Since 2018, the International Task Force on Benzodiazepines (ITFB), a group of academic psychiatrists and academic psychologists, has advocated that clinical guidelines should change to promote benzodiazepines from second- to first-line treatment for anxiety disorders, accept their use as maintenance treatment for anxiety conditions (in particular, panic disorder) and increase their use in gastrointestinal disorders. There is merit in much of what the ITFB argues, but in this article I analyse four major claims it has made in opinion editorials that I believe are not fully supported by the available evidence.

This editorial introduces the first of two special issues of BJPsych Advances on neurodevelopmental disorders, including intellectual disability, autism spectrum disorder, attention-deficit hyperactivity disorder and epilepsy. This issue is intended to offer a clinical tool kit for mental health professionals giving guidance on assessment and management of these disorders and associated conditions, such as behaviours that challenge.

People detained in prisons, psychiatric hospitals, police custody and immigration detention centres remain a cause of concern, particularly to professionals, politicians and the media. As the number of people detained by the state increases, Courts have been taking an increasing interest in cases in which individuals have died in state custody. Such cases are subsumed under Article 2 of the Human Rights Act 1998 – the right to life. Article 2 case law has elucidated key principles that can be applied in practice. Importantly, it imposes on states not only a negative duty not to take life intentionally or negligently, but also a positive duty to safeguard life. The inherent positive obligations have two aspects: first, there is a duty to provide an effective and impartial investigation in cases of death resulting from the activities of state officials, and second, a duty to safeguard and protect life.

Mental disorders are overrepresented in the criminal justice system, and this applies equally to police custody. These environments are complex and often pressured, and the acuity of the situation, combined with underlying mental disorders, comorbid medical problems and substance misuse, can lead to behavioural disturbance and increased psychiatric risk. Police custody may also present an opportunity to identify and signpost people with mental disorders and vulnerabilities who are ordinarily hard to reach by standard health services. This article considers the purposes of mental health screening of detainees in police custody. It gives an overview of research into screening for a range of psychiatric disorders and vulnerabilities (including substance misuse and traumatic brain injury) and summarises data on deaths in and immediately following release from custody. Given the inadequacy of statutory screening procedures in some jurisdictions, the authors offer a pragmatic evidence-based protocol to guide screening for mental disorders in custody detainees.

Gamblers Anonymous (GA) is perhaps the least used of the twelve-step approaches to dealing with addictions. This relative lack of visibility and use, at least in the UK, is reflected in healthcare professionals' lack of awareness and knowledge of gambling addiction and its treatment, including GA. In this article, we introduce the basic tenets of GA and discuss how these translate into treatment.

This article discusses sceptical arguments about measurement scales. Measurement scales are part of a promising agenda of openness, transparency and patient and public involvement (PPI) in medical research, but have received critical, sometimes hostile attention from anthropologists. This is because scales repackage localised cultural assumptions about distress as something universal and pan-human and have the capacity to reshape people's interior lives in unhelpful, possibly harmful ways. We take as an example the Patient Health Questionnaire-9 (PHQ-9). Use of the PHQ-9 is currently mandated by major funders. But its history suggests flawed PPI and a lack of openness. The article suggests a constructive role for anthropology in mental health research, using ethnographic evidence and theory to show how, although they have their uses, mental health scales should not be regarded as inert or harmless.

This article critically reviews the case law, guidance and standards related to the provision of expert psychiatric evidence in immigration and asylum cases in the UK. It discusses the potentially complex and medico-legally challenging process of psychiatric evaluation of asylum seekers, and the implications of the presence of psychiatric disorders for issues such as the individual's ability to give oral evidence in court, immigration detention, fitness to fly, removal, deportation, ability to reintegrate into the destination country and appeal rights. To give context to the discussion, it outlines the asylum process in the UK from claiming asylum, initial screening and the ‘substantive interview’ to, if a claim is rejected, appeal to the First-tier Tribunal (Immigration and Asylum Chamber), detention and the removal process.

The book Psychotherapy by Reciprocal Inhibition (1968) is widely acclaimed as the masterwork of Joseph Wolpe, a great pioneer in the development of behavioural therapy, and is considered one of the most influential books in the history of clinical psychology. In this article, a brief biography of Wolpe is followed by a critical review of the book that illustrates his major contributions to the evolution of cognitive–behavioural therapy (CBT) as the most empirically supported model of psychotherapy.

Motivational interviewing is a form of psychotherapy in which ambivalence towards an aberrant behaviour is targeted. Rather than challenge the behaviour directly, the clinician encourages the patient to devise a list of problems that are caused by the behaviour and to identify solutions. There are many trials of motivational interviewing, although it has been most studied as treatment for substance misuse. The effect sizes for motivational interviewing are small, they probably diminish over time, the trials often use multiple outcome measures and the outcomes of some very large trials have been disappointing. Large effects are occasionally reported, although these tend to be from small trials conducted by highly motivated research groups and the results tend to diminish when the trials are repeated or enlarged. Nonetheless, motivational interviewing is a well-validated approach supporting and enabling engagement in therapeutic process. It could be argued that even though it might not be as efficacious as a primary/stand-alone means of changing patients’ behaviour, it can still be highly effective when combined with other approaches or used as a conduit to a more intensive therapy.

In this article we start with the effectiveness paradox between different psychotherapeutic modalities, considering common factors, before moving on to give a brief overview of the three main psychotherapeutic approaches – psychoanalytic, cognitive–behavioural and humanistic – and their developments. We conclude that it is the therapeutic relationship – considered in the context of the above – that is core to all therapeutic engagement, medical or otherwise.

The January 1997 issue of this journal contained four reviews that compared tricyclic antidepressants with selective serotonin reuptake inhibitors (SSRIs) and other newer antidepressants in terms of their pharmacology (Palazidou, 1997), adverse effects, potential drug interactions and toxicity (Henry, 1997), efficacy in the prevention of relapse and recurrence (Edwards, 1997), and findings from meta-analyses (Anderson, 1997). In July 1997 reboxetine was promoted as the first selective noradrenaline reuptake inhibitor (NARI), and in October of the same year mirtazapine was promoted as the first noradrenergic and specific serotonergic antidepressant (NaSSA). Milnacipran is presently being registered by the manufacturers, after which it will be the second antidepressant drug promoted as a specific serotonin and noradrenaline reuptake inhibitor (SNRI).

Methodological issues such as social desirability bias, subjective outcome measures, therapist enthusiasm and fidelity to the intervention remain a major problem in assessing the effectiveness of psychosocial treatments for substance misuse. Alcoholics Anonymous and other 12-step programmes are still widely used, although it is difficult to formally assess their effectiveness. Motivational interviewing is perhaps the most commonly used professional psychosocial treatment for substance misuse, but brief interventions based on this technique report a disappointing effect size (∼0.2). Contingency management is perhaps the most effective reported modality, although it remains politically controversial. Cognitive—behavioural therapy and community reinforcement have been widely studied, but the results are often disappointing (effect sizes seldom exceed 0.5, despite very large trials). Residential rehabilitation remains an established treatment, but patient selection prevents formal cost-effectiveness studies.

Psychiatrists have a role in teaching all medical undergraduates and foundation year doctors generic skills to become good doctors, but they also have to appeal to and nurture the interests of future psychiatrists by maintaining core psychiatric skills/knowledge in their teaching. They must tackle poor recruitment to psychiatry and stigma against both the profession and its patients. Medical students and junior doctors tend to be strategic learners, motivated by passing assessments, and psychiatrists are often guilty of gearing their teaching only to this. This article explores the assessment process itself and ways to optimise it, and presents a case for going beyond teaching how to pass exams in order to address wider issues relating to psychiatry.

Considering the ample evidence of involvement of the glutamate system in the pathophysiology of depression, pre-clinical and clinical studies have been conducted to assess the antidepressant efficacy of glutamate inhibition, and glutamate receptor modulators in particular. This review focuses on the use of glutamate receptor modulators in unipolar depression.

In medical practice it is crucial that symptom descriptions are as precise and objective as possible, which psychiatry attempts to achieve through its psychopathological lexicon. The term ‘autism spectrum disorder’ has now entered psychiatric nosology, but the symptom definitions on which it is based are not robust, potentially making reliable and valid diagnoses a problem. This is further compounded by the spectral nature of the disorder and its lack of clear diagnostic boundaries. To overcome this, there is a need for a psychopathological lexicon of 'social cognition’ and a classification system that splits rather than lumps disorders with core difficulties in social interaction.

This paper explores the range of expectations of psychiatrists held by those in general management in the health service.

In most Western countries, including the UK, comprehensive mental health services are predominantly funded from State resources. The role of the psychiatrist has changed in the past 20 years and will without doubt change further in the next 20 years. Expectations of psychiatrists have changed and will continue to do so. We take the position that psychiatrists should continue to have the major leadership role in mental health and in so doing must become increasingly responsive to the changes taking place in health care planning and provision.

In their recent articles in APT Mace & Binyon described a four-level approach to the teaching of the psychodynamic formulation. The fourth level requires development of confidence in the use of an operationalised psychodynamic diagnostics (OPD) manual. Here I critically reconsider the aspects necessary to develop the ability to arrive at a psychodynamic formulation. I argue that as one develops more sophistication and clinical confidence, one needs to move from a manualised to a more open-minded reflective mode.

The importance of personality is recognised tacitly by the development of the multiaxial classifications of ICD–10 (World Health Organization, 1992) and DSM–IV (American Psychiatric Association, 1993). The separation of axis 1 or current mental state diagnosis from axis 2, on which personality is described, is a recognition that personality is separate from other aspects of the patient's diagnostic status. Nevertheless, many clinicians are sceptical that personality can be assessed reliably and some hold that the diagnosis should be abandoned as being merely judgemental and pejorative (Lewis & Appleby, 1988). There is some basis for scepticism in respect of reliability in view of the evidence that even with operational criteria the clinical assessment of personality is not transportable, and the level of agreement between practising clinicians is much less than that achieved during field trials (Mellsop et al, 1982).