People with schizophrenia make a significant contribution to violence in our communities and, in so doing, often lay waste to their own lives. The 10% or so from which will emerge the perpetrators of most of the serious violence are identifiable in advance. A structured programme in which the criminogenic personality and behavioural factors, substance misuse and social dislocation are managed together with the active symptoms of the disorder could prevent the progress to violence. Such systems of care could significantly reduce serious criminal violence and homicide, reduce the number of people with schizophrenia who end up in prison, stop the rising number of forensic psychiatric beds and, most importantly, improve the lives of many of the most disturbed and disadvantaged of those with the disorder.

Operational criteria for detecting prodromal, or at-risk, mental states have been developed largely on the basis of individuals seeking help for attenuated or brief, self-limiting symptoms that do not meet threshold criteria for psychotic disorder. These individuals present largely to primary care and other non-specialist mental health settings. Follow-up studies have confirmed that 15–40% will make the transition to full psychosis within 12 months. Cognitive therapy alone or in combination with low-dose atypical antipsychotics has been shown to be efficacious in reducing or delaying the transition to psychosis, as well as in ameliorating the severity of non-psychotic symptoms and distress. Antipsychotic medication alone has not shown significant efficacy, but results are suggestive of some advantage from drug treatment. Further work is needed to clarify the relative merits of these interventions.

New data have emerged over the past 10 years regarding the efficacy and mechanisms of action of lithium. This article briefly summarises the evidence for the use of lithium to treat affective disorders and psychosis, reviews its putative anti-suicidal effect, highlights new research on its mechanism of action and provides an update on some important side-effects and consequences of its use.

In their recent articles in APT Mace & Binyon described a four-level approach to the teaching of the psychodynamic formulation. The fourth level requires development of confidence in the use of an operationalised psychodynamic diagnostics (OPD) manual. Here I critically reconsider the aspects necessary to develop the ability to arrive at a psychodynamic formulation. I argue that as one develops more sophistication and clinical confidence, one needs to move from a manualised to a more open-minded reflective mode.

As a gold-standard methodology for the testing of the effectiveness of health treatments, the randomised controlled trial (RCT) continues to evolve to meet the challenges of new contexts and areas of medicine. This article reviews two particular evolving features of RCTs that make them increasingly well adapted to testing psychological interventions in mental health. The first is a new confidence that RCTs can be successfully adapted to test the more complex (often psychosocial) health interventions and technologies. The second is an increasing emphasis on using the RCT method to explore many facets of the process of treatment as well as its outcome. These two developments should help the RCT method to come of age in mental health, increase the face validity of the RCT method for practitioners and aid the effective translation of research work into improvements in practice.

Clinical records are the most basic of clinical tools. Aggregated, they form a permanent account of individual considerations and the reasons for decisions. Essential for effective communication and good clinical care, they are often accorded low priority, are poorly maintained and not readily available. Independent inquiries, health ombudsmen's reports and the courts have repeatedly criticised the quality of records and the resulting failings of care. Most advice from professional bodies, indemnity organisations and the General Medical Council is extremely brief and confined to individual entries in the record. Patient safety and the demands of clinical governance make change essential. This article draws together standards and concludes with some good practice points for a fit-for-purpose, structured, multidisciplinary record to support good care and protect the interests of patients and clinicians. These principles should be equally applicable to electronic records.

The history of the concept of the placebo effect and research into its quantification and mechanisms are reviewed, particularly in relation to psychiatry. Research has demonstrated a notable placebo effect in depression: a large proportion of the clinical effect of antidepressant medication is attributable to the effect. Various mechanisms have been hypothesised: anxiety relief, expectation, transference, ‘meaning effects' and conditioning. Recent research from neuroimaging has unveiled that the effect is associated with biological correlates in the brain. Despite the renewal of research into the placebo effect, many questions remain unanswered. This partly reflects philosophical obstacles such as the mind/body dichotomy, which are inherent in conceptualising the effect. However, it also demonstrates the vast scope for further research into this area. Ultimately, an understanding of the processes that underlie the placebo effect should allow a rationalised therapeutic approach to be developed to maximise the clinical benefit of the therapeutic encounter.

If personality disorder is no longer to be a diagnosis of exclusion it needs a conceptual framework that fits both the symptoms of the illness and the behavioural problems that constitute its current diagnostic criteria. In this article, we suggest that personality disorder is best understood as disorganisation of the capacity for affect regulation, mediated by early attachments. We present evidence for this argument based on both developmental and neurobiological research.