The internet abounds with promises of ‘miracle cures’ for autism and within the published research literature there are numerous claims and counter-claims for the effectiveness of specific therapies. Systematic evaluations, however, indicate that few treatment programmes have a sound evidence base, and even those interventions that do produce positive findings are not successful for all children. To date, the best researched programmes are those involving intensive, early, home-based intervention, and those with a focus on communication and parent–child interaction. This article assesses the evidence base for some of the better evaluated therapies. There is, as yet, no evidence that any one programme is superior to all others. Indeed, large individual differences in response to intervention suggest that the focus of research now needs to shift to the study of which components of therapy work best for which children and under which conditions.

Nearly a decade ago, the Department of Health published its strategic development plan for mental healthcare for women. It focused on the ways in which mental health services for women should be configured to take account of the context of women's lives and the complexity of their health needs. This commentary argues that attention to the reproductive and sexual health of women in mental healthcare is at the centre of a gender-sensitive and modern mental health service.

Benchmarking has been advocated by the Department of Health as a tool of clinical governance. The essence of benchmarking is learning from the best practice of others. Its ability to compare services and outcomes of care can facilitate change, ensuring quality control and continuous service improvement. The concept is in its infancy in the National Health Service despite its exceptionally rapid growth in business organisations over the past 25 years. Many of the characteristics that make the process so valuable in business are equally relevant in healthcare. This article reviews the history of benchmarking and describes its application in mental health services for improving patient care. It includes an analysis of the centrality of the benchmarking doctrine to the core principles of clinical governance and reflects on the assets health services possess to facilitate benchmarking. It concentrates on the principles of setting up a team and uses a case example to highlight the organisational and clinical effect that a benchmarking project could have.

It is a sign of the progress we have made in the field of learning disability that it is possible to consider three previously taboo subjects in one paper. Before 1979, there was no published English clinical or theoretical paper which looked at either talking treatments for people with learning disabilities, treatment for those who survived physical and sexual abuse or, specifically, talking treatment for survivors of abuse who also have learning disabilities. Such steps forward bring hope for the future, but also pain concerning the past. How often have emotional and behavioural communications of betrayal and violation been ascribed to ‘disability’ and not been properly considered because there was no social intellectual context to help us to consider that there might be a reason for them? This also illustrates the need for continuing professional humility and toleration of uncertainty. What painful experiences and communications of our patients are we missing today because of internal and external taboos? How will we feel when we become aware of them in another 10 or 20 years' time?

This article reviews what we should tell patients and carers about dementia. The attitudes and views of patients, carers and peer groups are examined, as is the practice of doctors and other professionals working in dementia care. Factors influencing the decision to disclose the diagnosis of dementia, including the degree of certainty of the diagnosis, the degree of insight of the patient and the severity of the dementia are considered. Advantages, disadvantages and ethical issues of disclosure are discussed, as well as when or whether and how to disclose the diagnosis. Flexible guidelines regarding the process of disclosure are introduced.

Violence by and towards young people has become a major public health issue. Increased lethality, more random violence and fewer safe places largely account for the high levels of fear experienced by both children and adults. In the field of child protection and domestic violence, where traditionally the child is referred as the victim not the perpetrator, child psychiatrists are well versed, practised and skilled in the assessment of children and families. However, young people are increasingly being referred to child and adolescent mental health teams for assessment because of violent acts that they have carried out. This is reflected in heavy case-loads of children with conduct disorder who have multi-morbidity and complex need. In England and Wales, health (including mental health), social care and education services are mandated to assist youth offending teams.

In the first two articles of this series (Williams & Garland, 2002; Wright et al, 2002), we looked at the different areas of human experience that alter during times of mental illness. The Five Areas Assessment model (Williams, 2001; see also Fig. 1 of Williams & Garland, 2002) provides a clear summary of the range of problems and difficulties faced by the individual in each of the following domains:

1. 1 life situation, relationships, practical problems

2. 2 altered thinking

3. 3 altered emotions (moods or feelings)

4. 4 altered physical feelings/symptoms

5. 5 altered behaviour or activity levels.

The epidemiology and management of schizophrenia have been well studied over the past few decades. In the UK, key findings that have emerged time and again are the excess prevalence and incidence rates of schizophrenia among people of African–Caribbean origin. The reasons for this excess and the implications of this finding are many. The findings may reflect a true excess or a methodological artefact related to errors in the estimation of numerator and denominator data. The findings have been increasingly accepted as better designed studies have emerged, but these still do not fully address concerns about the nature of schizophrenia in other cultural groups and in societies in which industrialisation and economic productivity of the individual are not considered to be as crucial for an individual's sense of belonging in a community.

Neuroimaging has been used in clinical practice for over 30 years, but it is still perceived as rarely offering the psychiatrist much help in direct patient management. As newer imaging modalities are introduced (from computed tomography and positron and single photon emission tomography to magnetic and functional magnetic resonance imaging), the promise of imminent clinical utility is reawakened, only to fade as the innovation is shown to be another, albeit useful, research tool. The aim of this article is to update readers on some recent advances that are starting to align the research and clinical functions of neuroimaging. As imaging becomes more accessible and affordable there is real promise that both clinicians and patients will begin to benefit more directly.

With new developments in image generation and transmission, researchers have studied the feasibility of using comunications technology for remote diagnosis and care delivery. The term ‘telepsychiatry’ has been used to describe the application of telemedicine and telecare to mental health. This article reviews the development of telepsychiatry and key research findings. Results suggest that service users are more comfortable with mediated services than are professsonals. Most work has been done in areas of low population density, where accessibility to conventional services is limited by economics and geography. In urban settings, with distributed community services, telepsychiatry can improve communication between primary and secondary sectors and within secondary services.

What prior assumptions might a psychiatrist bring into the room when the patient is an asylum-seeker? First, as a member of the public he or she is likely to have a view on asylum-seeking as a sociological phenomenon – up to 5 million have sought asylum in Western Europe in the past decade – and on how ‘deserving’ the average case is. After all, two adversarially opposed constructions of asylum-seeking have predominated. Governments, and the conservative social sectors, have stressed the prevalence of ‘bogus' applications by people who are essentially economic migrants, portraying them as wily, determined and tough rather than as having suffered. On the other side are the agencies and interests who support asylum-seekers, and the liberal and radical social sectors. They portray asylum-seekers as people who had no choice but to run from their countries, innocent of any thought but to escape further persecution and the risk of death. This portrayal invokes the image of suffering and vulnerability rather than resilience and agency. The reality is the muddied, uneven terrain that lies between these two entrenched positions. Many asylum-seekers do not have stories that easily fit the definition of a political refugee in the 1951 United Nations Convention. Even those with the clearest-cut cases – such as those with a credible history of torture – usually cannot prove it; few are vulnerable in any medically attestable sense and, however much they have suffered, they continue to make choices and actively engage with their situations. All asylum-seekers are looking for a better life for themselves and their children.

Treatment of illicit drug dependence typically involves a combination of pharmacotherapy and psychosocial interventions. Efficacy research supports methadone maintenance in opiate dependence. There is less evidence to support buprenorphine (an opiate receptor partial agonist), lofexidine (an α2-adrenoreceptor agonist) and naltrexone (an opiate receptor antagonist). Evidence for the effectiveness of detoxification, which one of the most widely used treatments, is poor. Of the psychosocial interventions, reasonable evidence exists for the effectiveness of motivational interviewing. Other psychosocial treatments have rarely been compared with no or minimal contact conditions in randomised trials, and their reported effectiveness is often weak. Residential treatments are not demonstrably more effective than community programmes.

Patients detained at high and medium security reveal significant gender differences in the presentation of psychopathology, mental disorder and social and offending profiles. However, secure mental health services in England, like prisons, generally fail to recognise the core importance of the differing biopsychosocial development in women and the impact of life experiences on women's subsequent biopsychosocial functioning. As a consequence, women are often inadequately provided for in services dictated by the identified needs, risks and responsiveness of men. The lack of clinically appropriate facilities for women may account for the increased frequency with which women are readmitted to medium security and for their longer admissions to both high and medium secure care. New tertiary services are developing as a result of the lessons learnt while providing gender-blind care. However, further development is required to ensure that women receive services of the same quality, range and nature of those received by men.

This article gives a general overview of the current situation in relation to a range of widely recognised and also newly identified types of child maltreatment. The academic and clinical evidence relating to the impact of child maltreatment on the mental and physical health of child victims is substantial and steadily increasing in volume. New types of abuse are being identified, and changing environmental circumstances, which exacerbate the possibility of widely recognised types of child maltreatment occurring, are also being described. These include multi-type maltreatment, female genital mutilation and online child maltreatment. Serious questions may arise regarding neglect of the moral and social development of children and young people who become addicted to online gaming and pornography. Multiple national and local definitions of each of these existing and new forms of maltreatment have been created, some of which are covered here. The impact of these abuses on the physical and mental health and development of child victims in families or settings where abuse or neglect has occurred is discussed.

The association of life events with the onset of various psychiatric disorders is well-known. The body of evidence has highlighted the impact of negative or positive life events on the genesis of common mental disorders, especially depression. These findings have been replicated across different cultures, although the impact of different life events varies between cultures. In addition, the roles of chronic difficulties (defined in Life events and psychiatric disorders, below) and resulting ongoing chronic stress have been shown to contribute to vulnerability to certain mental illnesses. However, data on the impact of life events, especially those perceived as racial, on members of minority ethnic groups are rather sparse. The questions that need to be addressed concern the perception of life events as racial, the role of pervasive and perceived institutional and individual racism, and chronic difficulties.

This article reviews the literature on advance statements, including current mental health law and guidance in England and Wales, ethical and practical advantages, disadvantages and barriers to implementation. The idea of planning psychiatric treatment for a time when mental capacity may be impaired is not new. Yet there has been a renewed interest following the introduction of the Mental Capacity Act's 2005 provision of legally binding advance decisions to refuse treatment. In addition to information on treatment refusals, advance statements provide information on treatment preferences and personal care instructions which, although not legally binding, should inform treatment decisions. Advance statements are not yet widely used, but existing limited evidence suggests that they could reduce coercion and improve service users' satisfaction with treatment.

Anxiety has reported prevalence rates between 38 and 72% among people with dementia. It has a negative impact on cognitive impairment and is associated with agitation and poor quality of life. The presence of excessive anxiety can be difficult to establish in people with dementia, especially when expressive or receptive speech is impaired. Unfortunately, there is a lack of research on the treatment of anxiety in dementia, and also on the wider issue of the management of anxiety disorders in old age. We explore the prevalence, presentation and diagnosis of anxiety in dementia and discuss the therapeutic options available.

Stress-related disorders are diverse and they may be mental and physical. Often, several body systems and organs are involved simultaneously. The pathophysiology of stress-related disorders involves many factors: an observable or perceived stressor, an individual dynamically evolving vulnerability and maladaptation leading to imbalance, as well as environmental, cultural, gender and life-cycle variables. There is a need to develop a comprehensive quantifiable stress assessment instrument. It would be based on the ‘stress factor’, a dimension that would integrate biological, psychological, social, economic and spiritual parameters and would allow for cultural sensitivity. It would contribute to clinical operational sophistication and would illuminate treatment options and multidimensional well-being interventions. Hopefully, it would facilitate development of culturally sensitive pharmaceutical or biophysiological adaptogens and homeostatic interventions.

We review key recent research and guidance for staff working with acutely disturbed psychiatric patients. Assessment of aggressive patients and their situation should enable full risk assessment, which may ideally involve the use of advance directives. We discuss appropriate use of the Mental Health Act 1983 and consider benefits and adverse effects of rapid tranquillisation. We present a simple protocol for oral or intramuscular rapid tranquillisation. Staff using physical restraint should be properly trained and consider sensitively issues of the patient's diginity, gender and the most appropriate location for restraint to occur. Simple precautions can improve safety when working with potentially disturbed patients. Staff need support during and after the management of an aggressive incident.

About 6% of older people in the UK are immigrants. Concentrated in deprived inner-city areas, their numbers are rising rapidly, with the ageing of those arriving after the Second World War. Cultural, language and educational differences cause problems in studying this group's mental health. Idioms of distress may affect presentation, help-seeking behaviour and acceptability of treatment. Ethnic elders may be considered vulnerable to depression because of socio-economic deprivation, immigrant status and old age but studies are contradictory and may use inappropriate screening instruments. Relatively few consider immigrant status and dementia. Uncontrolled hypertension could relate to higher dementia rates in Black immigrants which are not reflected in the country of origin. No genetic risk has been found. There is potential for prevention in this population.