Assisting another person's suicide is a criminal offence in England and Wales, although the offence is rare and the law allows for charges not to be brought where there has been no criminal intent. Campaigners for ‘assisted dying’ want something else – a law licensing assisted suicide in advance for certain groups of people in certain circumstances. The present law has been challenged in the courts, hitherto unsuccessfully, as incompatible with article 8 of the European Convention on Human Rights. The Supreme Court has taken the view that, given its social policy implications, this is a matter that Parliament is better placed to consider than the courts.

It has been argued that the routine use of patient-reported outcome measures (PROMs) should be encouraged in order to improve the quality of services and even to determine payment. Clinician-rated outcome measures (CROMs), patient-reported experience measures (PREMs) and process measures also should be considered in evaluating healthcare quality. We discuss difficulties that the routine use of outcome measures might pose for psychiatric services. When outcome and experience measures are used to evaluate services they are difficult to interpret because of differences in case mix and regression to the mean. We conclude that PROMs and CROMs could be useful for monitoring the progress of individuals and that clinical audit still has an important role to play in improving the quality of services.

Autoimmune encephalitides can present with altered mental states, particularly psychosis and delirium. Psychiatrists need to be particularly vigilant in cases of first-episode psychosis and to look out for other, sometimes subtle, features of encephalitis. Encephalitis related to N-methyl-d-aspartate (NMDA) receptor autoantibodies is the most common autoimmune cause of isolated psychosis, the second being related to voltage-gated potassium channel (VGKC)-complex antibodies. Psychiatrists should note ‘red flag’ signs of seizures, autonomic instability, movement disorders and sensitivity to antipsychotic medication (including neuroleptic malignant syndrome). They should also be aware that, in some cases, encephalitis is a non-metastatic manifestation of malignancy. Treatment primarily involves suppression of immunity and is often successful if delivered early. There is accumulating evidence that isolated psychiatric syndromes can be caused by autoimmunity and this could potentially signal a significant change in the approach to disorders such as schizophrenia. Psychiatrists and neurologists need to work together to diagnose, manage and understand this group of conditions.

Medical revalidation was introduced in the UK in 2012 (‘year zero’) after years of discussion and debate. This article describes what it aims to achieve. The General Medical Council's Good Medical Practice is used as a framework on which to build to provide evidence of competencies. Practical aspects of appraisal and revalidation are discussed, with suggestions of how to get the most out of the process both for patients and doctors.

Metabolic syndrome comprises a number of cardiovascular risk factors that increase morbidity and mortality. The increase in incidence of the syndrome among psychiatric patients has been unanimously demonstrated in recent studies and it has become one of the greatest challenges in psychiatric practice. Besides the use of psychotropic drugs, factors such as genetic polymorphisms, inflammation, endocrinopathies and unhealthy lifestyle contribute to the association between metabolic syndrome and a number of psychiatric disorders. In this article, we review the current diagnostic criteria for metabolic syndrome and propose clinically useful guidelines for psychiatrists to identify and monitor patients who may have the syndrome. We also outline the relationship between metabolic syndrome and individual psychiatric disorders, and discuss advances in pharmacological treatment for the syndrome, such as metformin.

The relationship between alcohol use and cognitive impairment has been notoriously difficult to disentangle. We present what is known about cognitive impairment associated with alcohol use/misuse, covering the spectrum from mild and subtle cognitive change through to severe alcohol-related brain damage, including Wernicke-Korsakoff syndrome. We highlight aids to the diagnosis and management of these conditions, and emphasise the benefits of prompt treatment on outcome. We also review progress in understanding their neurobiology. Suggestions for possible service configuration based on both our clinical practice and national guidelines are given.

Providing optimal healthcare for increasingly elderly hospital populations who have high rates of cognitive disorder is a great challenge. Using delirium as an example, we describe how improved management of acute cognitive problems through a multifaceted hospital-wide programme can promote cognitive-friendly hospital environments. A specific plan of action is described that spans interventions in day-to-day clinical care of individual patients all the way to wider organisational practices.

Psychiatrists are wanting in Sweden and many other countries. Among Swedish efforts to improve specialist training in psychiatry and to make a future psychiatric career attractive is a national course-based project named METIS. An evaluation of METIS courses run between 2007 and 2012 revealed that, in parallel with the initiative, the number of doctors obtaining proofs of specialist competence in psychiatry increased by more than a third. This article outlines current specialist training in Sweden and describes how the 40-hour METIS programme fits within it.

In medical practice it is crucial that symptom descriptions are as precise and objective as possible, which psychiatry attempts to achieve through its psychopathological lexicon. The term ‘autism spectrum disorder’ has now entered psychiatric nosology, but the symptom definitions on which it is based are not robust, potentially making reliable and valid diagnoses a problem. This is further compounded by the spectral nature of the disorder and its lack of clear diagnostic boundaries. To overcome this, there is a need for a psychopathological lexicon of 'social cognition’ and a classification system that splits rather than lumps disorders with core difficulties in social interaction.

Good communication is central to psychiatric consultation. It informs assessment, diagnosis and treatment, and is an important part of empowering people to take more control of their own mental health. But active listening and personally tailored explanations may require additional skills and may need to be practised in the context of ethical and legal frameworks. In this article we consider the additional impairments that occur in people with intellectual disabilities who use psychiatric services and describe practical steps that can be taken by clinicians and service providers to overcome these impairments, to make reasonable adjustments and to ensure that patients obtain maximum benefit from services.

Young adults and adolescents who experience a first episode of psychosis are faced with important issues and choices concerning their future mental health. Individual and family psychological treatments and psychosocial supportive measures are now well recognised interventions for this group of individuals. This article considers the complexity surrounding medication management after the initial recovery from psychosis. The discussion focuses particularly on the medical treatments, developmental considerations and roles of psychiatrists in improving outcomes for this group of patients.

Patrick Hamilton's (1904–1962) books are filled with gin and jealousy and depict obsessive desire in oppressive circumstances. His early financial success funded his heavy drinking, but also allowed him to write some of the best fiction of the 20th century. Following a depressive illness towards the end of his short life he never wrote again, leaving his final series of novels unfinished, the villain forever escaping justice. Hangover Square, set on the eve of the Second World War, tells the tense story of a man whose ambivalence for the woman he is pursuing (who has no interest in him) is manifested in two psychological states, between which he flips without warning. In one state he yearns for her, yet in the other has only one purpose – to kill her. Hamilton precisely describes a number of mental symptoms while not convincing readers of the implied diagnosis of schizophrenia. However, the similarities with a late-19th century French fuguer are clear and perhaps this condition provides a better frame for the main character's experiences.

General hospitals and hospices see mostly older people, many of whom have dementia and multiple pathologies: delirium is common, costly and damaging. Informed and kindly care can reduce the incidence of delirium and hasten its resolution. O'Connell et al demand ownership of this phenomenon by the whole hospital. This will require a turnabout of philosophy, management and training for all professions.

The care of women with anxiety and depressive disorders in the perinatal period is complex. The literature in this field is vast and may be difficult for busy clinicians to keep abreast of. The first part of this article provides an overview of the potential risks and benefits of treatment options, including no treatment, at various stages in the perinatal period. The second part explores the frameworks which may assist clinicians in decision-making with their pregnant patients, including risk-benefit analysis, ethical considerations, evaluating capacity, and mental health legislation. The common pitfalls and limitations of these approaches are examined to guide good practice.

Should the law be changed to allow health professionals to assist mentally competent, terminally ill people to end their own lives? In this article Philip Graham (P.G.) puts the arguments in favour of such a change in the law and Julian Hughes (J.H.) opposes these arguments. J.H. then sets out why he believes such a law should not be passed and P.G., in turn, sets out counterarguments. Before concluding comments, both P.G. and J.H. independently make brief closing statements supporting their own positions.

Professional practice explicitly focused on supporting the recovery of those it serves is broadly backed by an emerging profile of necessary knowledge, key skills and innovative collaborations, although there is no universally accepted practice ‘model’. This article outlines these components and discusses the associated need for change in the culture of provider organisations along with implementation of wider social and economic policies to support peoples' recovery and social inclusion. This is a values-led approach supported by persuasive advocacy and international endorsement but still in need of further development, systematic evaluation and confirmatory evidence.

This brief article describes the main health indicators of Brazil and gives an overview of psychiatric care. It points out the primary pitfalls of the mental healthcare system and presents some suggestions for the future of mental health in the country.

We describe the work of a psychodynamic psychotherapy group for individuals affected by chronic schizophrenia in our community-based rehabilitation and recovery service. Despite presenting with negative symptoms, over time patients made good use of the psychodynamic setting: they attended, expressed emotions, made connections and reflected within the group on their personal experience of mental ill health. We discuss the rationale and indications for psychodynamic psychotherapy for individuals with severe and enduring mental illnesses. We also reflect on the challenges we faced working psychodynamically with psychosis and on the necessary adaptation of the approach to work with chronic psychosis. We present vignettes from group sessions to illustrate themes that we identified in the therapy, making links with the literature. We conclude that the unstructured setting of the psychodynamic group approach can help individuals affected by most severe forms of psychosis to make sense of their experiences and use the space.