The National Service Framework for Older People has placed older people with mental-health problems squarely and properly alongside others who are old and require careful consideration of health matters across the physical-mental spectrum. In this article, David Jolley highlights that unresolved or odd physical symptoms may be derived from a psychiatric disorder and successful treatment of this may resolve a complex of distress.

The mentally ill are not a breed apart, they are you and me Ñ everyone's mum, dad, brother, or sister. The presence of an eccentric lifestyle or altered behaviour doesn't protect against the possibility of developing new pathology, but it can so easily make it difficult for the problem to be identified and the prospect of treatment realized.

Even the best of GPs find it difficult when patients come back again and again and again, complaining that they are still feeling terrible when every effort has been made to identify and treat their problem.

It may be particularly difficult to recognize and diagnose a psychiatric disorder when physical pathology has earlier stared you in the face. Referral to a psychiatrist may be avoided in case it is interpreted as an insult in such circumstances, but it might just lead the way to recovery. An example comes from one of my most highly regarded GP colleagues who was on the brink of throwing in the towel: 'Please see Mr X, I am in despair and am considering removing him from my list!'.

A patient with unresolved pain following surgery for carcinoma of the colon was referred thus by his GP. The patient had no remaining serious pathology as far as was known. He had been seen and supported through a pain clinic and was receiving morphine and an SSRI, but with only modest effect. He had been referred to see a psychologist in the local teaching hospital. The man had a wonderful wife who was finding it difficult to come to terms with what had happened to her previously wonderful husband. He would no longer eat the food she cooked, was finding it difficult to sleep and was frequently restless and irritable in bed. Indeed, he spent much of the time clutching his abdomen or head bewailing his suffering and declaring he wished he was dead. His wife asked: 'Why can't the doctors do something? They must be missing something with all their tests.' Yes, indeed they were: a thoroughly treatable but severe agitated depression. The patient had a good recovery thanks to a combination of support by a community psychiatric nurse, repeated visits, and prescription of an effective antidepressant and a low dose neuroleptic.

An African-Caribbean man was going wild in the supermarket, crying out and attacking other shoppers and the police in turn, convinced they were aiming to kill him with darts and poisonous vapours. He was taken struggling into custody at the local police station: a 'place of safety'. However, this just confirmed his fears that the world is hostile, punitive, and prejudiced against him. The patient was found to be toxic with an infected perineal cyst and was managed successfully with a combination of the Mental Health Act, a modest, short course of antipsychotics and, very importantly, antibiotics. Following treatment, the experience seemed like a terrible dream to him. However, his family remember it more clearly and it is taking time for them to lose their fears: 'Can you trust a man who has been so mad? Will it come back again?' Spotting hidden pathology

Looking through the general status of a group of older people attending our day centre for people with learning disability, it is shocking to find how much pathology they carry and how little regular medical input they receive: