In the second of this occasional series, Mark Jones looks at Mozart and his 1788 masterpiece, Don Giovanni, and interviews Tom Sutcliffe, opera critic of The Guardian, about his views on this problematical work and its portrayal on the stage.

Idiot-savants are people of low intelligence who have one or two outstanding talents such as calendar calculation, drawing, or musical performance. The syndrome occurs with high frequency among autistic children (autism is about four times commoner in boys), and the male to female ratio is about 6:1 suggesting a sex linked disorder (Hill, 1977). It is estimated to occur in 0.06% of the mentally handicapped population or about 1 in 2,000 of those living in institutions (Treffert, 1988). The gift starts apparently spontaneously between age 5 and 8 years. Frequently the parents claim that they themselves do not have the talent and know of no one in the family who has, but there is a tendency for savant skills to run in families, suggesting that genetic factors play a role.

This speciality is concerned with the psychiatry of patients whose development of intelligence has been impaired.

In the study of suicide little attention has been paid to the role of life insurance. One might suppose that ‘deliberately accelerating the event insured against’ by homicide or suicide would void a policy. One might also predict that changes in attitude towards suicide, so that it is increasingly regarded as a medico-social problem rather than a criminal act, would be reflected in a softening of attitude among insurers. On the other hand, recent epidemiological changes, such as the increased suicide rate among young males, could make companies reluctant to relax their policy conditions.

A large crowd throngs the out-patient hall and all 300 children cry in unison. The father of an eight year-old girl pushes her through the crowd until she reaches a partitioned cubicle where four doctors sit round a table. He puts her in front of the first doctor and tells him about the chest pain she has had for months. The doctor, struggling to hear above the din, takes a brief history and examines the girl standing up. The history is inconclusive and there are no signs; he cannot understand why her parents have bothered to make the 30 mile bus ride that morning; why didn't they accept the advice of the paediatricians they had consulted nearer their home? Usually he would have written a prescription for a tonic costing the father two days' wages, but this time he directs the girl and her father back through the crowd to where I sit, alone in my cubicle, separated from the gaze of the attenders by a saloon bar door.

A useful part of the MRCPsych residential revision course at the University of Surrey in Guildford is the mock clinical examination. One of the peculiarities of the mock examination for the Membership course which I attended was that all examinees interviewed patients in one large hall. I found it intriguing to observe the note-taking techniques of my equally nervous colleagues. It seemed to me that there was little organisation in the way candidates wrote down the information acquired from their interviews. Most people left the hall clutching a jumble of disjointed sheets of paper to start a scrambled five minutes of hasty preparation before presenting the case. Much of this precious time was then spent attempting to decipher and organise their notes, when clearly it would have been better employed in thinking and trying to anticipate likely questions.

The Dutch have a tradition of tolerance and pragmatism in the fields of social policy, and nowhere is this better illustrated than in their policy and practice in the field of drug misuse. Indeed often exaggerated accounts of Dutch ‘liberalism’ are promulgated, and articles in the press have suggested a backlash is now occurring in Holland to these ‘progressive’ policies (Williams, 1989). The award of a Council of Europe Fellowship gave me the opportunity to spend two weeks in the Netherlands in October 1989, visiting drug services and talking to a wide range of people with responsibilities for such services. I was particularly interested to see how the Dutch were responding to the challenges of HIV infection in drug users (Fleming, 1989).

The view (Anon, 1990) that “drugs for Alzheimer's Disease (AD) are generally ineffective” is a reasonable conclusion to draw from the results of treatment studies to date. However in recent years there has been a rapid expansion of knowledge of both basic neurobiology and the pathology of AD. Future advances may be expected to arise from this, so when the authors of Drugs and Therapeutics Bulletin next review this subject they may well be able to draw a more optimistic conclusion.

A workshop organised by the Research Committee of the College took place on 20 November 1989, in which 14 invited delegates from nursing, psychiatry and general practice presented and discussed the implications of recent research developments in community psychiatric nursing. Papers were given by Helen Hally, Chairman of the Community Psychiatric Nurses Association, on recent developments in the workload of community psychiatric nurses. Dr Joseph Connolly presented the preliminary findings of the ‘Daily Living Project’ at the Maudsley Hospital in which comprehensive community care is given primarily by community psychiatric nurses. Professor Brandon outlined some of the difficulties in obtaining data on the working practices of community psychiatric nurses arising from a study in Leicester and this was followed by an account by Dr Alastair Wright, a general practitioner in Glenrothes, Fife, of the typical psychiatric workload of a general practitioner and the ways in which community psychiatric nurses may be of value in treating this without the necessity of referral to psychiatric care.

As usual, I bought my wife Vogue magazine for Christmas. It always serves well as, in North America parlance, a ‘stocking stuffer’. This year it had further value as it highlighted the brain. A well-known psychiatrist, Nancy Andreasen, set out to inform America about modern psychiatry (Andreasen, 1990). The article is entitled ‘Brave New Brain’ with the subtitle being ‘Modern Psychiatry has Left the Couch for the Laboratory’. She takes the reader through neuro-imaging, molecular genetics and psycho-pharmacology. It is an elegant synopsis and worthy of someone who had a doctorate in English before she took up medicine. Importantly, however, she prefaced her serious material with a mock-comic story about a conversation she had had with someone at a New York hospital recently. She was phoning about the retrieval of a brain for research and the ingenuous person at the hospital just could not put the idea of psychiatry and brains together. Another sad tale of psychiatric breast-beating? Those of us who trained in psychiatry in Britain a generation ago might give a wry smile. After all, biological psychiatry was all that we ever knew. When I entered the Maudsley in 1964, part of the orientation for registrars consisted of going to the laboratories. A mouse was popped into a jar containing liquid nitrogen, it went rock hard and the group was advised that freezing the neurotransmitters in that way was the royal road to solving problems.

The practice of out-patient psychiatry has undergone a number of significant developments in recent years: the number of patients referred by general practitioners has steadily increased: a large number of psychiatrists are now seeing patients in the primary care setting and more patients are being seen on one occasion only.

Mental health problems in primary care settings have received wider attention in recent years (Wilkinson, 1985). In India, the National Mental Health Programme (NMHP) was formulated with the purpose of promoting mental health care through primary health care (National Mental Health Programme, 1982). As part of the implementation of NMHP, training programmes for medical officers and health workers have been initiated in a number of centres in the country (National Mental Health Programme for India, Progress Report, 1988). At the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, a monthly training programme for doctors and health workers of primary health centres has been carried out since 1982. In order to evaluate the gain in knowledge and clinical skills, a multiple-choice questionnaire and case vignettes have been standardised (Sriram et al, in press). The doctors are also evaluated through a structured clinical examination which is carried out on the last training day. The focus of the present report is to evaluate the clinical skills of medical officers using the structured clinical examination.

It is ironical that of the two greatest Austrian psychiatrists, Freud and Wagner-Jauregg, Freud is now a household name throughout the world, whereas Wagner-Jauregg is hardly known outside German-speaking countries. Yet his work brought him the highest honours not only in his own country and was crowned by the award of the Nobel prize in 1927. The reason for the reversal of their reputations is not far to seek. The Nobel prize was awarded to Wagner-Jauregg for his malaria treatment of general paralysis of the insane (GPI), a severe and fatal form of neurosyphilis, which saved untold thousands of lives. Today GPI is rarely seen because syphilis can now be successfully treated with antibiotics. Wagner-Jauregg also did pioneering work into the relationship between thyroid deficiency and cretinism, which in those days was still in a speculative state, but his name is hardly ever mentioned in this context. He had the misfortune to publish in journals with a more restricted circulation than those in which the results of Schiff's and Kocher's work appeared.

Psychiatric services in Zimbabwe are, by African standards, relatively sophisticated and are modelled on the British system. A new patient is assessed using the Maudsley history-taking format modified to suit local situations, and a mental state examination. A physical examination and routine investigations follow. X-ray facilities and basic laboratory work-up such as haematology and microscopy are available at Provincial level. EEG, ultrasonography, echoencephalography, CT scanning and serum anticonvulsant levels are available in Harare and Bulawayo.