What does it mean to respect autonomy and encourage meaningful consent to treatment in the case of patients who have dementia or are otherwise incompetent? This question has been thrown into sharp relief by the Law Lords' decision in R.v Bournewood Community and Mental Health NHS Trust, ex parte L (1998). The effect of the Law Lords' ruling in the Bournewood judgment is to reinforce problematic and serious anomalies in the way we view patients whose competence is in doubt because of their mental disorder. Others, such as relatives and informal carers, are frequently allowed to decide on behalf of adults whose competence is doubtful in a way that English law generally abhors, even for totally incompetent patients in a persistent vegetative state. This raises profound questions about autonomy. And incompetent adults' consent to treatment is not required to be of the same quality as it is for the rest of us: mere absence of resistance will do. This paper will explore the philosophical, jurisprudential and legal implications of this difference. Throughout I will be more concerned with the ramifications of a finding of incapacity than with how such a finding is made (for the latter, see such classic texts as Applebaum & Roth (1982), Grisso & Applebaum (1998) and Bellhouse et al (2001)).

Clozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a number of side-effects, some of which are potentially life-threatening. Historically viewed as a relatively minor side-effect, there is increasing awareness of the potentially severe sequalae of constipation secondary to clozapine-induced gastrointestinal hypomotility (CIGH). These include ileus, intestinal obstruction, bowel ischaemia, gastrointestinal necrosis, toxic megacolon and death. CIGH is significantly more common than clozapine-induced blood dyscrasias and has a higher mortality rate. Although strict criteria must be followed to assertively monitor, detect and treat blood dyscrasias in patients taking clozapine, no such framework exists for CIGH. We recommend that prescribing guidelines, regulatory agencies and information from manufacturers should more clearly highlight the risks identified in the literature. Furthermore, we recommend that, in people taking clozapine, constipation should be prevented by prophylactic treatment with laxatives rather than treated only when clinically identified.

The care programme approach (CPA) has become an accepted part of clinical practice, despite the continuing lack of strong direct evidence of its value. Guidance from the Department of Health has refined the original requirements, which were to ensure health and social care assessment, discharge from hospital to appropriate accommodation with necessary support, appointment of a mental health professional to draw up a care plan, and coordination of its implementation with necessary follow-up. The CPA now specifies that care plans include provision, as necessary, for risk assessment and management, employment, leisure, accommodation and plans to meet carers' needs. Levels of care have been simplified to ‘standard’ and ‘enhanced’. In future it will need to incorporate issues arising from the development of specialist teams as part of the National Health Service Plan, concern about the physical healthcare of those subject to it and the continuing development of psychosocial interventions.

The diagnostic status of ‘complex’ post-traumatic stress disorder (PTSD) remains controversial. The revisions to PTSD diagnostic criteria in ICD-11 and DSM-5 take opposing positions on how best to conceptualise post-traumatic presentations that include affect dysregulation, interpersonal difficulties and negative self-concept. ICD-11 carved out a separate category of complex PTSD (CPTSD) that is distinct from PTSD, whereas DSM-5 expanded PTSD to encompass such symptoms. Each approach carries problematic implications for clinical care. ICD-11 creates a dichotomy but the criteria themselves suggest a difference in severity rather than category. Furthermore, separating CPTSD perpetuates expectations that a ‘simple’ PTSD can be easily treated with brief trauma-focused therapy. DSM-5 complicates the PTSD diagnosis, but does not revise treatment recommendations. Both ICD and DSM need to recognise that most patients with PTSD do not reflect the clinical trial samples and do not fully recover with brief manualised therapies. Treatment guidelines should be developed that address the multiple needs and challenges of all patients with PTSD.

The previous article (Rix, 2000) in this series described the process of dispute resolution and litigation under the new Civil Procedure Rules, which have now been implemented in England and Wales following the recommendations of Lord Woolf. The purpose of this article is to provide detail of the provisions of ‘Part 35: Experts and Assessors' and examine the accompanying practice direction, the pre-action protocols, the ‘Draft Protocol of Best Practice in the Instruction and Use of Experts' and the ‘Draft Code of Guidance for Experts and Assessors' as they relate to the role of the medical expert.

Around 7.1 million people in England drink hazardously or harmfully and a further 1.1 million are dependent on alcohol. Motivational interviewing is widely used to treat people with alcohol problems and is probably the best described example of a brief intervention. However, some recent trials have been disappointing. Specialised alcohol treatment services have also suffered from weakness in the evidence base. Investment in treating alcohol misuse has fallen far behind that for drug misuse. The Department of Health's Alcohol Harm Reduction Strategy for England embraces policies that are high-profile and cheap but are ineffective and ignore many effective measures. It recommends stepped care for alcohol treatment, but unlike the equivalent for drugs treatment, it sets no targets and leaves the small (7%) increase in funding to the discretion of local purchasers. UK spending on specialised treatment for drug misuse is estimated to be around £600 million for 2007 – around three times the estimated cost of treatment for alcohol misuse.

The rise of the risk industry in psychiatry in England and Wales can be given a precise date: 17 December 1992. That was the day that Christopher Clunis, a man who had been in contact with psychiatric services for some 6 years, murdered Jonathan Zito in an unprovoked attack. This tragedy received enormous publicity and resulted in a flurry of activity within the Department of Health. As a result of the moral panic surrounding Clunis, which crystallised long-term trends, the assessment and management of risk became a central focus of mental health policy and practice (Holloway, 1996). Risk remains a core issue, and indeed mental health services have come to be seen as a key element in a strategy for public protection that aims to keep people who are identified as a potential risk to others off the streets. (We await, with some professional trepidation, the legislation that will provide a sufficiently broad definition of mental illness to fully legitimate this social role.) Mental health staff are now required by government policy and their employers to assess an ever-expanding range of risks – most recently, following the Victoria Climbié Inquiry (House of Commons Health Committee, 2003), risks to dependent children, generally with the aid of unvalidated risk assessment tools. Increasingly, mainstream mental health services are being expected to provide interventions for people whose presenting problems are risky behaviours (or even risky feelings) rather than to offer treatment for mental illness.

Proposed changes to the regulation of healthcare professionals in the UK set regulators a considerable challenge. Here I examine the nature of the challenge and what the General Medical Council (GMC) and its partners are doing to meet it. Relicensing and recertification are crucial. Revalidation is the sum of their parts and the duty of any responsible regulator. Effective revalidation will provide affirmation of doctors' entitlement to practise, and give the public the assurance that the doctors who treat them are up to date and fit to practise. The GMC's Good Medical Practice is central to any new system, and I outline the GMC's long-term thinking and immediate priorities, including the development of colleague and patient questionnaires and plans to introduce licences to practise.

In this issue of APT Mitchell & Selmes present an article detailing why patients miss appointments and how clinicians should respond. Many of the papers quoted relate to the psychiatric out-patient clinic. In this commentary as well as picking up on some of the themes that emerge from their article, I explore the attachment that psychiatrists seem to have to this particular model of patient contact.

The terms ‘clinical audit’ and ‘clinical governance’ elicit a variety of responses, including boredom, frustration, incomprehension and, rarely, enthusiasm. This paper sets out to persuade the reader that clinical audit, as an integral component of clinical governance, will be reborn as an activity that clinicians will find interesting, developmental and a useful part of their everyday clinical practice. Under clinical governance, clinical audit will at last be able to achieve important and measurable improvements in patient care as a matter of routine.

Plants have been used for medicinal purposes for centuries, treating everything from non-specific ailments such as backache and colds to serious conditions, including depression and cancer. In this review, a few commonly known plants with psychotropic effects (St John's wort, Ginkgo biloba, kava, ginseng and valerian) are discussed by way of illustration. The readers' attention is brought to important interactions between herbal remedies and conventional drugs. A background to the constituents of herbs, possible mechanisms of action and an explanation of their antioxidant properties is given.

There have been many developments in mindfulness-based approaches (MBAs) since the original mindfulness-based stress reduction (MBSR) course was first delivered in the 1980s. There are now a variety of mindfulness approaches, which are used to good effect in a range of psychological and physical health disorders. The addictions field first witnessed the development of relapse prevention techniques more than 30 years ago. MBAs have been adapted for use in relapse prevention and can be offered as a mindfulness-based relapse prevention (MBRP) course. MBSR or mindfulness-based cognitive therapy (MBCT) courses may also be useful for those with addiction problems. In this article, we describe the MBAs that are commonly offered at present. We highlight ways in which these approaches may be useful in the addictions feld. We also make suggestions for clinicians who may be interested in offering MBAs within their own service.

Despite numerous UK government policies aimed at reducing the number of autistic people and people with an intellectual disability in mental health hospitals, little progress has been made, with many experiencing lengthy stays that offer little therapeutic benefit. Once admitted, people are at risk of restrictive interventions and significantly delayed discharge, resulting in trauma. This article draws on the cases of four people to illustrate the limitations of current mental health system approaches to the challenges experienced by autistic people and people with an intellectual disability. The importance of relational working and listening to people is explored, and we demonstrate how this can facilitate the provision of bespoke housing and care packages to enable a successful return to life in the community. Finally, we offer recommendations on the changes urgently needed to ensure that autistic people and people with an intellectual disability can live ordinary lives in their own homes, with timely and effective support from mental health services when needed, just like everyone else.

People with learning disabilities form only a small part of the general population, but because of their many special needs, they require the provision of specialist health services. National statistics on the prevalence of learning disabilities are poor, but it has been estimated that 160 000 people in England and Wales have severe or profound learning disabilities (Audit Commission, 1987).

The proceedings of a mental health review tribunal involve two psychiatrists – one to be found among its members and the other (having care of the patient) who appears before the tribunal as the responsible medical officer (RMO). Both have a very important role to play and the juxtaposition of two psychiatrists guarantees a lively debate at many tribunal hearings.

The first line of treatment for patients with psychotic disorders such as schizophrenia is neuroleptic medication. Neuroleptics have provided substantial benefits to patients with this type of severe mental illness since their discovery as a treatment for psychosis in the 1950s. Despite this, there are still a large number of patients who do not respond fully to neuroleptic medication or who are not able to tolerate it. For example, although as many as 70% of patients are substantially improved following drug treatment, a considerable proportion continue to experience persistent, distressing and recurrent symptoms. In a survey of patients in a London psychiatric hospital, Curson et al (1988) found that just under half of the patients continued to experience hallucinations and delusions despite the prescription of medication. In addition, many patients experience intolerable side-effects or do not wish to comply with neuroleptic medication, yet look for some effective alternative. Depression, anxiety and a high rate of suicide are additional problems faced by patients with schizophrenia.

Since its first description in 1863, ‘hebephrenia’ has highlighted a group of patients characterised by an early onset of illness, formal thought disorder, bizarre behaviour and incongruent emotional expression. A proportion of patients with the most severe form of mental illness have a clinical presentation that is best captured by this diagnosis. Here, we outline the construct of hebephrenia and two of its core overlapping constituent parts: bizarre behaviour and the disorganisation dimension. We argue that, despite the removal of hebephrenia (disorganised schizophrenia) from DSM-5, clinicians should consider it as a differential diagnosis, particularly in suspected personality disorder.

Multiple sclerosis (MS), an immune-mediated demyelinating condition, is the most common neurological disease affecting young adults in the UK. It has a high psychiatric comorbidity and over half of patients have some degree of cognitive impairment that adds to the burden of disability. This article reviews the psychiatric and cognitive manifestations of MS and their detection and treatment. Recent advances in the treatment of the disease are briefly reviewed and the impact of disease-modifying therapies on psychiatric morbidity and cognitive impairment is discussed.

Depression is missed more often in adolescents than in adults, partly because they present with symptoms different from those in adults and because many do not seek help. Early detection or the delay of onset can have a significant effect on a young person's development and social functioning. We briefly discuss diagnosis and screening instruments before presenting the wide range of educational and psychological preventive approaches developed for adolescent depression. Many of the latter are based on the cognitive-behavioural or interpersonal therapy models. We consider how clinicians might use the current evidence base to identify and prevent depression in adolescents, and outline the principles of management of the disorder.

Mental capacity refers to a person's ability to make decisions, which may include consenting to medical treatment. People are presumed to have this capacity. Individuals may lack capacity because of an impairment or disturbance that affects the way their mind or brain works. Legal frameworks are in place for acting and making decisions on behalf of individuals who lack the mental capacity to do so for themselves, in their best interests. A case illustration is used to outline the principles involved under the Mental Capacity Act 2005 for England and Wales. We describe in detail the assessment of capacity to consent to treatment in this case and good practice in making best interests decisions in everyday clinical practice.