Health reform in America will lead to major changes in medical care in the USA, with opportunities for improved access to care, especially for psychiatric patients. Combined with recently enacted ‘parity’ legislation, health reform will expand public and private insurance coverage to an additional 33 million Americans, leading to increased pressure on the psychiatrists who are willing to practise with the insured population and on opportunities for subspecialisation within the field. Some essential non-medical tasks will not be funded by insurance, and these must be given due consideration. A major emphasis of health reform is to integrate general health and mental health services. The reform will have an impact on the use of the hospital and emergency room as well. A major concern is the cost of care and how it will be controlled.

Major depression and bipolar disorder in children and adolescents are serious conditions associated with considerable morbidity as well as increased risk of suicide. The treatment of depression in young people is currently controversial and this article reviews the evidence base and potential risks and benefits of antidepressants. Although the diagnosis of bipolar disorder is also controversial, medication is the first-line treatment of choice in cases that meet diagnostic criteria. The limited evidence base in children and adolescents is presented, along with current treatment guidelines. Despite the controversies in this field, this article concludes that medication remains an important part of the treatment approach for both disorders, although the risks and benefits of pharmacotherapy need to be carefully assessed in each patient.

Issues pertaining to the medical treatment of children and young people can be both complex and emotive for all involved. At such times the courts may be asked to intervene and decide. Cases invariably need to consider issues of capacity to consent and treatment under best interests. Furthermore, such cases inevitably have human rights aspects. This article analyses the diverse role of the Human Rights Act 1998 in these cases and illustrates key underlying Human Rights Act principles that can be applied in clinical practice.

Very little attention has been paid to the invisible epidemic of substance misuse among older people in the UK. This article looks at the prevalence of substance misuse in the people over the age of 60. The reasons for difficulty in diagnosing substance misuse are explored and ways to improve diagnostic ability are discussed. Substance misuse leads to severe physical and psychiatric morbidity that is being managed by meagre resources. The article provides recommendations on specific issues related to interventions, biological and psychosocial, and training of psychiatrists.

The deprivation of liberty safeguards were introduced into the Mental Capacity Act in 2008 to enhance the protection of adults in residential homes or hospitals who lack capacity in relation to their care arrangements and who are or may be deprived of their liberty. Deprivation of liberty itself is an imprecise concept and there may be difficulty in applying the appropriate authority where there is a choice between the Mental Capacity Act 2005 and the Mental Health Act 1983. Therefore, this article explains the evolution of mental capacity legislation and the concept of deprivation of liberty, how it may be recognised, prevented and authorised by deprivation of liberty safeguards, along with some of the interface issues with the Mental Health Act 1983.

The deprivation of liberty safeguards apply to England and Wales. In Scotland, trends and uncertainties in the use of welfare guardianship (the equivalent action under Scottish law) provide a useful comparison. In both jurisdictions, there are risks to the rights of individuals.

Mental capacity refers to a person's ability to make decisions, which may include consenting to medical treatment. People are presumed to have this capacity. Individuals may lack capacity because of an impairment or disturbance that affects the way their mind or brain works. Legal frameworks are in place for acting and making decisions on behalf of individuals who lack the mental capacity to do so for themselves, in their best interests. A case illustration is used to outline the principles involved under the Mental Capacity Act 2005 for England and Wales. We describe in detail the assessment of capacity to consent to treatment in this case and good practice in making best interests decisions in everyday clinical practice.

This article reviews the literature on advance statements, including current mental health law and guidance in England and Wales, ethical and practical advantages, disadvantages and barriers to implementation. The idea of planning psychiatric treatment for a time when mental capacity may be impaired is not new. Yet there has been a renewed interest following the introduction of the Mental Capacity Act's 2005 provision of legally binding advance decisions to refuse treatment. In addition to information on treatment refusals, advance statements provide information on treatment preferences and personal care instructions which, although not legally binding, should inform treatment decisions. Advance statements are not yet widely used, but existing limited evidence suggests that they could reduce coercion and improve service users' satisfaction with treatment.

Advance statements in Scotland have a specific legal meaning and come into effect when someone is subject to the Mental Health (Care and Treatment) (Scotland) Act 2003. This Act requires a person being compulsorily treated to have significantly impaired decision-making ability in respect of medical decisions. The advance statement is intended to cover treatment wishes – both refusal and acceptance of treatment. In addition, a personal statement can be made which covers wider issues. There is evidence that in many statements these are being combined, raising questions about what is meant by treatment. Issues of revoking advance statements are also considered.

Mental health services are increasingly expected to engage in a process of cultural change to fulfil guiding values and hopes for choice, personalisation, self-determination, social inclusion and personal recovery. It is unclear how this will be achieved. This transformational agenda also engages with an ambition for progressive change in practice across mental health professions to support people in self-care and self-management, based on a new relationship between practitioners and users of mental health services. There is little consistent guidance on the content of recovery-oriented and socially inclusive practice and what may be the new competencies and skills that would most effectively support recovery outcomes. Life coaching to support recovery for people with mental health needs is emerging as a creative possibility with considerable potential to support this ambition. This is an exploratory article which offers an overview of experience so far, suggests further routes for development and, in line with the College's Fair Deal campaign, underlines the need for evaluation.

In making treatment decisions, psychiatrists, like other medical professionals, must adhere to rules of ethical medical conduct. They may also need to negotiate the legalities associated with detention and treatment against a patient's wishes. The growth in guidance produced by organisations such as the National Institute for Health and Clinical Excellence has added further complexity. Practitioners are increasingly required to consider cost-effectiveness in their treatment decisions and this can appear to conflict with the principles of medical ethics. With particular reference to mental healthcare, this article attempts to answer two questions: Is economic evaluation unethical? And are the methods of economic evaluation unsound for the purpose of achieving an ethical distribution of resources?

This commentary focuses principally on the semantics of using the term ‘mental health’ rather than ‘mental illness’ and the effect this has in creating a paradigm shift in psychiatry in relation to other medical specialties. The consequences, intended or unintended, are demonstrated and the relationship between ethics and economics in mental health is discussed. The view that economic evaluation is methodologically unsound in ‘mental health’, that it is a special case because of its complexity, does not acknowledge the significant paradigm shift that has occurred. Casual acceptance of the term ‘mental health’ in a serious economic debate about resources for people with mental illnesses is worrying and further diminishes the medical specialty of psychiatry that deals with mental diseases.