Almost a quarter of people with intellectual disabilities have epilepsy. This life-long condition adversely affects their health, safety and well-being and carries an increased risk of sudden unexpected death in epilepsy (SUDEP) in this population. This commentary considers what not only health and social services but also communities and people with intellectual disabilities themselves can do to improve outcomes.

Self-injury (self-harm) occurs frequently and is familiar in the accident and emergency departments and surgical and medical wards of ‘acute hospitals’. Despite its common presentation, there are frequent and authoritative reports that patients' experiences of emergency hospital treatment for self-harm are often negative. There is compelling evidence for the need to improve delivery of care for patients who self-harm, and to improve the training, supervision, support and coordination of the staff groups delivering that care.

Expert witnesses have recently had a bad press but they have long played an important role in the administration of justice. This article begins by drawing attention to the guidance of the UK Academy of Medical Royal Colleges for medical expert witnesses and then sets out the latest guidance for experts in civil cases.

About 85% of women experience some type of postpartum mood disturbance. Generally, the symptoms are mild and short-lived, but a minority of women develop depressive illness or sudden psychosis. About half of episodes of apparently postnatal depression start during pregnancy and some seemingly postpartum psychoses start before delivery. Untreated antenatal depression can lead to poor obstetric outcomes, subsequent depression in the mother, and developmental disadvantage and depression later in life in the offspring. In this article we discuss the aetiology of perinatal depression and consider recommended pharmaceutical and psychosocial management of postpartum blues, perinatal depression and postpartum psychosis.

Routine use of Health of the Nation Outcome Scales (HoNOS) has not produced the anticipated benefits for people using mental health services. Four HoNOS-specific reasons for this are: low relevance to clinical decision-making; not reflecting service user priorities; being staff-rated; and having a focus on deficits. More generally, the imposition of a centrally chosen measure on the mental health system leads to a clash of cultures, since frontline workers do not need a standardised measure to treat individuals. A better approach might be to use research from the emerging academic discipline of implementation science to inform the routine use of a standardised measure that is chosen by the people who will use it and hence is more concordant with existing clinical processes. This is illustrated using a case study of successful implementation of the Camberwell Assessment of Need (CAN) in community mental health services across Ontario, Canada.

The first electroconvulsive treatment was administered by Cerletti and Bini in 1938. The event was essentially an experiment, carried out like a military operation (Endler, 1988). The patient was stimulated three times, each time increasing the intensity of the stimulus before a generalised seizure was induced. He had been suffering from an acute psychosis with a poor prognosis, but responded to a course of 11 treatments and was discharged free of symptoms two months later. The first paper on electroconvulsive therapy (ECT) in English was published in the Lancet (Kalinowski) in 1939. At that time, somatic treatment alternatives for the severely ill in large mental institutions included lobotomy and insulin coma therapy. In comparison, unmodified ECT (albeit associated with a significant risk of serious physical morbidity) was predictable, efficient, quick and effective. It is understandable why the treatment became widely and fairly indiscriminately adopted before systematic objective evidence of its efficacy was collected.

Liaison and diversion services are concerned with ensuring that individuals with mental health problems and related vulnerabilities who come into contact with the criminal justice system receive appropriate support and treatment. In the past 15 years there have been significant changes in policy, legislation and the broader landscape in community, custodial and hospital settings which have shaped these services. The Bradley Report, published in 2009, represents an important landmark in this field. Bradley made 82 recommendations, from interventions to improve identification of mental illness and vulnerable individuals at risk of offending to effecting speedier transfers of mentally disordered prisoners to hospital. Some progress has been made in achieving these recommendations, and further investment is promised, but at present only half of England is covered by liaison and diversion services.

Anxiety is a very common and disabling condition which has serious consequences for patients, their families and society in general. The past decade has witnessed an increase in the recognition and understanding of the problem but considerable confusion and debate remains over attitudes towards treatment. The background to this controversy dates from the late 1980s when widespread and vehement criticism of doctors and drug companies over the use of benzodiazepines began. Although the litigation was unsuccessful, it resulted in a pervading feeling of uncertainty (both within the medical profession and among patients) about prescribing or taking any drug as a treatment for anxiety. The situation has been further confounded by the split that has occurred between the proponents of pharmacological and psychological approaches to management. These controversies have left the practising clinician in an unenviable position, with few practical or relevant guidelines to follow. Developments over recent years, however, should put an end to this confusion; new pharmacotherapies such as the selective serotonin reuptake inhibitors (SSRIs) and buspirone, and older ones such as the tricyclic antidepressants (TCAs), have emerged as effective alternatives to the benzodiazepines and have been paralleled by a similar growth in effective and available psychological treatments, particularly cognitive and cognitive–behavioural therapy. This progress seems set to continue with the rapid expansion of knowledge about the brain circuits and transmitters regulating anxiety that is now emerging from imaging studies.

Over 95% of cases of dementia are attributable to Alzheimer's disease, vascular, Lewy body and frontotemporal dementia, and a few other common causes. In this article we consider some of the rare and unusual causes that account for the remaining 5%. Categorising them according to aetiological group (degenerative, vascular and infectious causes, and human prion diseases), we discuss the presentation of these forms and reasons for variations in estimated prevalence rates in the general population.

This article is based on the idea that paintings carry much of their cultural power by being ways of embodying states of mind in physical material. It follows that the understanding we have of how people infer mental states in others can also be used to address how we respond to visual art: our facility for inferring mental states can help us understand paintings. In pursuing this argument, I discuss first how artists make meaning in paintings by a process that embodies mental states within a formal structure. Second, I support the notion of a link between the formal structure of art and mental states with evidence from my studies of children's drawings. Third, by analogy with the way we relate to another person's mental states, I look in more detail at the process by which we ‘read’ a painting and in consequence develop an aesthetic relationship to it.

This review focuses on screening and assessment in general psychiatric settings, where drug use is unlikely to be known to service providers. It builds on the recurrent finding that psychiatric patients are at high risk of substance misuse. The application of self-report questionnaires and rating scales and more in-depth assessment instruments is outlined, as are biological screening techniques. The use of brief self-completion questionnaires probably offers the most practical approach to routine screening by non-specialist staff in general hospital settings. The importance of implementing such tools lies in reaching an accurate diagnosis, choosing treatments more appropriately and monitoring the management of patients' psychiatric disorders.

Autism spectrum disorders (ASDs) are lifelong conditions. Although not all adults with ASD require psychiatric input, general adult psychiatrists increasingly find themselves responsible for the care of adults with the disorder. This may present a new and unique challenge to them. Here, we summarise the core clinical features of ASD; discuss appropriate diagnostic practice; review the principles of management; and identify key educational, social care and voluntary services for adults with ASD in the UK.

Body integrity identity disorder (BIID) is a rare and complex identity disorder described by the desire to acquire a physical disability and an associated sense of incompleteness at being able-bodied. Individuals with the disorder often delay presentation until later in life because of perceived stigma about wishing to acquire a physical disability, and may have sought amputation already through ‘underground’ means or self-harm (attempts at self-amputation). In this article we present an account of the recent history and origins of the disorder, from its early descriptions and case reports through to the current neuropsychiatric theory of right superior parietal lobe dysfunction as basis for the disorder. We consider the epidemiology, pathogenesis and clinical features of this identity disorder of bodily integrity, highlighting the associations with conditions such as gender identity disorder. With this we then discuss the ethical considerations for available treatment options, mainly elective surgical amputation.

Second-generation antipsychotic medications (SGAs) have advanced the treatment of schizophrenia over the past 30 years. However, a number of potentially life-threatening cardiac side-effects associated with these treatments concern and can discourage prescribers from administering these evidence-based treatments. This review provides a practical, psychiatrist-oriented understanding of the relative frequencies, mechanisms, investigations and treatments associated with these cardiac toxicities. We aim to highlight that these are relatively rare complications of an effective class of drug and to promote the advantages of early involvement of cardiologists in the psychiatric multidisciplinary team to guide the investigation and management of these conditions.

The prevalence of tattoos is higher among people with mental disorders and those likely to come in contact with mental health services. The motivations for acquiring a tattoo are varied and tattoos can give clues to the presence of particular psychiatric conditions and to the inner world of patients. Psychiatrists need to be aware of the health and safety issues surrounding the tattooing procedure and be able to give appropriate advice to their patients if they wish to acquire a tattoo. The issue of capacity must be considered. This may be particularly relevant for clinicians working with adolescents, the most common age group for acquiring tattoos. Owing to the high proportion of adults who subsequently regret their tattoos and the associated psychological and social distress, clinicians should be aware of methods of tattoo removal.

We propose a ‘drug-centred’ framework for understanding the nature of drug treatment in psychiatry. In contrast to the prevailing ‘disease-centred’ model, which suggests that drugs work by targeting underlying abnormalities, the drug-centred model maintains that drugs exert their effects through their psychoactive properties. According to this view, distinctive drug-induced alterations to normal cognition, emotion and behaviour can modify the manifestations of mental disorders independent of diagnosis or aetiological theory. The drug-centred approach already forms the basis of some current practice, particularly off-label prescribing. Within this framework, the matching of drug-induced effects to symptoms or difficulties, taking into account the unwanted aspects of the drug-induced state, becomes the focus of a collaborative endeavour between doctor and patient, consistent with the principles of the recovery model. More research into the full range of effects that psychiatric drugs produce is required to ground a judicious drug-centred practice and inform psychiatric training.

Different forms of excessive reassurance-seeking safety behaviours are explored, along with reasons why these unhelpful responses occur across a range of mental health disorders. This short update covers the rationale for reducing and stopping these behaviours and offers interventions to help people understand and overcome the unhelpful impact that excessive reassurance-seeking can have on them and others.

The Department of Health's best practice guidelines on risk management and violence prevention in UK mental health services highlight the importance of transparency and collaboration with service users. The recovery philosophy echoes the importance of service user inclusion and empowerment in treatment. Our experience in a medium and low secure hospital was that patients were largely excluded from the risk assessment process. In this article, we describe a model for achieving inclusion and transparency in the use of risk assessment tools based on structured professional judgement.

In this article we review the evidence base and practical experience supporting the use of psychopharmacological treatments for autism-spectrum disorders across the lifespan. Recent advances in knowledge are highlighted, as are the shortcomings of published data in this field. Psychosocial and educational interventions remain the core of treatment, but there is now evidence that medication management is a good option for certain domains of behaviour. We discuss the evidence in terms of symptom clusters, including the underlying social deficit of autism and common psychiatric comorbidities.

Recommendations by Lord Woolf for the reform of the civil justice system in England and Wales include proposals which are already beginning to influence the provision of expert evidence to the courts. Lord Woolf has himself been instrumental in the establishment of an Expert Witness Institute which has caused some controversy in medical circles. It is no coincidence that all of this is happening at a time when the courts are delivering judgments which are particularly critical of some expert witnesses.