The professional regulatory cases of the psychiatrist Dr Richard Pool and the neuropathologist Dr Waney Squier have given rise to concerns among expert psychiatric witnesses, and indeed medical experts in general. Here we restate the law on expert evidence with particular reference to the judgment of the Supreme Court in the case of Kennedy v Cordia. We emphasise that Pool does not change the law regarding ‘what is expertise’; in particular, the case does not establish restrictive, status-based tests governing the admissibility of expert evidence such as according to whether an expert psychiatric witness has undergone higher training, is on the specialist register as a specialist in a particular field or is a consultant. Rather, expertise continues to be legally defined in terms of a combination of qualification, knowledge and experience. Crucially, the test of medical expertise in legal proceedings is a legal test and not one determined within a medical paradigm.

Sex is central to most intimate relationships, and there is inevitably a two-way interaction between sex and intimacy. Sex is a physical, a psychological and an interpersonal event, and treatment of sexual problems should take account of all three aspects. Couple relationship problems that can affect sexual interaction include pervasive hostility, poor communication, lack of trust and disparate levels of sexual desire. Therapists should be able to manage therapy sessions with both partners present, without taking sides, and treating the relationship, rather than either individual, as the ‘client’. They should be able to balance the physical approach to problems with managing relationship issues and the partners' individual psychological problems. Techniques are recommended for understanding and modifying the couple relationship during therapy, as well as for dealing with specific sexual problems using a behavioural systems approach.

Clozapine is one of the most effective drugs available to psychiatrists for treating psychosis. It is currently licensed for use in treatment-resistant schizophrenia and psychosis in Parkinson's disease, but its use in old age psychiatry is very uncommon. With the ageing population, and the increased incidence of psychosis in older patients, it is important to consider whether this is a drug that is not being used to its full advantage.

There is now extensive evidence that different types of psychological therapy are effective for various psychiatric disorders, both in terms of symptom reduction and in improving the patient's capacity to function adaptively. In two articles, we set out some current ideas of how psychological therapies might ‘work’, drawing on neurobiological studies of brain plasticity and therapeutic efficacy. In this first article, we review the evidence that disorders of self-experience are common to many psychiatric disorders, and that psychological therapies ‘work’ on those disorders. The second article will appear in the next issue of Advances.

The purpose of this review is to familiarise the reader with the clinical utility of investigations in the diagnosis and management of alcohol use disorders (AUDs). Many biochemical and haematological tests are widely available, and can improve significantly the quality of diagnosis and management. However, there is no single test that can detect AUDs with complete accuracy. Further, the validity of a test will vary depending on the clinical application. Such tests should never be relied on in isolation. Adequate clinical evaluation also needs to include a combination of interview and examination of the patient, and interview of other informants (Cantwell & Chick, 1994; Edwards et al, 1997). In the research setting, self-report is generally a valid and reliable method of assessing alcohol consumption (Babor et al, 1987), particularly when it is elicited by a standardised method (e.g. Sobell et al, 1980) and the information is provided in confidence. In the clinical setting, however, the patient may report his or her version of past drinking subject to the demand characteristics of the situation, particularly if adverse consequences are likely to ensue (e.g. discharge from a treatment programme).

Although a rare form of ‘lethal’ catatonia, involving high temperature and rigidity, was first described long before the advent of neuroleptic drugs, Delay's description of a syndrome malin in 1960 is usually regarded as the first recognition of this syndrome. Over the next 20 years the number of case reports grew and the appearance of reviews such as Caroff's in 1980 marked the birth of the neuroleptic malignant syndrome (NMS). Reports of its incidence give variation rates of up to fiftyfold, possibly due to differences in diagnostic criteria, and mortality reports are similarly variable. Although it is debatable whether it is a rare, severe idiosyncrasy or one of many neuromuscular side-effects of dopamine antagonists (Levinson & Simpson, 1986), most clinicians nowadays regard it as a serious but recognisable risk of neuroleptic treatment which merits further attention.

Complaints of poor memory are common in the healthy elderly and to many it may seem unsurprising that cognitive function declines with ‘normal’ ageing. Virtually every biological system alters with age and, just as a 70-year-old cannot run as fast or hear as well as when he or she was 20, it is perhaps inevitable that cognitive function also becomes impaired. However, far from being straightforward, the nature, classification and clinical significance of age-related cognitive changes that fall short of dementia remain a most controversial and difficult area (see O'Brien & Beats, 1994; Dal Forno & Kawas, 1995). The recent emergence of new drugs for the treatment of Alzheimer's disease (donepezil and rivastigmine) and related disorders has emphasised the need to study groups with milder degrees of cognitive impairment. It is necessary to determine whether such conditions are benign and non-progressive, or harbingers of progressive dementia and so appropriate conditions to target for early therapeutic intervention. The presence of age-related cognitive changes raises other important issues including why such changes occur, how they should be classified and whether, even if ‘benign’, they can and should be treated.

The clinical assessment and management of suicide risk depends primarily on face to face contact with the individual who presents the risk, and aims to predict behaviour in the very near future. Whether or not clinical intervention prevents suicide depends a great deal on the clinician's skill in reaching out to the individual patient. This poses a dilemma, because much of what has been written about predicting suicide has been based on averaged data concerning long-term outcome in large cohorts of patients.

Sialorrhoea (hypersalivation) is a common adverse effect of clozapine. If severe, it can affect patients' quality of life and adherence to the treatment. Clinicians therefore need to proactively manage this effect. At present, no drugs are licensed to manage clozapine-induced sialorrhoea, although there are many off-label treatment options, with variable effectiveness. Anticholinergic medications are commonly prescribed for it, but they have limited effect and can worsen constipation. This article gives a brief overview of other practical and pharmacological management options.

Bright light therapy is an accepted and commonly used treatment for seasonal affective and circadian rhythm disorders. In the past 20 years, researchers have examined the effectiveness of bright light therapy in improving depression and agitation in older adults with dementia. This article provides clinicians with a summary of the neurophysiology of bright light therapy, bright light research considerations, an evidence-based bright light protocol, problems related to bright light therapy, and clinical implications for bright light therapy in older adults with dementia. Bright light exposure is a safe, non-pharmacological treatment that is currently underutilised in this population. Clinicians may find bright light therapy beneficial as a primary or adjunctive treatment in reducing depression and agitation in older adults with dementia.

The European Convention on Human Rights and the Human Rights Act 1998 (which enacts most of the Convention rights into UK law) are playing an ever-increasing role in determining the standards of treatment of those detained by the state and hence is of particular importance for those in hospitals, prisons or similar institutions. The European Convention on Human Rights is a ‘living instrument’ such that judgments emanating from the European Court of Human Rights will continually build upon previous jurisprudence and evolve over time. As Article 3 case law has evolved, its interpretation has broadened to now include a thorough scrutiny of hospital and prison conditions and healthcare provision where people are kept in detention. This article provides an in-depth update on recent Article 3 case law, but more importantly describes new developments in its application in the clinical setting.

This article looks at the use of large datasets of health records, typically linked with other data sources, in mental health research. The most comprehensive examples of this kind of ‘big data’ are typically found in Scandinavian countries, although there are also many useful sources in the UK. There are a number of promising methodological innovations from studies using big data in UK mental health research, including: hybrid study designs, data linkage and enhanced study recruitment. It is, however, important to be aware of the limitations of research using big data, particularly the various pitfalls in analysis. We therefore caution against abandoning traditional research designs, and argue that other data sources are equally valuable and, ideally, research should incorporate data from a range of sources.

Part-time training and working have become popular acceptable options for both male and female psychiatrists, regardless of age. There are a number of reasons for this, the most common being family commitments such as those to children or elderly relatives, but also including personal ill health, wanting to reduce stress and prevent burn-out, wanting to pursue different priorities, portfolioworking or simply trying to achieve a better quality of life. The importance of providing flexible working patterns has been emphasised by the Department of Health (1998) in Working Together – Securing a Quality Workforce for the NHS.

The clinical and public mental health aspects of alcohol misuse in older people (both men and women) have increasing relevance for both old age and addiction psychiatrists. Clinical presentations are often complex and involve a number of different psychiatric, physical and psychosocial factors. The assessment, treatment and aftercare of alcohol-related and comorbid other mental disorders will also involve a broad range of interventions from a wide range of practitioners. Given its growing clinical relevance, there are particular areas, such as alcohol-related brain damage and drug interactions with alcohol, that deserve special attention.

Abuse is an inter-generational problem. Abusers have been damaged in childhood by abusive action perpetrated on them, usually by their parents but sometimes by other significant adults. At times, in becoming adults, the early emotional damage can manifest into psychopathological features, including perversions or paraphilias and perpetration of abuse against children.

It is generally believed that the physiological consequences of stress could contribute to poor outcomes for patients being treated for cancer. However, despite preclinical and clinical evidence suggesting that stress promotes increased cancer-related mortality, a comprehensive understanding of the mechanisms involved in mediating these effects does not yet exist. We reviewed 47 clinical studies published between 2007 and 2020 to determine whether psychosocial stress affects clinical outcomes in cancer: 6.4% of studies showed a protective effect; 44.6% showed a harmful effect; 48.9% showed no association. These data suggest that psychosocial stress could affect cancer incidence and/or mortality, but the association is unclear. To shed light on this potentially important relationship, objective biomarkers of stress are needed to more accurately evaluate levels of stress and its downstream effects. As a potential candidate, the neuroendocrine signalling pathways initiated by stress are known to affect anti-tumour immune cells, and here we summarise how this may promote an immunosuppressive, pro-tumour microenvironment. Further research must be done to understand the relationships between stress and immunity to more accurately measure how stress affects cancer progression and outcome.

The origins of the probation service can be traced back to the late-Victorian era and the introduction of the so-called police court missionaries who supervised offenders on conditional release from the court. The service grew slowly, but mushroomed in the 1970s and 1980s when several major acts widened the scope of the service by introducing parole, aftercare of discharged prisoners, community service by offenders, and extended the scope of probation and bail hostels. Since the beginning of this decade the probation service has been working in an ever-changing legal and philosophical context. Public protection and the prevention of crime are our primary aims. Legislation and ministerial directives have necessitated increasing involvement of probation offices in work with offenders with mental disorder, and have brought into greater focus the relationship of the probation service with psychiatry.

Psychiatric emergencies are common and each case presents particular problems and difficulties. This article focuses on one subset of psychiatric emergencies, that of severe depression, and on the role of and use of antidepressant treatments in these conditions. The clinical situations to be discussed in this article include active suicidality, severe psychomotor retardation (with associated problems of hydration and nutrition), affective psychosis, bipolar depression and behavioural disturbance.

Since the start of the National Health Service, data have been collected on admissions to psychiatric in-patient units, first as the Mental Health Enquiry, then as part of Hospital Episode Statistics. Some details have changed but many have stayed remarkably consistent. Published literature on the wide range of research and policy work undertaken using this data source is reviewed. Early work was central to the government's deinstitutionalisation policy in the early 1960s. Subsequent studies cover a wide range of epidemiological and health services research issues. A new statistical base, the Mental Health Minimum Data Set, covering individuals receiving all types of health care is currently being set up. This will supplement (but not replace) admission statistics.