In May 1999, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness published its first major report since it was reestablished at the University of Manchester (Appleby et al, 1999a). Entitled Safer Services, it presented findings from a two-year sample of suicides and an 18-month sample of homicides occurring in England and Wales, and on the basis of these put forward 31 recommendations for mental health services (Appleby, 1999b; Shaw et al, 1999). This article, modified from a chapter in Safer Services, discusses how services might deal with the risk of suicide and homicide or serious violence.

Multiple sclerosis is the most common disabling neurological illness affecting young and middle-aged adults. Although attention has tended to focus mainly on its neurological manifestations, reports of the presence of neuropsychiatric symptoms date back to the writings of Charcot in 1877. This article details the neuropsychiatric sequelae of multiple sclerosis and the evidence base for available treatments.

Community psychiatric teams are an integral part of modern mental health services. The development of such teams has allowed the care of patients to be transferred from institutions to the community. A Cochrane review of community-based programmes showed that community team-based psychiatric services led to a reduction in suicide rates, improved patient engagement and were more acceptable to patients (Tyrer et al, 1999). Community care also reduces the number of days patients stay in hospital, but not the number of admissions (Marshall et al, 1995). However, community mental health teams (CMHTs) have been criticised for their ambiguous and overambitious aims, and their tendency to neglect people with the most challenging health- and social-care needs (Patmore & Weaver, 1991; Sayce et al, 1991). All mental health workers are not necessarily eager, or skilled, to work effectively in teams. Building and maintaining an effective team requires commitment, clarity of purpose, a shared vision and frequent review of team operations. In a previous issue of APT, Burns & Guest (1999) described the adaptation and running of an assertive community treatment team in an inner-city area. Here I examine the attributes of effective CMHTs (Box 1), enumerate barriers and challenges to team-working (Box 2) and suggest strategies for improving team effectiveness (Box 3).

Critical psychiatry has often been confused with what is widely known as ‘anti-psychiatry’. In this article the distinction is clarified and the particular contribution critical psychiatry makes is outlined. That contribution is constructive criticism: of the relationship between medicine and mental health practice, of the way drug and psychotherapeutic treatments for mental health difficulties might be better understood. These have implications for everyday clinical practice and there is much to be gained by openly embracing the controversies critical psychiatry highlights.

Sequenced (stepped) treatment approaches are widely endorsed in the management of depression. Combining antidepressants is a recognised step for those failing to respond to monotherapy. Despite the limited evidence base, this strategy is widely used by clinicians in practice. Not every combination used clinically has a sound neuropharmacological rationale and the use of such combinations may increase the side-effect burden without any additional advantage to the patient. Efficacy of various antidepressant combinations along with the data on side-effect profile and toxicity of such combined treatments are reviewed here. The different combinations are considered by each class of antidepressant available in the UK.

People who survive into late life with chronic or relapsing illnesses, which had their onset in youth or middle age, have special needs. In the past, those most severely affected often lived out their lives in mental hospitals. The mental hospital closure programme led to discharges to alternative care, and the successes and failures of these have been monitored by some services. Subsequent generations are at risk of falling between the care of general psychiatry, rehabilitation psychiatry and old age psychiatry. These patients are uniquely disabled by a combination of personal, social, mental and physical health disadvantage. The Royal College of Psychiatrists has produced guidance to highlight the special needs of these ‘graduates', encouraging every locality to investigate its own performance in their care and bring it into line with best practice in the light of local strengths and resources.

Antipsychotic drugs are among the most widely prescribed psychotropic medications for elderly people, particularly for the 5–8% of patients who are in institutions. The antipsychotics are indicated for treating psychotic disorders, including schizophrenia, delusional disorder, psychotic symptoms in mood disorders and for a number of organic psychoses.

This article examines the clinical, epidemiological and nosological aspects of short-lived psychotic disorders as currently classified under ‘acute and transient psychotic disorders' in ICD-10 and ‘brief psychotic disorder’ in DSM-5. After describing earlier diagnostic concepts such as bouffée délirante, cycloid psychosis, reactive psychosis and schizophreniform psychosis, we present an overview of the literature and discuss implications for classification, diagnosis and treatment of these conditions, pointing out differences from longer-lasting psychotic disorders.

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.

There has been little systematic study of personality disorders in older people (65 years of age and above). However, with an ageing population worldwide we should expect to find increased numbers of people with Axis II disorders surviving into old age. We undertook a qualitative review of the recent literature concerning personality changes and disorders in older people, their prevalence and possible amelioration.

The pharmaceutical industry is primarily responsible to its shareholders and so making profit is its primary motivation. The industry's marketing techniques affect not only prescribing habits of doctors but also concepts of mental health. This editorial examines the impact this has had on both theory and practice in child and adolescent psychiatry. Undue influence by the pharmaceutical industry contributes to a skewing of the literature towards biological disease models of childhood mental health in order to support the use of the pharmaceutical companies' products. Using fluoxetine and stimulants as two case examples, the article illustrates how pharmaceutical companies have contributed to widespread acceptance of erroneous beliefs about the safety and efficacy of using psychotropic drugs in children and adolescents. Suggestions are made on how child psychiatrists, both individually and collectively, can incorporate this knowledge into their professional development and practice.

Man can change and go on changing as long as he lives (Horney, 1942)

Dependence on alcohol or other drugs is a depressing experience. The way of life of the individual who is dependent on alcohol is replete with incidents that are demoralising, waking daily with a hangover or with tremor and retching, coupled with amnesia for events of the night before, a sense of inability to face the day ahead and awareness of recriminations at work and at home. Little wonder that depressed mood is common in such circumstances. Similarly, the drug addict, when life is dominated by the daily problem of obtaining supplies of a substance that brings transient relief or pleasure but also experiences of an impoverished existence and low mood. Add to this the fact that the biological action of many commonly misused substances can induce depression then it is hardly surprising that depression is common in this population. There are also a smaller number who use alcohol or illicit drugs to cope with primary depression. Teasing out the interplay of affect and substance misuse is a challenge for the general psychiatrist and the addiction specialist.

Post-modernism is a term that is omnipresent in the media, academic circles and contemporary culture. It is also a term that has caused substantial consternation among systemic family therapists. Systemic family therapy traces its origins from the 1950s, and there are currently several different models contained within the systemic paradigm. A unifying feature of systemic therapy is the importance placed on understanding psychological difficulties in the context of social relationships. Another point of agreement among systemic therapists is the significance of drawing distinctions and marking ‘difference’ as an aspect of creating change. A third common feature is the practice of working in teams, where one therapist conducts the interview, while a small number of others comment on their observations. The degree to which these models and practices have been influenced by postmodernism varies.

Systemic lupus erythematosus (SLE) is a disorder which can affect the central nervous system and result in a broad range of psychiatric syndromes such as psychosis, mood disorders, acute confusion and cognitive dysfunction. Despite the robust nomenclature of neuropsychiatric SLE (NPSLE), psychiatric syndromes in patients are often non-specific and may be secondary to concurrent non-SLE-related conditions and complications of medical therapies. Although the exact immunopathological mechanism for psychiatric presentation remains elusive, prompt exclusion of other factors contributing to the psychiatric symptoms coupled with effective assessment strategies and management with immunosuppression and psychiatric therapy are imperative. Psychiatrists and rheumatologists must work in close liaison to identify, treat and prognosticate patients with psychiatric syndromes in order to improve their quality of life, vocational aptitude and, ultimately, survival.

Compassion-focused therapy (CFT) is embedded in an evolutionary, functional analysis of psychopathology, with a focus on affiliative, caring and compassion processes. CFT has been applied in a number of adult settings, but its clinical applications in child and adolescent psychopathology and psychotherapy have not been systematically explored. This article describes the applications of CFT in paediatric populations. Specifically, the following developmental considerations are discussed: the unique importance of parent-child and attachment relationships for the development of self-compassion, being open to compassion from others and being compassionate to others; the potential effect of com passion training on the maturing brain (affective regulation systems); and the therapeutic targeting of shame and self-criticism to alleviate psychological distress and enhance the effectiveness of cognitive-behavioural interventions.

Doctors, like other health professionals, show increased rates of psychological morbidity, including anxiety, depression, suicide, drug and alcohol misuse and professional exhaustion (burnout). This might be due in part to the pressures of clinical work, but might also reflect Malan's ‘helping profession syndrome’, in which an individual chooses, usually unconsciously, to work as a carer as a response to personal vulnerability, or ‘the patient within’. This paper reviews the literature relating to the complex relationship that health professionals have with their work role, discusses the implications for the profession, and proposes areas of prophylactic or remedial action.

Paranoid personality disorder is a neglected topic in clinical psychiatry, and is often the subject of diagnostic confusion and therapeutic pessimism. This article presents a summary of the key diagnostic issues relating to paranoid personality disorder and describes various psychological and social processes mooted to be central to the genesis of paranoid thinking and behaviours. The evidence relating to paranoid personality disorder and risk of violence is summarised and clinically useful guidance for the safe treatment of people with the disorder is outlined.

Routine outcome measures are essential to chart individual patient progress and evaluate models of service provision. The Health of the Nation Outcome Scales (HoNOS) were commissioned by the Royal College of Psychiatrists as a simple, brief measure for this purpose. It is one of the most widely used outcome measures in mental health services globally and has been translated into at least seven languages. Its use has broadened beyond its original purpose and in several countries collection of HoNOS data is mandatory. We review 585 potential articles to chart the development and evolution of HoNOS, as well as its psychometric properties, qualitative attributes and uses in clinical practice and research. The potential barriers to implementation of HoNOS on a wide scale are considered and its future role in evaluating effectiveness and benchmarking of services are discussed.

The evidence base for cognitive–behavioural therapy (CBT) for depression is discussed with reference to the review document Treatment Choice in Psychological Therapies and Counselling (Department of Health). This identifies the need to deliver evidence-based psychosocial interventions and identifies CBT as having the strongest research base for effectiveness, but does not cover how to deliver CBT within National Health Service settings. The traditional CBT model of weekly face-to-face appointments is widely offered, yet there is little evidence to support these traditions in the outcome literature. Reducing face-to-face contact by introducing self-help into treatment may be one method of improving access. The SPIRIT course is discussed which teaches how to offer core cognitive–behavioural skills using structured self-help materials.