Significant problems exist in understanding and implementing the Mental Capacity Act 2005 (MCA) despite it having been in place in England and Wales for more than 15 years. Although many guidelines exist on the assessment of capacity, it is difficult to apply such guidance in practice, given the complexity of actual situations. We may know the stages of the test for capacity, but do we really understand what they mean and how to assess them? In this, the first of two articles examining the MCA and challenges in its application, we add to existing legal guidance to explore capacity assessment in detail using a clinical scenario, and use case law and case studies to illustrate the subtleties and difficulties that may arise.

Multiple epidemiological studies have shown an increased prevalence of adverse mental health outcomes in refugee populations and have highlighted children and adolescents to be particularly at risk. This commentary considers a Cochrane Review examining the efficacy of community-based interventions at improving the mental health of refugee children and adolescents in high-income countries. The review concludes that community-based interventions are ineffective at improving mental health in such populations. Notably, the data are limited by significant risk of bias and a small sample size. This article aims to critically appraise this systematic review, extrapolate implications for current practice and identify avenues for further research.

This article is the second of two looking at assessment of mental capacity in clinical practice. In it, we explore capacity assessments in the context of suicidal thoughts and acts. The laws governing doctors’ responsibility to suicidal patients in England and Wales are poorly understood, with tensions at the interface between the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). Dynamics of the clinical encounter (including the countertransference) further exacerbate uncertainty about how clinicians should balance patients’ autonomy with protection of life. We use a case example of a patient presenting with suicidality to describe good practice, based on a balance of legal and clinical principles and up-to-date case law. We discuss the difficulty in applying the MCA in relation to patients who appear to lack a consistent and coherent sense of self and others and consider whether the MCA is fit for purpose in determining whether someone with a personality disorder diagnosis should be permitted to end their own life.

Music therapy has been a recognised form of therapy for mental illness for many years. This commentary on a Cochrane Review on music therapy for depression sheds light on the evidence. It aims to give further clinical context to the findings, to help guide practice and examine music therapy as an evidence-based practice. The review compares music therapy plus ‘treatment as usual’ (TAU) with TAU alone, music therapy with psychological therapy, and ‘active’ with ‘receptive’ music therapy (the two main types of music therapy). The review points to music therapy being beneficial for people with depression when combined with TAU (versus TAU alone) in the short term, as well as improving anxiety and functioning. We need more evidence looking at longer-term outcomes, comparing music therapy with psychological therapies and comparing different forms of music therapy.

Diabetes and depression have a bidirectional relationship, but some antidepressants (such as the tricyclics) may have detrimental effects in diabetes that are exacerbated by behavioural changes associated with depression. This month's Cochrane Review evaluated the efficacy of psychological and pharmacological treatments of comorbid depression in diabetes and found that such interventions have a moderate and clinically significant effect on depression outcomes in people with diabetes. However, conclusions were limited by significant heterogeneity within examined populations and interventions, and significant risk of bias within trials. This commentary critically appraises the review and aims to contextualise its findings.

Antipsychotics are commonly prescribed to manage the behavioural and psychological symptoms of dementia (BPSD) despite their modest efficacy and significant adverse effects. Psychosocial interventions are recommended as the first-line approach in treating BPSD before considering pharmacological options. A Cochrane Review by Lühnen et al (2023) evaluated the effects of psychosocial interventions on reducing antipsychotic prescription in care homes, and found that no generalisable recommendations can be made based on the currently available evidence. This commentary attempts to critically appraise and add context to the review.

Cold-water immersion (e.g. adapted cold showers, partial or whole-body immersion, cold swimming) are nowadays increasingly being used as an adjunctive procedure to enhance the effects of primary treatment of various clinical conditions, including depressive and anxiety disorders. This brief article reviews the evidence regarding the beneficial effects of cold-water immersion on clinical depression and anxiety and outlines potential therapeutic mechanisms underlying the intervention. Promising avenues for future research and best practice recommendations are also discussed to improve the clinical effectiveness of cold-water immersion.

This is a commentary on two articles on assessing mental capacity in everyday practice and in the case of the suicidal patient. It explores some of the conceptual problems with capacity, including the lack of a ‘right’ answer and the value-laden nature of capacity assessments in suicidal patients. In England and Wales, in addition to the Mental Capacity Act 2005 clinicians must also consider their duty of care as part of the European Convention on Human Rights as enacted in the Human Rights Act 1998.

Eye movement desensitisation and reprocessing (EMDR) is an established psychotherapy developed in the late 1980s to treat post-traumatic stress disorder (PTSD). It involves the use of repetitive eye movements or other bilateral stimulation to aid in the reprocessing of traumatic memories. It is unique in that it does not require extended exposure to or discussion of distressing memories and may result in symptom resolution in fewer sessions than other psychotherapies. In the decades since its initial development, a wealth of high-quality evidence has suggested that EMDR is a safe and effective treatment for trauma- and stress-based conditions, resulting in its inclusion in various treatment guidelines. This article reviews the theory behind how EMDR works, how it is conducted, the evidence supporting its use in the treatment of PTSD and its approved indications and contraindications.

The outgoing Editor in Chief of BJPsych Advances considers the 30-year history of the journal, outlining its development from a slim four-paper issue to an authoritative publication offering blended learning approaches for consultant psychiatrists and also for trainees preparing for their examinations.

Teenagers often present in crisis with risk issues, mainly risk to self but sometimes risk to others. Adolescent violence is commonplace and is not just the remit of adolescent forensic psychiatry. Clinicians may lack confidence assessing risk of violence and can neglect vital areas that are essential to reduce risk. Use of structured violence risk assessments enables the multi-agency professional network to formulate a young person's presentation and their violence in a holistic way and consequently develop targeted risk management plans addressing areas such as supervision, interventions and case management to reduce the risk of future violence. Of the several validated tools developed for young people, the Structured Assessment of Violence Risk – Youth (SAVRY™) is that most used by UK-based forensic adolescent clinicians. This article outlines the epidemiology, causes and purposes of violence among adolescents; discusses types of risk assessment tool; explores and deconstructs the SAVRY; and presents a fictitious risk formulation.