General psychiatry, still in no-man's land after all these years.

Mental health services have changed beyond recognition in my 38-year career. In this editorial I reflect on those changes and highlight the issues that undermine patient care and damage staff morale. In particular, modern mental health services have undermined the therapeutic relationship, the bedrock underpinning all psychiatric treatment.

Operational mental health. . .what practitioners and commanders should know.

BACKGROUND: Mental Health support to military operations is well established as an integral part of military medicine. Unfortunately, Commanders often receive little or no training in how best to use their mental health assets or what their capabilities are. Conversely, members of a Field Mental Health Team frequently have no operational experience and try to merely translate their civilian practice onto the battlefield. AIM: This article describes what mental health professional can, and should do on military deployments and calls for greater training and awareness of both Mental Health professionals and Operational Commanders to foster mutual understanding and use the Field Mental Health Team to best effect. METHOD: The paper drawson the experience of working in a Field Mental Health Team on six operational deployments in Iraq and Afghanistan. RESULTS: Military mental health professionals work mostly in peacetime and this work ill prepares them for the very different type of work required of them on operations. CONCLUSION: More training is required to prepare both practitioners and commanders for the mental health issues that confront them on operational deployments.

What's in a memory? PTSD and working with survivors of psychological trauma.

BACKGROUND: Treating the consequences of psychological trauma and PTSD is of major concern to psychiatry although outcomes are often rather poor, often giving to the fact that the diagnose of PTSD is misused and no consideration of the trauma settings and its consequences on the brain. AIMS: This paper looks at the impact of false or induced memories in the trauma narrative and their potential impact on therapy with examples from the everyday world. The consequences of this in civilian therapy sessions is discussed compared to the classical debriefing for PTSD in the armed forces. METHODS: We take a theoretical overview of the interaction between therapist and patient with PTSD and consider the shortfalls of any therapy that requires the patient to recount their experiences. RESULTS: We argue the uncritical acceptance of trauma history fails to take account of, and even lends itself, to induced or false memories which undermine treatment. CONCLUSIONS: We conclude that, this is also often leading to a wrong conception of the outcome of treatment for PTSD, which is often much more sombre than the treatment outcome of lesser conditions.

Psychiatric colonialism, PTSD and the Western psychiatric diagnostic tradition . . . is one man's food another man's poison?

Sadly, much of the world is no stranger to Psychological Trauma, particularly in poorer areas with poor health infrastructure. Western Aid Organisations frequently deploy to such areas bringing with them a western psychiatric tradition of nosology and therapy which may not be appropriate in other cultures. We argue that imposing a western system of diagnosis and treatment may not only undermine local culture but may also be bad for the patient. We discuss this with reference to the WHO's Mental Health Gap initiative (MHGap).

Youth violence and knife crime in ethnic minorities in the UK: A review of the literature.

BACKGROUND: Youth violence and knife crime is increasing dramatically, so much so it has been described as a global epidemic. The social, economic and political forces fuelling this rise mean that minority groups are particularly affected. AIM: This paper reviews the literature primarily from a UK perspective, and illustrates the disparate factors that are influencing the rise in youth violence and knife crime and illustrates the complexities of integrating the perspectives of different disciplines into coherent intervention strategies. METHOD: We conducted a systematic review of the literature that explores both the causes of increasing youth violence and knife crime as well as some of the interventions that have attempted to deal with the problem. RESULTS: A complex interplay of social, economic, mental health and political factors underpin the increase in youth violence and knife crime. An uneasy tension exists between a traditional criminal justice system-based approach based upon deterrence and punishment, and a more liberal preventative model focusing on adolescent mental health. None of the interventions thus far have been particularly effective. CONCLUSION: Youth violence and knife crime is a global social issue that causes untold suffering to individuals, families and communities as well as fear that reverberates through society. Interventions have often been devised through the lens of particular disciplines or ideologies. Integrating these perspectives into a coherent approach that is actually effective demands greater co-operation, dialogue and mutual understanding between disciplines and agencies, as well as a robust framework for the evidence-based assessment of outcomes.

Structural inequalities, knife crime: A qualitative study.

The importance and impact of youth violence is increasingly being recognised and is a cause of international concern. In the UK, youth violence, specifically knife crime, is on the increase and has resulted in the deaths of many young people. In order to explore the impact of knife crimes on mental health and wellbeing of individuals, a number of focus groups were conducted with 24 professionals from multiple agencies. Qualitative analysis showed various emerging themes, which included ineffective mental health systems, structural violence and inequalities, policing, safety and community engagement, vulnerability and resilience in minority communities. Equity in mental health services, further development and roll-out of public mental health approaches and training accompanied by sufficient resources is needed.

Ukraine: Meeting the mental health needs of service veterans.

The current conflict in Ukraine is a tragedy of epic proportions that without doubt is causing serious psychological damage with inevitable long term consequences affecting combatants, civilians, not to mention displaced refugees. This paper focuses on the mental health needs of service veterans returning home to a country, devastated by the current conflict.

The costs of conflict: meeting the mental health needs of serving personnel and service veterans.

Military mental health has, until recently, been a neglected and marginalized area of interest and although both World Wars saw important advances, in peacetime we typically forget lessons learned in earlier conflicts. Since 2003 however, with high intensity war-fighting on two fronts involving the service personnel of many nations, attention has, once again focused on the immediate and long-term emotional and psychological impact of combat. Whilst we know a lot about posttraumatic stress disorder (PTSD), much less attention has been paid to a variety of other equally, if not more salient yet superficially less dramatic problems facing service personnel deployed on operations, but which are much more likely to lead to mental disorder than traumatic events and the 'horrors of war'. This article describes some of these broader yet less tangible and under-researched issues and discusses the provision of services for the burgeoning veteran community. The mental health of service personnel and veterans is politically sensitive and attracts significant public and media interest. Understanding and responding appropriately to the needs of this group should be of concern to all mental health professionals and it has important consequences, not only for affected individuals but, for the public perception of mental health services as a whole.

The Fair Deal campaign: a call to arms.

The UK healthcare economy is facing an unprecedented downturn, mental health services being particularly vulnerable. The Royal College of Psychiatrists' Fair Deal campaign is a potentially important tool to help protect services. However, like the College itself, it is only as strong as the membership, and requires individual commitment and involvement if it is to be effective.

Use of psychological decompression in military operational environments.

This article reviews the use of psychological decompression as applied to troops returning from active service in operational theaters. Definitions of the term are considered and a brief history is given. Current policies and practices are described and the question of mandatory decompression is considered. Finally, the evidence base for the efficacy of decompression is examined and some conclusions are drawn. This article highlights variations in the definition and practice of decompression and its use. Although there is, as yet, no evidence that decompression works, there is also no evidence to the contrary. Given the lack of knowledge as to the balance of risks and benefits of decompression and the absence of any definitive evidence that decompression is associated with improved mental health outcomes or that lack of decompression is associated with the reverse, it is argued that the use of decompression should remain a matter for discretion.

The presentation of depression in the British Army.

BACKGROUND: The British Army is predominately composed of young men, often from disadvantaged backgrounds, in which Depression is a common mental health disorder. OBJECTIVES: To construct a predictive model detailing the presentation of depression in the army that could be utilised as an educational and clinical guideline for Army clinical personnel. METHOD AND PARTICIPANTS: Utilising a Constructivist Grounded Theory, phase 1 consisted of 19 interviews with experienced Army mental health clinicians. Phase 2 was a validation exercise conducted with 3 general practitioners. RESULTS: Depression in the Army correlates poorly with civilian definitions, and has a unique interpretation. CONCLUSION: Young soldiers presented with symptoms not in the International Classification of Disorders and older soldiers who feared being medically downgraded, sought help outside the Army Medical Services. Women found it easier to seek support, but many were inappropriately labelled as depressed. Implications include a need to address the poor understanding of military stressors; their relationships to depressive symptoms and raise higher awareness of gender imbalances with regard to access and treatment. The results have international implications for other Armed forces, and those employed in Young Men's Mental Health. The results are presented as a simple predictive model and aide memoire that can be utilised as an educational and clinical guideline. There is scope to adapt this model to international civilian healthcare practice.

Self harm on prescription: the lesser of two evils?

This article reports an innovative method of using a diabetic lancet pen to reduce complex self-injurious behaviour and discuss the ethical considerations.