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.

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.

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.

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.

This article is aimed at psychotherapists and health practitioners who have not reflected on the role of race, culture and ethnicity in the provision of psychological treatments. We highlight the key issues of importance in engagement, assessment and ongoing therapy, supporting practitioners to reach a stage of pre-competency. Competency will be achieved with additional training, supervision and innovation.

The World Health Organization (WHO) has indicated that 8–12% of couples worldwide experience infertility, and in recent years the number seeking treatment has dramatically increased. The diagnosis and therapy put a heavy psychological and physical burden on most patients, female and male. The incidence of depression in couples presenting for infertility treatment is significantly higher than in comparable fertile couples. Anxiety is significantly higher in infertile couples than in the general population. Professionals have become aware of the importance of providing educational interventions to address patients' fears and concerns, and to better prepare patients for the demands of treatment. Health professionals should follow a patient-centred approach to provide for the specific needs of the couple. Women in general have a positive attitude to seeking psychological help in the form of cognitive-behavioural therapy, couples counselling and infertility counselling.

Previous studies have demonstrated that smartphones are useful tools in everyday, evidence-based medical practice. This article gives an overview of the current use in psychiatry of smartphone apps aimed at patients and the general public, highlighting associated benefits and disadvantages. It also outlines how practising psychiatrists could embrace such technologies at an individual, organisational and national level.

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.

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.

Medically unexplained somatic complaints are among the most common clinical presentations in primary care in developing countries and they are a considerable burden for patients and the healthcare system. They are assumed to be the result of psychosocial factors, and the process by which symptoms are experienced is termed somatisation. Common mental disorders, somatoform disorders and socio-economic adversities are the major risk factors for these complaints. There is evidence suggesting that cognitive–behavioural therapy, which has proven efficacy for somatoform disorders in the developed world, can be used in developing countries with some adaptations (e.g. by simplifying the content so that it can be applied in primary care by non-specialist health practitioners; using culturally appropriate analogies; and delivering the intervention over fewer and shorter sessions). The main components of such an intervention are presented in this article.

Sexual dysfunction is one of the most common psychiatric disorders, but it is often ignored in assessment. It can be primary or secondary (a result of psychiatric disorder or medication). Success rates in managing sexual dysfunction are relatively high, with good response to psychological and medical interventions. In ICD-10 and DSM-IV-TR, sexual dysfunctions are broadly classified on the basis of the stages of sexual activity, from arousal to orgasm. There are major similarities between ICD and DSM in diagnosis and classification of sexual dysfunction, but both systems raise challenges. These include definitions of what is ‘normal’ and how abnormality is defined. In this article, we describe the role of the two systems and possible amendments that might help researchers and clinicians. We also present key principles for the assessment and treatment of people who experience sexual dysfunction. We consider problems that need to be managed in engaging and in the therapeutic alliance.

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.

Over the past few decades, care for people with intellectual disability in the UK has moved from long-stay hospitals to the community. As in the general population, a number of these people have mental health and behavioural difficulties for which they may require in-patient services. Consequently, psychiatrists need to be aware of the in-patient mental healthcare provision for these individuals. This article describes the different categories of in-patient bed for patients with intellectual disability and ways to monitor the quality and outcomes of in-patient care.

Medication non-adherence is a major obstacle to translating treatment efficacy in research settings into effectiveness in clinical practice (Dickson & Kendall, 1986; Scott, 1995). Randomised controlled trials indicate that brief interventions such as cognitive-behavioural educational packages for depression, cognitive therapy for lithium clinic attenders and compliance therapy for people with schizophrenia may be beneficial (Cochran, 1984; Katon et al, 1995; Kemp et al, 1996). However, clinical psychiatry has been surprisingly slow to investigate individual risk factors for medication non-adherence or to use strategies to enhance adherence that have been used extensively in other chronic illness populations.

The proportion of children affected by chronic illness is relatively high, approximately 10–12%. For these children, there is no available cure and the best that medical care can currently offer is relief from symptoms and the opportunity to participate in normal life as far as possible. Epidemiological work suggests that many of the children experience relatively few restrictions on everyday life, but about 1–2% of the total population of sick children have more severe conditions (Gortmaker & Sappenfield, 1984).

There is a widespread concern that the medical profession is itself sick. This is represented in professional disillusionment and demoralisation, an increasing inclination to consider leaving the profession, and the ill-health of its practitioners in terms of their mental health, marriages and use of drugs and alcohol (British Medical Association, 1992). These trends have been attributed, at least in part, to protracted job stress and dissatisfaction, which may in turn be a major determinant in the quality of health care (Caplan, 1994). Although these issues have been cautiously acknowledged for some time, the concept of ‘burn-out’ has provided an opportunity for more open acceptance and creative debate.

Ten per cent of the general adult population have a diagnosable personality disorder (Zimmerman & Coryell, 1990) and in 4% this is clinically severe (Tyrer, 1988). The clinical management of such patients may be difficult. However, much clinical difficulty is generated by interpersonal aspects deriving from the particular interaction of the patient and psychiatrist involved and the respective roles they play.

The Draft Mental Health Bill was published in June 2002 and was widely criticised. There were particular concerns regarding the possible detention of those with personality disorders solely for the protection of the general public. Subsequently the Draft Bill was omitted from the Queen's speech in November 2002. The Department of Health has stated that it intends to push for the Bill's inclusion in the next Parliamentary year. This review attempts to summarise the present situation so as to inform the debate. It considers the relationship between personality disorder and risk, with examination of treatment models and the existing and proposed mental health legislation.

This article outlines the rationale for dedicated specialist services for high-risk young people about whom there may be family or professional concerns in relation to mental disorder. It provides an overview of the development and remit of such services and emphasises the need for them to form part of overall service provision for children and young people.

Hope has long been considered a relevant variable in medical disciplines, but little attention has been paid to the concept, and its clinical and research implications, in psychiatry. This article illuminates the topic of hope from four different perspectives relevant to psychiatric research and practice. The four authors discuss hope from the viewpoint of their specific area of expertise, providing an overview of philosophical, conceptual, research and recovery-related reflections concerning hope in psychiatry.