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A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially ‘applied neuroscience’. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.

Bill Fulford has argued convincingly that the widely held view that bodily illness is ‘relatively transparent in meaning’ and less ‘value-laden’ than mental illness does not stand up to scrutiny. 1 For him, it is simply that the values inherent in our concepts of bodily disorder are just not as obvious as those involved in our discourse of mental illness. When the presenting problem is pain from an arthritic joint or from a myocardial infarction, there is usually agreement between the doctor, the patient and the carer about what the priorities are and what would count as recovery. In the world of mental health, disagreements about values, priorities and frameworks have always been part of day-to-day work and thus value judgements more obvious.

Moving ‘beyond the current paradigm’ is not about a search for another singular framework, but a realisation that the complex world of mental health demands openness to multiple paradigms. Many psychiatrists strive to work in this way already and there is evidence that an increasing number are keen to move towards recovery-oriented service models. 1 We do not claim to have all the answers and value the work of Professor Holmes, for example in relation to the role of narrative in mental health practice. 2 However, we would caution against any attempts to explain the insights of psychodynamics through the discourse of neuroscience. Crucially, it involves a rethinking of the nature of mental health expertise and, with this, a commitment to rethinking the power structures of our field. 1 Baker E, Fee J, Bovingdon L, Campbell T, Hewis E, Lewis D, et al From taking to using medication: recovery-focused prescribing and medicines management.

Background Knowledge of types and co-morbidities of disorders seen in any facility is useful for clinical practice and planning for services. Aim To study the pattern of co-morbidities of and correlations between psychiatric disorders in in-patients of Mathari Hospital, the premier psychiatric hospital in Kenya. Study Design Cross-sectional. Methods All the patients who were admitted at Mathari Hospital in June 2004 and were well enough to participate in the study were approached for informed consent. Trained psychiatric charge nurses interviewed them using the Structured Clinical Interview for DSM-IV Axis I disorders Clinical Version (SCID-I). Information on their socio-demographic profiles and hospital diagnoses was extracted from their clinical notes using a structured format. Results Six hundred and ninety-one patients participated in the study. Sixty-three percent were male. More than three quarters (78%) of the patients were aged between 21 and 45 years. More than half (59.5%) of the males and slightly less than half (49.4%) of the females were single. All the patients were predominantly of the Christian faith. Over 85% were dependants of another family member and the remainder were heads of households who supported their own families. Schizophrenia, bipolar I disorder, psychosis, substance use disorder and schizo-affective disorder were the most common hospital and differential diagnoses. Of the anxiety disorders, only three patients were under treatment for post-traumatic stress disorder (PTSD). Nearly a quarter (24.6%) of the patients were currently admitted for a similar previous diagnosis. Schizophrenia was the most frequent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders—fourth edition) diagnosis (51%), followed by bipolar I disorder (42.3%), substance use disorder (34.4%) and major depressive illness (24.6%). Suicidal features were common in the depressive group, with 14.7% of this group reporting a suicidal attempt. All DSM-IV anxiety disorders, including obsessive–compulsive disorders, were highly prevalent although, with the exception of three cases of PTSD, none of these anxiety disorders were diagnosed clinically. Traumatic events were reported in 33.3% of the patients. These were multiple and mainly violent events. Despite the multiplicity of these events, only 7.4% of the patients had a PTSD diagnosis in a previous admission while 4% were currently diagnosed with PTSD. The number of DSM-IV diagnoses was more than the total number of patients, suggesting co-morbidity, which was confirmed by significant 2-tailed correlation tests. Conclusion DSM-IV substance use disorders, major psychiatric disorders and anxiety disorders were prevalent and co-morbid. However, anxiety disorders were hardly diagnosed and therefore not managed. Suicidal symptoms were common. These results call for more inclusive clinical diagnostic practice. Standardized clinical practice using a diagnostic tool on routine basis will go a long way in ensuring that no DSM-IV diagnosis is missed. This will improve clinical management of patients and documentation.