Significant evidence has accrued suggesting that the hypothalamic–pituitary–adrenal (HPA) axis plays a role in some psychiatric disorders. This article reviews the physiology of the HPA axis, evidence of dysfunction in this axis in psychiatric illnesses and the role that this dysfunction might play in pharmacological treatment resistance. Future therapeutic strategies that may potentially arise from these researches are briefly outlined.

In the search for antidepressant drugs with enhanced efficacy, targeting the hypothalamic–pituitary–adrenal (HPA) axis is a valid strategy. This commentary critically summarises the evidence for the efficacy of antidepressant drugs targeting the HPA axis, and concludes that the available clinical trials do not support claims that this class of drugs is superior to existing treatments.

Around 7.1 million people in England drink hazardously or harmfully and a further 1.1 million are dependent on alcohol. Motivational interviewing is widely used to treat people with alcohol problems and is probably the best described example of a brief intervention. However, some recent trials have been disappointing. Specialised alcohol treatment services have also suffered from weakness in the evidence base. Investment in treating alcohol misuse has fallen far behind that for drug misuse. The Department of Health's Alcohol Harm Reduction Strategy for England embraces policies that are high-profile and cheap but are ineffective and ignore many effective measures. It recommends stepped care for alcohol treatment, but unlike the equivalent for drugs treatment, it sets no targets and leaves the small (7%) increase in funding to the discretion of local purchasers. UK spending on specialised treatment for drug misuse is estimated to be around £600 million for 2007 – around three times the estimated cost of treatment for alcohol misuse.

Alcohol policy varies in different jurisdictions and is subject to change. Understanding policy development requires an international perspective. Current models of alcohol treatment systems require an understanding of the different impacts of interventions on different patient groups and clarity in the description of interventions and populations. Several systematic reviews have evaluated the outcome of alcohol treatment favourably and shown it to be highly cost-effective.

Violent behaviour in people with a psychiatric disorder causes great public concern and leads to stigma for people with mental illness. There is good evidence for a correlation between schizophrenia and increased rates of violence but any association between mood disorders and violence has been comparatively overlooked. It appears that there may be more evidence relating mood disorders and violence than many clinicians realise. This article highlights the difficulties in assessing this, summarises what is known and discusses what this means for clinical practice.

A series of psychoanalytic theorists and clinicians have suggested that conflicts about anger play a central role in the development of depression. Research data have supported the notion that patients struggle with the experience and expression of angry feelings. Anger in people with depression often stems from narcissistic vulnerability, a sensitivity to perceived or actual loss or rejection. These angry reactions cause intrapsychic conflicts through the onset of guilt and the fear that angry feelings will disrupt relationships. These conflicts lead to anger being directed inwards, further lowering self-esteem, creating a vicious cycle. Defence mechanisms that are triggered, including passive aggression, reaction formation, denial and identification with the aggressor, are ineffective at managing these conflicts and further prevent the appropriate expression of anger. This article discusses how to identify and detoxify angry feelings and fantasies using a psychodynamic approach.

The classification of depression has been debated for decades. The introduction of operational criteria and the category of major depression were significant advances in the 1970s. However, the validity of the major depression category is controversial. The article highlights the limitations of using severity criteria and cross-sectional evaluation to diagnose depression. It recommends the classic typologies (melancholia, dysthymia and adjustment disorder) for clinical presentations of depression, highlighting the need to use longitudinal clinical patterns and context for diagnosis. Major depression owes its success to its loose definition, to the subordinate status of adjustment disorders and dysthymia and to the mechanistic application of the diagnostic hierarchy and criteria. There is a need to focus more on the context of depression (stress, coping and support) and to reduce the medicalisation of distress.

Cinema is at once a powerful medium, art, entertainment, an industry and an instrument of social change; psychiatrists should neither ignore nor censor it. Representations of psychiatrists are mixed but psychiatric treatments are rarely portrayed positively. In this article, five rules of movie psychiatry are proposed, supported by over 370 films. Commercial and artistic pressures reduce verisimilitude in fictional and factual films, although many are useful to advance understanding of phenomenology, shared history and social contexts in psychiatry. Acknowledging some negative representations, three areas are explored where cinema gets it mostly right: addictions, bereavement and personality disorder. Although there are excellent representations of psychosis on film, film-makers have more often portrayed it violently – ultimately demonising people as psychokillers in more than 100 films cited. When people with mental illness are stigmatised through stereotypes, examining unwelcome depictions can uncover important truths. Psychiatrists' engagement with film will ensure professional and artistic gains.

Psychostimulants (dexamphetamine, methylphenidate, modafinil) reduce fatigue, promote alertness and wakefulness, and have possible mood-enhancing properties. In modern psychiatric practice, their use has been limited to attention-deficit hyperactivity disorder and sleep disorders such as narcolepsy. Despite this, research has continued into psychostimulant use in general psychiatry, especially in the treatment of depression and fatigue. This article reviews the recent literature regarding psychostimulant use in general and consultation-liaison psychiatry. Although psychostimulants continue to attract clinical research, there is currently not enough evidence to recommend their routine use for general psychiatric conditions.

Chronic physical illness is a significant risk factor for psychological symptoms, psychiatric disorder and suicide. Properly targeted cognitive–behavioural therapy (CBT) can improve outcomes for people with chronic physical illnesses. This article looks at practical aspects of the use of CBT as part of the overall medical and psychiatric management of chronic physical illness.