiatric service at University College Hospital, London, in the Accident and Emergency (A&E) Department and to the A&E Ward for assessment of deliberate self harm (DSH) cases. It incorporated existing commitments of liaison to the UCH wards and provision of urgent psychiatric assessments. The service had previously been shared among a number of psychiatric staff. The registrar can thus be seen as a ‘central pivot’ within the District Psychiatric Services.

Consumer attitudes are of the utmost importance in achieving adequate care of a psychiatric population and may directly influence compliance with drug treatment, attendance at out-patient appointments and willingness to accept admission to a psychiatric unit. It is therefore surprising that despite the original Griffiths Report (1987) highlighting the need for consumer input into the psychiatric audit process, little research has been undertaken in this area and knowledge into the quality of inpatient care is especially sparse.

Thailand, unlike many Asian countries, never experienced colonial or imperial subjection and thus lacked the portal through which psychiatric services usually gained entry. As a result, progress in this field was initially slow. The first mental hospital was established in 1889, a century later than in India. The country has been fortunate inasmuch as it has been spared involvement in the wars, revolutions, and other social upheavals that have plagued Asia in the 20th century. Recent national stability and impressive economic growth have provided a sound base for the development of health services, and progress has been rapid in comparison with many neighbouring countries. Due attention has been paid to family planning, maternity and child welfare services. The provision of comprehensive primary health care in urban and rural areas is improving all the time. The education of children is universally regarded as important. Schooling is compulsory and attendance satisfactory.

In spite of all the publicity in recent years about child abuse, very little mention has been made of another group of people who are also very vulnerable to abuse, namely adults with a mental handicap. Although chronologically adults, and therefore not susceptible to the laws designed to protect children, they may be functioning intellectually and emotionally at a much lower level. Because they are often dependent on other people for many aspects of their care, this makes them vulnerable to physical and sexual abuse and neglect. Difficulties with speech and communication may render them unable to inform anyone of their plight or ask for help, therefore many problems remain hidden. Personal involvement in one such case made me aware of this problem and the current lack of legal protection for this group of people. I therefore undertook a national survey in order to gain more information on the prevalence of abuse, factors associated with it, and possible legal solutions.

In June 1989, while the Polish people took part in their first free elections for 40 years, I spent a busy day in the company of Dr CY, an English-speaking Polish psychiatrist, visiting state psychiatric facilities in the Gdansk/Gdynia region and sitting in on consultations in Dr Y's private clinic in Gdansk.