Cognitive–behavioural therapy (CBT) is an effective treatment for a number of psychiatric disorders in adults of all ages. With the proportion of the population aged 65 or over increasing steadily, it is important to be aware of how the CBT needs of this age group can be best met. This article provides an overview of CBT and the historical context of using it with older people. Although an understanding of the individual, irrespective of age, is at the core of CBT, potential modifications to the procedure and content aimed at optimising its effectiveness for older people are discussed.

In this article on getting on with colleagues in the workplace we explore how the nurse–doctor relationship in psychiatry has evolved and discuss its current status in both the in-patient ward and community mental health teams. In particular, we outline the changed roles and expanding responsibilities of nurses in the UK today. We suggest ways in which doctors can improve the relationship and give areas of possible future collaboration between doctors and nurses.

Some people with obsessive–compulsive disorder (OCD) experience recurrent intrusive sexual, aggressive or death-related thoughts and as a result may be subjected to lengthy or inappropriate risk assessments. These apparent ‘primary’ risks can be dealt with relatively easily through a careful understanding of the disorder's phenomenology. However, there are other, less obvious ‘secondary’ risks, which require more careful consideration. This article discusses the differentiation of intrusive thoughts and urges in people with OCD from those experienced by sexual or violent offenders; assessing the risk of self-harm and suicide; discussing the nature of repugnant obsessions with a patient; assessing risk of harm and violence to the dependents and family living with someone with the disorder; and assessing the lack of insight and the use of the Mental Health Act. Issues specifically related to children and young people with OCD are also highlighted.

Despite the higher prevalence of learning disabilities among some minority ethnic communities and the greater burden of care, families from minority ethnic communities with a member who has learning disabilities are doubly disadvantaged as a result of racial discrimination and culturally inappropriate forms of care and service provision. This paper looks at the issue of discrimination, as well as the generally negative attitudes towards people with learning disabilities, and synthesises these into the concept of ‘double jeopardy’. It concludes by proposing ways of developing cultural competence in the delivery of care to this population.

Epidemiological research has revealed that psychiatric disorders in children and adolescents are common, persistent and handicapping. Only 1 in 10 of those with a disorder is seen in specialist mental health services. However, the majority of children and adolescents see their general practitioner (GP) every year. Although the majority present with physical complaints, there are indications that rates of psychiatric disorder in those attending are increased and that psychiatric disorder is associated with increased consulting. These findings raise questions about the role of primary care in the promotion and management of mental health in young people.

Anorexia nervosa is a potentially fatal illness that affects women and a smaller proportion of men. When a patient becomes so severely ill that admission to a medical unit is required, the risk of a poor outcome is high. Most medical services do not have sufficient expertise, without psychiatric help, to manage the nutritional, medical, behavioural and family problems that often appear. These problems interact and this can adversely affect outcome. This article discusses, with reference to the MARSIPAN report, the procedure that should be followed when such a patient presents to an acute medical service. It considers diagnosis, risk assessment, consent, re-feeding syndrome, underfeeding syndrome and treatment-sabotaging behaviours. It stresses the importance of collaboration between expert medical and psychiatric staff, and involvement of the family. When these issues are adequately addressed, the outcome for the patient is more likely to be positive.

Most disorders in medicine are classified using the ICD (initiated in Paris in 1900). Mental and behavioural disorders are classified using the DSM (DSM-I was published in the USA in 1952), but it was not until DSM-III in 1980 that it became a major player. Its success was largely influenced by Robert Spitzer, who welded its disparate elements, and Melvyn Shabsin, who facilitated its acceptance. Spitzer pointed out that most diagnostic conditions in psychiatry were poorly defined, showed poor reliability in test-retest situations, and were temporally unstable. The consequence was that the beliefs of the psychiatrist seemed to matter much more than the characteristics of the patient when it came to classification. Since DSM-III there has been a split between those who adhere to DSM because it is a better research classification and those who adhere to ICD because it allows more clinical discretion in making diagnoses. This article discusses the pros and cons of both systems, and the major criticisms that have been levelled against them.

Multi-sensory therapy is an activity which usually takes place in a dedicated room where patients experience a range of unpatterned visual, auditory, olfactory and tactile stimuli (Baker et al, 1997). These rooms are designed to create a feeling of comfort and safety, where the individual can relax, explore and enjoy the surroundings (Fig 1.).

Drug treatment is an essential part of much of psychiatric practice, in patients from a wide age range, across many diagnostic groups and in a variety of settings. Despite the availability of many classes of psychotropic drug, significant numbers of patients remain troubled by distressing and disabling symptoms even after a succession of licensed pharmacological treatments. Psychiatrists may then consider the prescription of a psychotropic outside the narrow terms of its licence, as part of an overall management plan. This article reviews the nature and extent of this aspect of prescribing, outlines when it may be appropriate and makes recommendations for a suggested procedure when prescribing medication ‘off-label’.

Psychiatric nursing has changed significantly since I wrote a similar article almost 10 years ago. Community psychiatric nurses now focus their attentions almost entirely on people with serious and enduring mental illnesses and undertake case management roles in community teams. Many nurses have now been trained in the use of psychosocial interventions and there have been particular advances in the training of nurses in medication management. In turn, prescribing by nurses has become a reality and this role will expand rapidly over the next few years. Unfortunately, the potential for nurses to deliver cognitive–behavioural therapy to those with common mental disorders has not been realised and it is unlikely that this situation will change. Psychiatric nursing roles have increased in the forensic system and nurses are now working with people with dangerous and severe personality disorders and within prison healthcare. The education and training of nurses has undergone a fundamental shift and nurses of the future are likely to be graduates. Here I discuss the implications of these changes.

Recovery approaches are now being developed in forensic as well as general mental health services. These are welcome developments that offer new ways of working with a socially excluded group of patients. However, the theoretical basis of recovery, with its individual humanistic ethos, may struggle to articulate the unique problems of forensic service users. In this article, we describe those problems and propose a ‘third way’ of thinking that bridges the recovery agenda (which looks for the best in people) and the forensic agenda (which must consider the worst in people). We propose using a ‘narrative approach’, which sees the forensic service user's offence and cruelty as part of their human story. We link this explicitly with the work of Dan McAdams and his concept of the redemption narrative.

The death of a patient by suicide can severely affect mental health professionals, particularly if it occurs despite major efforts to intervene. Notwithstanding the difficulties faced by clinicians, suicide prevention remains of paramount importance in order to help save lives. This article seeks to promote a pragmatic and compassionate biopsychosocial response using evidence-based interventions to reduce suicide. It introduces practical strategies that psychiatrists can use in everyday clinical practice, in particular the paradigm shift of suicide mitigation to help prevent suicide. We believe that every encounter with a suicidal person is an opportunity to intervene to reduce their distress and, potentially, to save a life. We believe that it is no longer acceptable for clinicians to state that if patients wish to kill themselves they can do so, in the absence of any attempt at a compassionate intervention.

Good communication is central to psychiatric consultation. It informs assessment, diagnosis and treatment, and is an important part of empowering people to take more control of their own mental health. But active listening and personally tailored explanations may require additional skills and may need to be practised in the context of ethical and legal frameworks. In this article we consider the additional impairments that occur in people with intellectual disabilities who use psychiatric services and describe practical steps that can be taken by clinicians and service providers to overcome these impairments, to make reasonable adjustments and to ensure that patients obtain maximum benefit from services.

“The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself” George Bernard Shaw, Maxims for Revolutionists.

Professional practice explicitly focused on supporting the recovery of those it serves is broadly backed by an emerging profile of necessary knowledge, key skills and innovative collaborations, although there is no universally accepted practice ‘model’. This article outlines these components and discusses the associated need for change in the culture of provider organisations along with implementation of wider social and economic policies to support peoples' recovery and social inclusion. This is a values-led approach supported by persuasive advocacy and international endorsement but still in need of further development, systematic evaluation and confirmatory evidence.

Patient risk factors for suicide are well known to psychiatrists, yet the availability of clinically useful, routine and systematic methods for risk recognition are limited. This article outlines the structured professional judgement approach to suicide risk assessment and management. This method combines psychiatric assessment and formulation with the evidence base for suicide risk factors. Structured professional judgement is contrasted with actuarial and clinical judgement approaches. A categorisation of risk factors is presented, with four groups described – static, stable, dynamic and future. Case histories illustrate long-term high risk contrasted with sudden and unpredictable onset of suicidality.

Bipolar disorder is arguably a pivotal diagnosis in adult psychiatry bounded by schizophrenia on one side and unipolar depression on the other. It represents a wide spectrum of disorders, all sharing common features of elated and depressed mood. The early descriptions of symptom-free euthymia have long been dismissed and the chronic and enduring deficits associated with the disorder are beginning to be better understood. We review the current literature with regard to the course of the disorder, factors that may influence prognosis and common comorbidities.

Cognitive–analytic therapy (CAT) is a brief focal therapy informed by cognitive therapy, psychodynamic psychotherapy and certain developments in cognitive psychology. It was developed by Anthony Ryle specifically in response to the needs of the National Health Service (NHS) for treatment approaches of short duration. However, it has advanced far beyond its initial aims and is now a well-developed self-contained methodology backed by a fully structured theory of mental functioning and therapeutic change.

Nidotherapy is the formal term introduced to describe the systematic manipulation of the physical and social environment to help achieve a better fit for a person with a persistent or permanent mental disorder. This approach is described in detail and its merits are compared with more conventional ways of dealing with such problems. This involves the creation of a certain number of terms that may be viewed as unnecessary jargon but help to shorten communication in an area where systematic monitored interventions are relatively uncommon.

People with learning disabilities suffer an increase in common morbidity, communication difficulties, a high prevalence of serious conditions such as epilepsy, and specific patterns of health needs associated with the aetiology of their disability. Unfortunately, this combination of need is mirrored by a consistent picture of poor health promotion uptake, inadequate care for serious morbidity, unrecognised health need and poor access to health care. Consequently, there is a great disparity between the health of learning-disabled people and that of the general population. Psychiatrists can address this disparity in clinical practice by focusing on these patients' mental health, epilepsy management and the impact of behaviour on health. They can also influence health planning and service development.