The legacy - or not - of Dr Thomas Szasz (1920-2012).

Dr Trevor Turner was asked to provide a commentary on the preceding paper in this issue, '"Freedom is more important than health": Thomas Szasz and the problem of paternalism', by Joanna Moncrieff.

'The patient is medically cleared'.

It is standard practice for psychiatric nurses and junior doctors working in emergency departments to ask that patients be 'medically cleared' before psychiatric admission or even assessment. However, there is a lack of agreement over what this process should entail.

Suicide now and then ... an elusive comparison: invited commentary on: Lifetime suicide rates in treated schizophrenia: 1875-1924 and 1994-1998 cohorts compared.

Comparing suicide rates between Victorian and modern times, and the impact of the asylum, should enable a useful historical perspective on how effective our treatment approaches really are. Difficulties include clarifying the 'social geography', the underlying diagnoses, the reasons for admission and the reliability of case book data and follow-up arrangements.

Complementary medicines in psychiatry: review of effectiveness and safety.

BACKGROUND: The use of complementary medicines in those with mental health problems is well documented. However, their effectiveness is often not established and they may be less harmless than commonly assumed. AIMS: To review the complementary medicines routinely encountered in psychiatric practice, their effectiveness, potential adverse effects and interactions. METHOD: Electronic and manual literature search on the effectiveness and safety of psychotropic complementary medicines. RESULTS: Potentially useful substances include ginkgo and hydergine as cognitive enhancers, passion flower and valerian as sedatives, St John's wort and s-adenosylmethionine as antidepressants, and selenium and folate to complement antidepressants. The evidence is less conclusive for the use of omega-3 fatty acids as augmentation treatment in schizophrenia, melatonin for tardive dyskinesia and 18-methoxycoronaridine, an ibogaine derivative, for the treatment of cocaine and heroin addiction. CONCLUSIONS: Systematic clinical trials are needed to test promising substances. Meanwhile, those wishing to take psychotropic complementary medicines require appropriate advice.

Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries.

OBJECTIVE: To establish whether reinstitutionalisation is occurring in mental health care and, if so, with what variations between western European countries. DESIGN: Comparison of data on changes in service provision. SETTING: Six European countries with different traditions of mental health care that have all experienced deinstitutionalisation since the 1970s--England, Germany, Italy, the Netherlands, Spain, and Sweden. OUTCOME MEASURES: Changes in the number of forensic hospital beds, involuntary hospital admissions, places in supported housing, general psychiatric hospital beds, and general prison population between 1990-1 and 2002-3. RESULTS: Forensic beds and places in supported housing have increased in all countries, whereas changes in involuntary hospital admissions have been inconsistent. The number of psychiatric hospital beds has been reduced in five countries, but only in two countries does this reduction outweigh the number of additional places in forensic institutions and supported housing. The general prison population has substantially increased in all countries. CONCLUSIONS: Reinstitutionalisation is taking place in European countries with different traditions of health care, although with significant variation between the six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to risk containment in a society, as indicated by the size of the prison population, may be more important than changing morbidity and new methods of mental healthcare delivery.

Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia.

BACKGROUND: Little evidence exists to indicate whether community psychiatric nurses can achieve the results reported by expert cognitive-behavioural therapists in patients with schizophrenia. AIMS: To assess the effectiveness and safety of a brief cognitive-behavioural therapy (CBT) intervention in a representative community sample of patients with schizophrenia in secondary care settings. METHOD: A pragmatic randomised trial was performed involving 422 patients and carers to compare a brief CBT intervention against treatment as usual. RESULTS: Patients who received CBT (n=257) improved in overall symptomatology (P=0.015; number needed to treat [NNT]=13), insight (P<0.001; NNT=10) and depression (P=0.003; NNT=9) compared with the control group (n=165). Insight was clinically significantly improved (risk ratio=1.15, 95% CI 1.01-1.31). There was no increase in suicidal ideation. CONCLUSIONS: Community psychiatric nurses can safely and effectively deliver a brief CBT intervention to patients with schizophrenia and their carers.