England and Wales, Scotland and Northern Ireland are all at different stages in developing their mental health legislation. All jurisdictions have encountered problems in interpretation and operation of the various acts. As an introduction to a series of articles to appear in Advances on mental health and incapacity law, this editorial offers a commentary on some of the critical issues and suggests some key principles that everyone should follow in order to provide care and treatment that accords with best legal and ethical practice.

This editorial summarises the work done to prepare ICD–11 and DSM–V (which should be published in 2015 and 2013 respectively). It gives a brief description of the structures that have been put in place by the World Health Organization and by the American Psychiatric Association and lists the issues and challenges that face the two organisations on their road to the revisions of the classifications. These include dilemmas about the ways of presentation of the revisions (e.g. whether dimensions should be added to categories or even replace them), about different versions of the classifications (e.g. the primary care and research versions), about ways to ensure that the best of evidence as well as experience are taken into account in drafting the revision and many other issues that will have to be resolved in the immediate future.

The cover of this issue heralds a series of articles in which a visual image derived from cell biology or neuroscience is used to promote understanding of the biological mechanisms fundamental to psychiatry. ‘Images in neuroscience’ are intended to demonstrate the structures and mechanisms of the basic building blocks of brain function, including ionotropic and metabotropic receptors, second messenger systems, specialised ion channels, transmitter pathways, transporters, neuroglial function, and the complex mechanisms within cells that are being revealed, as new genetic associations for mental illness are discovered.

Bipolar disorder is arguably a pivotal diagnosis in adult psychiatry bounded by schizophrenia on one side and unipolar depression on the other. It represents a wide spectrum of disorders, all sharing common features of elated and depressed mood. The early descriptions of symptom-free euthymia have long been dismissed and the chronic and enduring deficits associated with the disorder are beginning to be better understood. We review the current literature with regard to the course of the disorder, factors that may influence prognosis and common comorbidities.

Health reform in America will lead to major changes in medical care in the USA, with opportunities for improved access to care, especially for psychiatric patients. Combined with recently enacted ‘parity’ legislation, health reform will expand public and private insurance coverage to an additional 33 million Americans, leading to increased pressure on the psychiatrists who are willing to practise with the insured population and on opportunities for subspecialisation within the field. Some essential non-medical tasks will not be funded by insurance, and these must be given due consideration. A major emphasis of health reform is to integrate general health and mental health services. The reform will have an impact on the use of the hospital and emergency room as well. A major concern is the cost of care and how it will be controlled.

The process of forced immigration is a challenge for a person's sense of identity. The traumatic events that precede flight (e.g. torture or rape) may have an impact on the individual's sense of self. By the time the person arrives in the UK, their sense of identity may also have been affected by the significant loss of their homeland and, often, family members. On arrival, the person is given the ‘temporary’ label of asylum seeker. Although this status offers many the hope of refuge from persecution, there are significant constraints inherent in this role. Until recently, asylum seekers in the UK could be in limbo for many years as their case was considered. Although more recent legislative changes have attempted to speed up the process it can still be lengthy. This article outlines the multiple threats to an asylum-seeking person's sense of identity and associated mental health problems. Ways in which mental health professionals can support the person's sense of identity during this transition are discussed.

This article deals with the provisions for the lawful detention and compulsory treatment of patients in England and Wales. The 2007 amendments to the Mental Health Act 1983 redefine ‘mental disorder’ and ‘medical treatment’ and remove the classifications required for longer-term detention, abolishing the so-called ‘treatability test’ and introducing a new appropriate-treatment test. ‘Learning disability’ is brought within the definition of mental disorder but only if ‘associated with abnormally aggressive or seriously irresponsible conduct’. The exclusion for promiscuity, other immoral conduct or sexual deviancy is repealed; the exclusion for dependence on alcohol and drugs is retained. The revised definition of ‘medical treatment’ includes psychological treatment and removes the requirement that treatment is under medical supervision. The basic structure of the 1983 Act is retained. Use of the powers is discretionary. The principles of the Mental Capacity Act 2005 are imported into the decision-making framework through the wording of the Mental Health Act Code of Practice.

Supervised community treatment (SCT) is one of the most prominent amendments to the Mental Health Act 1983. It has divided opinion among health professionals and introduces significant powers not previously available in England and Wales. This article considers how SCT fits into the established legislative framework and how it may affect the care delivered by mental health practitioners.

The Mental Health Act 1983 now incorporates amendments introduced in 2007. This article explores features of the amended Act that affect the treatment of patients with personality disorder in England and Wales. It discusses issues such as the broad definition of mental disorder, treatability and professional roles, with specific reference to how they might, or might not, affect usual practice concerning patients with personality disorder. It also comments on elements within the Act that could positively affect people with personality disorder, such as community treatment orders, provision to change their ‘nearest relative’ and statutory advocacy services. The political climate in which the Act has been amended is commented on, as well as how this might potentially compromise some of the positives within the Act.

The principles of primacy of patient welfare, patient autonomy and social justice are fundamental to medical and psychiatric professionalism. Medical professionalism is also about encouraging and celebrating good practice. As a set of values and behaviours on the one hand, and relationships with patients, carers and other stakeholders on the other, the implicit contract between psychiatry and society needs to be renegotiated regularly. Serious threats to medical professionalism in the past 30 years have led to the demoralisation of professionals. Learned helplessness and a perceived loss of autonomy have been recognised as important factors in the ‘loss’ of professionalism. Psychiatry as a profession needs to identify its core attributes, skills and competencies. Professionalism should allow individuals to set and maintain their own standards of care.

Major depression and bipolar disorder in children and adolescents are serious conditions associated with considerable morbidity as well as increased risk of suicide. The treatment of depression in young people is currently controversial and this article reviews the evidence base and potential risks and benefits of antidepressants. Although the diagnosis of bipolar disorder is also controversial, medication is the first-line treatment of choice in cases that meet diagnostic criteria. The limited evidence base in children and adolescents is presented, along with current treatment guidelines. Despite the controversies in this field, this article concludes that medication remains an important part of the treatment approach for both disorders, although the risks and benefits of pharmacotherapy need to be carefully assessed in each patient.

This article proposes a simplification to the chapter structure of current classifications of mental disorder, which cause unnecessary estimates of ‘comorbidity’ and pay major attention to symptom similarity as a criterion for deciding on groupings. A simpler system, taking account of recent developments in aetiology, is proposed. There is at present no simple solution to the problems posed by the structure of our classification, but the advantages as well as the shortcomings of changing our approach to diagnosis are discussed.

This commentary explores the issue of personality disorder and mental health legislation from a UK perspective, highlighting the differences between its four countries and three mental health acts. It discusses data from Scotland that support the contention that the addition of the term ‘personality disorder’ to mental health legislation is not alone sufficient to change current practice. The legislative criterion of risk to others is discussed and the varying responses in the UK to the contentious issue of preventive detention, highly likely to be relevant to serious offenders with personality disorder, are described, including the indeterminate sentence of imprisonment for public protection and the order of lifelong restriction. It is concluded that, regardless of location, care of patients with a primary diagnosis of personality disorder will be driven forward not by legislation but by service development, research and changing attitudes.