Herbal remedies are used by many people suffering from anxiety or depression. It is therefore important to know whether they generate more good than harm. A systematic review of the published literature revealed trial data for Ginkgo biloba, Lavandula angustifolia, Hypericum perforatum, Valeriana officinalis, Crataegus oxyacantha, Eschscholzia californica, Matricaria recutita, Melissa officinalis, Passiflora incarnate and Piper methysticum. Only two of these herbal remedies are supported by sound evidence: Hypericum perforatum (St John's wort) for mild to moderate depression and Piper methysticum (kava) for anxiety. Neither is free of risks. Our knowledge of herbal remedies is incomplete and the subject merits rigorous study.

Almost all psychiatric training programmes include a journal club. These clubs are experiencing a revival as a result of the introduction of a critical review paper into Part II of the MRCPsych examinations. Successful clubs are generally those with a single designated leader and mandatory attendance; provision of food is also helpful. A number of possible formats are discussed, designed to make the club an entertaining and stimulating experience.

In the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.

Cognitive dysfunction is one of the major contributors to the burden of epilepsy. It can significantly disrupt intellectual development in children and functional status and quality of life in adults. Epilepsy affects cognition through a number of mechanisms in complex interrelationship. Cognitive deficits in epilepsy may be treated indirectly through aggressive seizure control using anti-epileptic drugs or surgery, and by treating comorbid conditions such as depression. The beneficial effects of reducing seizures may offset the adverse cognitive side-effects of these therapies. Direct treatment of cognitive impairment in epilepsy mainly involves memory rehabilitation. Other direct treatments are mostly experimental and their evidence base is currently poor.

Conversion disorders tend to be poorly understood and diagnosis can be difficult. In this article, we aim to clarify what conversion disorders are and how they can be distinguished from other psychiatric disorders that involve physical symptoms. Prevalence, prognosis and relationship to organic disease are controversial areas; we outline what is known about them and provide some historical context. Aetiological theories and management strategies are discussed, the latter with the aid of case vignettes.

Mental health professionals regard the assessment of suicide risk as part of normal clinical practice, but most shy away from assessment of risk of interpersonal violence, either doubting that such predictions are possible, or, if possible, are part of their role. In part, this fastidiousness reflects the influence of a consensus which emerged in the 1970s to the effect that there was no substantial relationship between mental illness and violent behaviour. The only basis for risk assessments which remained were those factors in the general population known to be associated with criminality. Even here, however, the accuracy of predictions made by clinicians had been subject to considerable critical scrutiny, which undermined any claims the profession may have had to expertise (Monahan, 1981; Brizer, 1989). There seems to have been wide acceptance that psychiatrists were doubly disabled in the business of predicting violence by having no relevant specialist knowledge and by being poor at applying knowledge gleaned from other disciplines such as criminology.

General principles of management of patients with personality disorders admitted in crises to the in-patient unit are discussed. The role of the acute ward in the overall plan of care, the clinical thresholds to consider in deciding whether admission is appropriate and the main elements of the in-patient care plan are outlined. The management of patients with borderline personality disorder, who constitute the majority of such admissions, is discussed in detail.

During the past decade, increasing attention has been paid to the primary care level of service for children and adolescents with mental health problems. In particular, a number of national reports have advised service commissioners and providers to increase the amount of specialist child and adolescent mental health services (CAMHS) support to primary care colleagues (Department of Health/Department for Education/Social Services Inspectorate, 1995; National Health Service (NHS)/Health Advisory Service (HAS), 1995; Audit Commission, 1999).

Sensory (visual and hearing) impairment has significant detrimental impact on sociocognitive and language development. Despite this, it is very much underrecognised and underdiagnosed in people with intellectual disability. Raising awareness of sensory impairment among professionals and carers is extremely important for early management to prevent further social handicap in people with intellectual disability. This article reviews sensory impairment in intellectual disability and its association with autism-spectrum disorder and mental illness.

For nearly three decades, closure of large psychiatric and learning disability hospitals has continued and more people with mental health needs remain in the community. With this continuing decrease in hospital provision, there has been an increased focus on the development of systems of safe care and effective treatment for people with significant mental health problems living in the community. Attempts to make this a central plank of mental health care have been reflected in legislation and guidance produced by the Department of Health. The Care Programme Approach (CPA) was introduced in 1991 after the publication of HC (90) 23/LASSL (90) 11 and subsequent guidance from the White Paper Caring for People (Department of Health, 1990).

Homeless families are defined as all adults with dependent children who are statutorily accepted by local authorities (housing departments) in the UK, and are usually accommodated for a brief period in voluntary agency, local authority or housing association hostels. This period varies from a few days to several months, although the target for rehousing is usually around 4 to 6 weeks. Some housing departments, particularly in London, also use bed and breakfast accommodation.

Health anxiety is an important new diagnosis that is increasing in frequency because of changing attitudes towards health, particularly excessive use of health information on the internet (cyberchondria). People with abnormal health anxiety become over-diligent monitors of their health, misinterpret most somatic sensations as evidence of disease, consult medical professionals unnecessarily and frequently, and are often over-investigated. Relatively few patients with health anxiety present to psychiatrists; most are seen in primary and secondary medical care. This paper reviews the diagnosis and presenting features of health anxiety, its identification in practice and its treatment. A range of simple psychological treatments have been shown to have long-lasting benefit for the disorder but are greatly under-used.

The different cultures of doctors and managers and the impact of these on their working relationships are described. A historical resumé tracks organisational change, the evolving nature of the relationship and the stresses it engenders. The phenomenon of scapegoating and an approach to managing risk is explored. Vignettes describing familiar problems, with suggested strategies for analysing them and resolving difficulties, are presented.

Against the backdrop of a tight financial climate, a new method of funding mental health services is being rolled out in England's National Health Service. Called payment by results (PbR), it represents a fundamental change to the way providers of psychiatric services are paid for care of patients. The Mental Health Clustering Tool has been developed to capture activity which reflects the relative needs of patients, and cluster costs are being collected by service providers. The ultimate goal is the creation of a national tariff or fixed price for each cluster. This article describes the incentives generated by PbR and gives evidence on PbR in acute physical care services where it has been in operation for a decade, with respect to efficiency, quality, volume of activity, administrative costs, upcoding or gaming, equity of provision, and cross-subsidisation. It explores the challenges for mental health services as PbR is introduced.

In the interest of road safety, driving license holders who suffer from a medical condition likely to affect fitness to drive must notify the Driver and Vehicle Licensing Agency (DVLA) and not drive. The Secretary of State for the Environment, Transport and the Regions (of the Department for the Environment, Transport and the Regions, DETR) has the responsibility, via his Medical Advisers at the Drivers Medical Unit of the DVLA, to ensure that all licence holders are fit to drive.

Effective pharmacological management of depression resistant to antidepressant medication is best carried out in the context of a supportive and collaborative relationship, following a mutually agreed care plan. Simpler pharmacological approaches such as switching antidepressant classes are tried first, then augmentation is used if needed. New classes of antidepressants have made antidepressant combination a popular augmentation strategy, but lithium addition has most supporting evidence. The use of atypical antipsychotics as augmenting agents is increasing. For patients unresponsive to these strategies, monoamine oxidase inhibitors and electroconvulsive therapy remain important. Large randomised pragmatic trials are needed to help clinicians and patients make better treatment choices.

Puerperal (postpartum) psychosis – the acute onset of a manic or psychotic episode shortly after childbirth – most commonly occurs in women with a bipolar disorder diathesis who have a vulnerability to a specific childbirth-related trigger. Women with bipolar disorder are at particularly high risk of puerperal psychosis, with a severe affective episode following between 25 and 50% of deliveries. Suicide is a leading cause of maternal death in the UK and it is clear that we must do more to identify and better manage women at high risk of illness related to childbirth. The clinical picture of puerperal psychosis can vary dramatically from hour to hour and can escalate quickly to a true psychiatric emergency. It is vital that clinical services identify women who are unwell and can respond quickly to the severity of illness, delivering treatment in the most appropriate setting for the mother and her baby.

Parity of esteem means valuing mental health as much as physical health in order to close inequalities in mortality, morbidity or delivery of care. There is clear evidence that patients with mental illness receive inferior medical, surgical and preventive care. This further exacerbated by low help-seeking, high stigma, medication side-effects and relatively low resources in mental healthcare. As a result, patients with severe mental illness die 10–20 years prematurely and have a high rate of cardiometabolic complications and other physical illnesses. Many physical healthcare guidelines and policy recommendations address parity of esteem, but their implementation to date has been poor. All clinicians should be aware that inequalities in care are adversely influencing mental health outcomes, and managers, healthcare organisations and politicians should provide resources and education to address this gap.

Epidemiological evidence has identified key strategies that may be used in the prevention of both Alzheimer's disease and vascular dementia. These strategies may be loosely divided into three areas: treatment of vascular risk factors, neuroprotection and increasing neuronal reserves. Evidence from randomised controlled trials already exists for treatment of hypertension but results for statins have been disappointing. Most of the intervention trials currently in progress focus on one or two risk factors and include cognition or dementia only as a secondary outcome. The potential of intervention strategies awaits confirmation by randomised controlled trials that target multiple risk factors in at-risk people with mild cognitive impairment, with incident dementia as the primary outcome.

Hyperprolactinaemia is a common endocrine disorder that can be associated with significant morbidity. Antipsychotic medications are frequently linked to hyperprolactinaemia. This disorder usually presents as menstrual problems in women and sexual problems in men, which affect the patients' quality of life and adherence to antipsychotic treatment. In the past, treatment for hyperprolactinaemia was recommended only for symptomatic patients. However, it has become clear that persistent asymptomatic hyperprolactinaemia can be associated with long-term physical morbidities such as osteoporosis and possibly breast cancer. Hence, it is imperative that hyperprolactinaemia is managed even if asymptomatic when initially detected. This article discusses the various management options, such as reducing the dose of antipsychotic medication, switching to a prolactin-sparing antipsychotic and adding aripiprazole to the treatment regimen.