Over the past decade there have been few advances and no real breakthroughs in the treatment and management of anorexia nervosa. There has perhaps been a consolidation of opinion and practice. A clinical guideline for eating disorders published under the auspices of the National Institute for Clinical Excellence (NICE) has summarised our present ideas of good practice as well as highlighting the lack of good evidence on which to base this.

Children and adolescents with intellectual disability have high rates of psychiatric morbidity, the most common presentation being behavioural difficulties, especially in the context of autism. This clinical review describes the applicability of the full range of current psychopharmacological agents to the mental health difficulties commonly encountered in clinical practice in this field, with an emphasis on informing the choice of an initial ‘best fit’ single agent for the various clusters of symptoms and signs presented by individual patients. It is emphasised that the evidence base for most practice parameters in this area is extremely modest and that a high level of caution is recommended when applying this information in everyday practice. The article also discusses some of the specific difficulties and challenges encountered within the field and makes some practical suggestions for good practice.

Over the past decade, important research has been performed into the therapeutic use of dihydrocodeine, injectable opioids (diamorphine) and supervised disulfiram in addiction treatment. There have also been interesting developments regarding baclofen for alcohol problems and use of stimulants in adult Attention-deficit hyperactivity disorder (ADHD). However, evidence for the effectiveness of medication to promote alcohol abstinence remains modest at best.

The evidence base for cognitive-behavioural therapy (CBT), family therapy, psychoeducation and cognitive remediation as adjuncts to antipsychotic medication in the treatment of schizophrenia is well established. It is, however, clear that the moderate effect size of the best researched of these treatments (CBT) compared with treatment as usual reduces to small when compared with an active psychological treatment. It would seem that many different psychosocial interventions de liver benefit in schizophrenia. We are now at a stage in their development when new treatments are being energetically piloted and combination treatments tested. This article outlines the most promising of these new interventions and attempts to answer the crucial question as to their differential effects on different psychotic presentations.

Miscarriages of justice occur as a result of unsafe convictions and findings and inappropriate sentences. In cases involving expert psychiatric evidence it is possible that the way evidence is presented by experts or interpreted by the courts has a direct bearing on the case. Using illustrative cases from the Criminal Division of the Court of Appeal, advice is offered to expert psychiatric witnesses on ways to reduce the likelihood of contributing to such miscarriages of justice and on how they may assist in rectifying such miscarriages, should they occur.

There is much evidence from clinical trials that antidepressants help prevent relapse and recurrence of major depression. However, this is unlikely to hold true for all patients with depression, particularly those treated in primary care. Individual antidepressants are equally efficacious, so choice (as first-line treatment in general or for individual patients) is largely determined by differences in side-effects, even though many of these disappear during long-term treatment, owing to adaptation. Specific effects that are considered in choosing a drug include those on cognition, psychomotor performance and sexual function; drug interactions, lethality in overdose and the potential for teratogenicity are also considered. There are insufficient entirely objective and generally accepted data on pharmaco-economics to allow for confident recommendations on drug choice for long-term treatment. Drug acquisition costs must be considered by those with restricted budgets, and especially patients in developing countries where difference in cost between newer and older drugs can be translated into more food for a hungry family.

It is highly likely that a psychiatrist will be called to an inquest at some point in their career. Our aim in this article is to educate psychiatrists in relation to the law and processes of a coroner's court in England and Wales and provide guidance on engaging with the system. To achieve this we review and discuss the relevant law and medico-legal aspects of inquests. Knowledge and preparation are key to negotiating any inquest and we would hope that the understanding and guidance offered in this article will reduce anxiety, make the situation manageable and aid professionalism, in often tragic circumstances.

The development of rational treatments for tardive dyskinesia has been held back by limitations to our understanding of its aetiology, which even now does not extend far beyond its association with centrally acting dopamine-blocking drugs. This article reviews briefly the major aetiological theories and addresses general management and specific treatment options. Primary prevention and early recognition remain the crucial management issues because, once the condition is established, there are no satisfactory treatments. The article considers two newly developed drugs, valbenazine and deutetrabenazine, in some detail as, although they are not yet licensed in Europe, they have largely been responsible for an upsurge in interest in tardive dyskinesia in the North American literature and are likely to be widely promoted in the future. Although possessed of undoubted benefits, the evidence suggests that these represent small steps rather than large leaps forward in treatment.

The problem of occupational stress in healthcare workers is hardly new, but effective interventions in this area are lacking despite being sorely needed – especially in the ongoing COVID-19 pandemic. The results of a Cochrane review suggest that cognitive–behavioural therapy and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions, and that changing work schedules may lead to a reduction of stress. Other organisational interventions showed no effect on stress levels. However, the evidence is of low quality owing to risk of bias and lack of precision. This commentary critically appraises the review and attempts to put its findings into the current real-world context.

The development of the concept of clinical leadership over the past 5 years, in conjunction with an ever-increasing emphasis on its importance in the medical world, has led to an explosion of reviews, resources, fellowships and other academic programmes in this area. Arguably, with the focus on clinicians as individual leaders, teamworking is a fundamental aspect of effective clinical leadership that has perhaps received less attention. This article explores aspects of leadership in the team setting and covers theories and concepts relating to team dynamics, team roles and functioning. This is with a view to providing clinicians with a sound knowledge base in this area, increased understanding of issues they may face in their own clinical teams, and ideas and tools to help increase team effectiveness.

Three recent advances have increased the importance of obsessive–compulsive disorder (OCD) for the general psychiatrist. It is a more common disorder than previously realised, there are effective treatments, and the basic neurobiological substrate for the condition is being identified. This review will consider these advances but focus mainly on the practical aspects of assessing the condition and planning treatment.

Mental health services in the state of Victoria, Australia, have undergone enormous change over the past 15 years, with the closure of all stand-alone psychiatric hospitals and a shift of resources and services into the community. Although successful overall, various areas cause concern, including pressure on acute beds, a paucity of alternative residential options, and suboptimal integration of government and non-government agencies concerned with the care of people with mental illnesses. Certain groups, notably those with complex symptom sets such as substance use and mental illness, intellectual disability and forensic problems, remain poorly catered for by the system. Finally, community stigma and lack of work inclusion for mentally ill individuals are ongoing challenges.

Psychological therapies are a necessary component of any mental health service. Psychiatrists will require a working knowledge of different psychological approaches and many will wish to develop clinical skills to practice at least one model of psychotherapy. Historically, most psychiatry training schemes have offered exposure to psychodynamic psychotherapies, while training in other approaches has been less systematic. The expansion of research into brief psychological therapies and a wealth of recent publications on the subject have led to an increasing awareness of the benefits of training in other models of psychotherapy. The most widely practised and researched brief psychological intervention is cognitive-behavioural therapy (CBT). This paper will outline the principles behind providing training in CBT, and the barriers to successful implementation of a training programme.

Gender dysphoric disorders are currently attracting a great amount of attention. Generally, this attention is appropriately scientific and not condemnatory. This is possibly because of changing attitudes, but also because of the dissemination of information about what may be done to help people with these disorders. People are coming forward to request such help. Whether the surge of applicants to gender identity clinics (GICs) is due entirely to the change in attitude or whether there is a true increase in incidence of these disorders is at present undetermined. The fact, however, remains that prior to the second half of the present century little professional attention was paid to gender dysphoria (Bullogh, 1975).

What is happening in and around psychiatric services that raises fears of a harmful separation between psychiatrists and the rest of the medical fraternity? The last National Health Service (NHS) reforms at the beginning of the 1990s split some mental health services into separate organisations from their local acute services. Paragraph 5.14 in the Government's White Paper The New NHS (NHS Executive, 1997a) seems to favour specialist mental health trusts. Combined whole district trusts are under threat. Shotguns are loaded to ‘encourage’ the marriage with social services. All this may seem to conspire against psychiatrists maintaining close professional relationships with physicians and surgeons in general hospitals. Instead it puts the emphasis on aligning psychiatric work much more closely with social services and primary care. Much restructuring is already afoot. It is a time for sober reflection on what is in the best interests of patients now and in the future (see Box 1).

In psychiatry we are perhaps fortunate that the death of our patients is not such a regular occurrence as for our colleagues in other specialties or in primary care. However, when death does occur it is more likely to result from some unnatural cause such as suicide. Consequently, the prospect of being involved in a coroner's inquest is a very real and anxiety-provoking possibility for many psychiatrists. This article considers the role of the coroner in England and Wales and the process of investigation of sudden and unexplained deaths, and offers some practical advice regarding such proceedings. It illustrates a number of issues that have been highlighted in coroners' verdicts and have implications for the process of clinical governance. It also considers possible changes to the coroner system that have been proposed recently in several high-profile reports.

Making potentially critical clinical decisions in complex cases with the real risk of death by suicide is a most challenging job in psychiatry. Sadly, risk assessment and management of harm to self is a largely ignored area compared with risk of harm to others. The legal and ethical challenges are more nuanced, and contemporary training schemes and textbooks on psychiatry have not always done justice to this area, where front-line clinicians require probably most assistance. This article is an attempt to integrate the seemingly disparate threads from legal, ethical and clinical realms to assist decision-making, and it introduces a set of principles for managing these in clinical practice. It refers in particular to legislation in England and Wales, but the clinical and ethical issues discussed are universal.

The purpose of this review is to outline current knowledge on the life expectation of people suffering from organic brain disease, the techniques available for describing and comparing life expectation in populations, factors which are associated with longer and shorter life expectation, and the causes of death among patients with this condition.

Most literature discussing the introduction of foundation year 1 (F1) psychiatry posts has focused on recruitment. However, for F1 posts to offer a valuable learning experience and a potential recruitment boost, psychiatrists and employing organisations should be aware of general issues arising in the first postgraduate year. These include the inherently stressful student-to-doctor transition, the need for bespoke induction programmes for new graduates, F1 doctors' specific needs for support, supervision and peer support, and the centrality of the relationship with the consultant supervisor to the new doctor. Understanding these themes will enable psychiatrists and mental health organisations to offer better F1 psychiatry experiences, which may boost recruitment and could maximise the opportunities for F1 doctors to develop skills and qualities that will be of value in their future careers, whatever specialty they end up working in.

Antipsychotics are useful at reducing acute symptoms, but recent evidence calls into question their long-term efficacy and raises concern about adverse effects on the brain.