This article gives an update for practitioners on recent developments in the use of electroconvulsive therapy (ECT) and related treatment modalities in the contemporary treatment of depression in the UK. Details are provided on new information on the efficacy and side-effects of ECT both in research studies and in the real world, together with recent research on ECT's mode of delivery. There is a focus on the safe administration of ECT in clinical practice. An update on the regulatory framework for ECT in the UK is provided, together with up-to-date information on the legal situation regarding its prescription. Finally, brief summaries of the current position for other neuromodulatory treatment modalities are given.

Autoimmune disorders in children and adolescents can have significant neuropsychiatric complications and there is growing interest in the association between autoimmune conditions and psychiatric syndromes, particularly in Down syndrome. Acute presentations with psychiatric symptoms require careful assessment in order to recognise and plan treatment of underlying autoimmune disease in collaboration with paediatric colleagues. Difficult treatment decisions arise in children with established autoimmune diagnoses and psychiatric symptoms that may be a result of neuroimmunological processes associated with their condition, psychiatric side-effects of drug treatments or psychopathology resulting from other factors in the history that may or may not have a direct relation to the autoimmune diagnosis. This article illustrates these complexities through discussion of specific autoimmune disorders and three case histories.

A 19-year-old student, wandering the streets of a Northern city, is picked up at 3am by a taxi driver. The student requests delivery to a fictitious destination. The student recounts to the driver a series of events including abandonment by parents at the age of six in a forest in the West Country, and subsequent adoption by an elderly couple who live in Birmingham. The taxi driver takes the student to the central police station, where, after a brief interview, sectioning under the Mental Health Act 1983 takes place.

This article updates previous evidence on the role of primary care in the management of depression and related disorders, unexplained physical symptoms, and severe and enduring mental illness. Regarding depression and related disorders, there is now evidence for the benefits of non-medical interventions and collaborative care, providing alternatives to the simplistic over prescription of antidepressant medication. For severe and enduring illness, the emphasis in primary care is now on the effective management of comorbid physical health problems. The article also summarises best practice for the primary care assessment and management of dementia, including the need for holistic review of care quality and the potential benefits of collaborative care. Finally, it notes the growing emphasis on primary mental healthcare in low- and middle-income countries (LMIC).

It is estimated that 29% of adults in the UK smoke (Office for National Statistics, 2000). Each year smoking kills 120 000 people (13 deaths per hour), making it the single most common preventable cause of death in Britain (Callum, 1998). Around half of all smokers will die prematurely because of their addiction (Peto et al, 1994). Their overall life expectancy is, on average, 8 years less than for non-smokers (Callum, 1998). Smoking also costs the National Health Service (NHS) £1500 million, with around 1000 admissions every day for smoking-related illnesses (Parrott et al, 1998). (However, the UK treasury earns £8 billion in tax on tobacco sold in the UK alone, in addition to the enormous revenue from overseas markets.)

The severe dissociative disorders of dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS) are complex, not uncommon presentations associated with severe symptoms, high rates of comorbidity, high service use compared with other psychiatric disorders, and high suicidality. They exact high personal and socioeconomic burdens and show poor response to standard treatments, with high levels of treatment attrition and ‘revolving-door’ out-patient and in-patient service use; patients are often misdiagnosed or labelled ‘untreatable’. DID and DDNOS diagnoses remain controversial, but they have been repeatedly validated internationally over the past 20 years and the disorders can be accurately identified using screening tools and structured clinical interviews. Neurobiological understanding of the disorders is increasing; findings are consistent with a trauma origin and have commonality with features seen in other trauma-related disorders. Specialist treatment that addresses the dissociative symptoms alongside their trauma origins shows promise in early evidence. Working knowledge of these disorders among non-specialist psychiatrists and psychologists in the UK remains poor, resulting in long delays before diagnosis and treatment.

Most of the novel psychological therapies reviewed by Turkington & Lebert have their roots in at least one traditional approach of cognitive, behavioural and meditation practice. These therapies offer exciting prospects, but none as yet has a strong enough evidence base to warrant routine implementation in the National Health Service. In a climate of scarce resources, implementation of novel therapies is likely to come at the cost of traditional therapies with a stronger evidence base. Clinical practice must not run ahead of the evidence, but we must enable new, targeted treatments to be implemented in a timely manner once their evidence base becomes secure.

Autism is a neurodevelopmental condition associated with differences in social communication and interaction, as well as a restricted, repetitive repertoire of behaviours and interests. Autistic people will have areas of interest and can possess abilities that are of potential benefit to both themselves and wider society. However, many find that their opportunities are limited. Here, we will discuss how a social model of care can help meet the needs of autistic people.

There is no direct coherence between medical and legal concepts or between medical and legal ways of thinking (Eastman, 1992). As a result, there are often substantial difficulties in translating the findings of one (medicine) into the decisions of the other (law). In order to minimise interdisciplinary confusion, it is necessary for each to have an understanding of the approach of the other. This paper attempts to elucidate the relationship between law and psychiatry as it is played out specifically in personal injury litigation and in relation to civil legal claims for (legal) ‘nervous shock’. It is not confined solely to claims arising out of the development of post-traumatic stress disorder (PTSD) (Eastman, 1995; Napier, 1995), but is applicable to any psychiatric sequelae of events for which legal liability of a defendant can be established. It also offers general comments about the provision of civil psycho-legal assessments, advice and opinion writing (Carson et al, 1993) as a backcloth to its more specific purpose.

The care of women with anxiety and depressive disorders in the perinatal period is complex. The literature in this field is vast and may be difficult for busy clinicians to keep abreast of. The first part of this article provides an overview of the potential risks and benefits of treatment options, including no treatment, at various stages in the perinatal period. The second part explores the frameworks which may assist clinicians in decision-making with their pregnant patients, including risk-benefit analysis, ethical considerations, evaluating capacity, and mental health legislation. The common pitfalls and limitations of these approaches are examined to guide good practice.

The Mental Health Act 1983 now incorporates amendments introduced in 2007. This article explores features of the amended Act that affect the treatment of patients with personality disorder in England and Wales. It discusses issues such as the broad definition of mental disorder, treatability and professional roles, with specific reference to how they might, or might not, affect usual practice concerning patients with personality disorder. It also comments on elements within the Act that could positively affect people with personality disorder, such as community treatment orders, provision to change their ‘nearest relative’ and statutory advocacy services. The political climate in which the Act has been amended is commented on, as well as how this might potentially compromise some of the positives within the Act.

Psychiatry faces a number of external and internal challenges. At the heart of its difficulties is an identity crisis and attempts to resolve this have so far split the specialty. British psychiatry has in recent years taken an increasingly ‘neurophobic’ stance. This article argues that, despite the current situation, opportunities remain for a medicine of the mind to thrive. Neuroscientific advances in our understanding of psychiatric disorders need to be made more explicit in training and in the structure of mental health services.

Historically, depressive disorders in adolescents have been conceptualised as variants of the nonspecific class of childhood emotional or neurotic disorder, which encompassed depressive, anxiety, hysterical and obsessional disorders. Over the past decade, however, the field has shifted towards greater diagnostic refinement. Research evidence has shown that severe depressive disorders differ from other mental disorders in this age group in their epidemiology, outcome and correlates (Harrington & Wood, 1995). Treatment therefore includes not only general techniques of clinical management, but also a variety of treatments targeted at the symptoms of depressive disorder.

The term ‘epilepsy’ refers to a tendency to have recurrent seizures. Epileptic seizures arise from an imbalance of excitatory and inhibitory cerebral neurotransmitters associated with sudden, paroxysmal, synchronous and repetitive discharges of neurones. All normal brains have the capability to have seizures. Epileptic seizures arise where there is lowering of the naturally occurring seizure threshold. Excitotoxins such as glutamate released in the brain during seizures can cause irreversible cell damage. Young children are especially vulnerable. Prolonged seizures (greater than 30 minutes) in children correlate with subsequent learning disability.

Doctor (2004, this issue) raises the important question of how to assess and manage violent behaviour. He claims that actuarial models of risk assessment based on epidemiology have failed, and that indeed the most reliable risk assessment is one based on clinical methods. He proposes that psychodynamic psychotherapy be used for this purpose, to uncover the meaning of the violent behaviour. Such therapy will, Doctor argues, help the violent person be aware of and understand the function of their behaviour. This understanding in turn will reduce the need in the patient to act out violently.

Public health has traditionally been concerned with the primary prevention of disease, either by eliminating its causes or by enhancing host resistance. Clean water supplies, efficient sewage and rubbish disposal, and refrigeration of food have largely eliminated the micro-organisms responsible for a wide range of infectious diseases, while anti-smoking campaigns have reduced mortality from cancer of the lung and coronary heart disease. Immunisation programmes have had a similarly dramatic effect on the incidence of many bacterial and viral diseases. Indeed, they have completely eliminated smallpox, and the polio virus seems likely to follow it into oblivion.

Stress is the most important proximal precipitant of depression, yet most large genome-wide association studies (GWAS) do not include stress as a variable. Here, we review how gene × environment (G × E) interaction might impede the discovery of genetic factors, discuss two examples of G × E interaction in depression and addiction, studies incorporating high-stress environments, as well as upcoming waves of genome-wide environment interaction studies (GWEIS). We discuss recent studies which have shown that genetic distributions can be affected by social factors such as migrations and socioeconomic background. These distinctions are not just academic but have practical consequences. Owing to interaction with the environment, genetic predispositions to depression should not be viewed as unmodifiable destiny. Patients may genetically differ not just in their response to drugs, as in the now well-recognised field of pharmacogenetics, but also in how they react to stressful environments and how they are affected by behavioural therapies.