Alcohol can induce a wide spectrum of effects on the central nervous system. These effects can be recognized at the neurophysiological, morphological and neuropsychological levels. Several studies of the effect of alcohol on the frontal lobes were identified for review from MedLine, PsychLIT databases and by manual searching. In this review article, the different changes are examined in detail. Computed tomography studies have reported changes of frontal lobe in alcoholism, while magnetic resonance imaging studies supported these findings. Neurophysiological studies with positron emission tomography and single photon emission computed tomography have reported a decreased frontal lobe glucose utilization and reduced cerebral blood flow. There is also evidence from neuropsychological studies that there are specific deficits in alcoholism that suggest frontal lobe dysfunction. Considered together, these studies lend a strong credence to the concept of frontal lobe pathology in alcoholism. However, frontal lobe is not an isolated part of the brain and should be considered with its heavy connections to different cortical and subcortical areas of the brain.

Aims and methods A postal questionnairesent to all psychiatrists working in four NHStrusts in and around Birmingham was used to survey the number of new cases of drug and alcohol misuse identified in the previous month and the degree of postgraduate training in the management of such cases. Attitudes and beliefs about substance misuseproblems were also elicited. Results A responserate of 70%wasachieved acrosssix sub-specialities in psychiatry and four levels of training. Of the 143respondents, over half had identified at least one new case of alcohol (61%)or drug misuse(55%)in the previous month. Approximately half of the sample admitted to having received no training in management of substance misuse cases in the previous five years (45% alcohol. 50% drugs). There was general agreement about the potential management role of the doctor in the field, but less consensuson whether the clinician had a responsibility to intervene in such cases. A clear discrepancy was demonstrated between psychiatrists' perceptions of the evidence supporting various treatments and the actual evidence base. Clinical implications The study highlightsthe pressing need for training psychiatristsat all levels and in all subspecialities in the management of substance misuse.

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