Demands on health and social care are growing in quantity and complexity, with resources and staffing not projected to match this. The landmark NHS Long Term Plan calls for services in England to be delivered differently through integrated care systems (ICSs) that will better join commissioners and providers, and health and social care. The scale of these changes is immense, and the detail can feel confusing. However, they are important and will affect all clinicians in the public service. This three-part series provides a primer on integrated care, explaining why it is happening, how services are changing and why clinicians should get involved. In this first article we focus on the changing demographics, and the workforce and financial resources required to address these.

Part 1 of this three-part series on integrated care discussed the drivers for change in healthcare delivery in England set out in the NHS Long Term Plan. This second part explores the evolution of mental health services within the wider National Health Service (NHS), and describes important relevant legislation and policy over the past decade, leading up to the 2019 Long Term Plan. We explain the implications of this, including the detail of emerging structures such as integrated care systems (ICSs) and primary care networks (PCNs), and conclude with challenges facing these novel systems. Part 3 will address the practical local implementation of integrated care.

In this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.

Nitrous oxide (N2O) misuse is widespread in the UK. Although it is well-known that it can cause devastating myeloneuropathy, psychiatric presentations are poorly described. There is little understanding of who it affects, how it presents, its mechanism of action and principles of treatment. We begin this article with a case study. We then review the literature to help psychiatrists understand this area and deal with this increasing problem, and make diagnosis and treatment recommendations. We describe a diagnostic pentad of weakness, numbness, paraesthesia, psychosis and cognitive impairment to alert clinicians to the need to urgently treat these patients. Nitrous oxide misuse is a pending neuropsychiatric emergency requiring urgent treatment with vitamin B12 to prevent potentially irreversible neurological and psychiatric symptoms.

Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary healthcare has been identified as essential to improving the delivery of mental healthcare. Consultation liaison is a model of mental healthcare where the primary care provider maintains the central role in the delivery of mental healthcare, with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental healthcare in the primary care setting and, in turn, improve outcomes for people with a mental disorder.

‘Collaborative care’ (involving a case manager) and ‘primary care liaison’ or ‘consultation liaison’ (with no case manager) are models of liaison psychiatry in primary care. Here, I briefly consider the evidence for collaborative care, discuss Gillies et al 's Cochrane review on consultation liaison, and suggest avenues for future study and development of liaison psychiatry in primary care.

Adjustment disorder has been included in psychiatric classifications for over 40 years but has received little attention from the research community. It is particularly common in consultation liaison psychiatry. Evaluation is problematic since it may be mistaken for major depression, generalised anxiety or non-pathological reactions to stress. Its measurement by structured interview is difficult since it is not included in many instruments and, in others, cannot be diagnosed once the threshold for another disorder is reached. There are few evidence-based treatments and it is possible that these transient reactions may not require any formal intervention. Adjustment disorder generally carries an excellent prognosis but in some individuals is associated with self-harm and suicide.

The interpersonal dynamics between patient and doctor remain a daily challenge for clinicians, and reflective practice is a tool that allows them better understanding of how patients engage with treatment. The interpersonal dynamics consultation is a form of group-based reflective practice for patients with difficult relational (interpersonal) styles. It includes the whole multidisciplinary team in a systematic consultation in order to arrive at new understanding and management plans for these patients. Interpersonal dynamics consultations have been used successfully for many years in mental healthcare, and this article has arisen from a project exploring their application in physical healthcare settings. The project works to promote effective working at the interface of physical and mental healthcare and facilitates the important translational work of making psychiatry and psychotherapeutic ideas applicable in a broader context. This article outlines the interpersonal dynamics consultation model and illustrates its use in three fictitious cases from different medical specialties.

This article summarises key areas of research informing understanding of vulnerability factors and risk assessment and management across the lifespan, with particular reference to risk to self (self-harm and suicide). It relates the discussion to people attending sexual assault referral centres (SARCs), but is applicable in a range of clinical settings. Although people accessing SARCs often present with mental health difficulties and various other vulnerabilities, SARC practitioners often do not have specialist training in working with mental health difficulties, including individuals at risk to self. We discuss developmental differences that should be considered when assessing and managing risk to self, and examine relationships between mental health difficulties, risk to self, and rape and/or sexual assault. Finally, we offer advice on how to respond to risk presented by individuals who have experienced sexual violence.

The authors summarise the evolving understanding of the neuropsychophysiology of chronic pain, including the relevance of adverse childhood experiences in facilitating it and similarities between the central physiology of chronic pain and opioid addiction. Emerging understanding highlights the importance of dopamine-expressing GABAergic neurons in the nucleus accumbens and suggests that D1 expression is associated with a sense of pleasure and approach behaviour and D2 with a sense of punishment and behavioural inhibition. Regulation of D1 and D2 expression may be mediated by nigrostriatal and medial frontal striatal pathways within the increasingly understood brain as a ‘predictive’ organ. The distinction between the predictive brain and personal ‘expectations’ and the importance of the latter for clinical outcomes are emphasised. The relevance of findings for possible future psychopharmacological treatment avenues is also presented.

Multi-agency public protection arrangements (MAPPA) have been in operation for around 18 years in England and Wales. The primary purpose is for the sharing of information between agencies regarding the risk management of offenders returning to the community from custodial and hospital settings. The legal framework regarding information by psychiatrists is not dealt with in one single policy or guidance document. Psychiatrists must use their clinical and professional judgement when engaging with the MAPPA process, mindful of guidance available from professional bodies such as the Royal College of Psychiatrists, General Medical Council and British Medical Association.

Owing to the continuing shortage of organs, the demand for transplantation outstrips supply. Liaison psychiatrists, as part of a multidisciplinary team, have a key role in the assessment of transplant candidates and participate in the decision-making process regarding ‘listing’ the patient for transplantation. Psychiatric and psychosocial factors affect prognosis post-transplantation and there are absolute and relative contraindications to transplantation. The skills of the liaison psychiatrist are employed throughout the patient's illness journey, in the pre-, peri- and post-transplantation periods.

This article aims to clarify what ‘care closer to home’ means to a community psychiatrist. Care closer to home can be operationalised as primary care liaison and the article reviews experience across England of how a liaison service can work with the recently organised primary care networks. Key competencies needed for liaising with primary care are discussed using seven questions, including bias mitigation, reducing bed-days, consultation skills, knowledge of emerging treatments and reducing administrative overheads while improving access.

In recent years, mass violence associated with men who identify as involuntary celibates (incels) has been of increasing concern. Incels engage in an online community where misogyny and incitements to violence against women are prevalent, often owing to the belief that women are denying them a ‘right’ to sex. Indeed, inceldom can be considered a form of extremism. Information released about the prepetrators of incel-associated violence consistently suggests that mental disorder is a contributory factor and may increase vulnerability to engaging with the incel community. Depression, autism and personality disorder are particularly relevant. To date, there has been little research into the mental health of incels and how, in some, this contributes to violence. This article considers the associations between mental disorder and inceldom, including the risk factors for incel-related violence, and makes recommendations for best practice in risk assessment and clinical intervention.

Measuring outcomes is becoming an increasingly standard (and highly complex) part of what mental health services are expected to do. Practising psychiatrists will need to have a good understanding of approaches to outcome measurement: used well, they have the potential to amplify the patient voice, promote good-quality services and facilitate research. We discuss what constitutes an outcome measure, the different ways that such measures can be obtained and the mechanisms for assessing the quality and appropriateness of an outcome measure. We outline the rapidly evolving research and policy context regarding outcome measurement, with particular reference to the UK's National Health Service. We also consider the potential pitfalls to outcome measurement, such as added clinical burden, inappropriate incentivisation of behaviour and incorrect interpretation of results. We discuss ways that such difficulties can be avoided or their effects mitigated.

Managing isolation protocols for distressed, cognitively impaired COVID-19-positive patients presented a range of new challenges to our liaison psychiatry for the elderly service. In this article we present some of the scenarios we have experienced, our own reflections on the needs of this specific group and how this has challenged us in terms of tolerating risk, prescribing off-label, collaborating with distressed colleagues, professional boundaries and being creative in non-pharmacological interventions.

Psychodermatology is an emerging field at the interface between psychiatry, psychology and dermatology. There is a strong bidirectional relationship between a number of dermatological disorders and psychiatric disorders. This article provides an overview of psychiatric disorders with dermatological symptoms, and dermatological disorders with secondary psychophysiological consequences. The principles of management and our insights into establishing a psychodermatology service in the UK are discussed.

We review the various functional cognitive disorders (FCDs) – complaints about memory function or another cognitive process in the absence of relevant neuropathology. These are increasingly coming to the attention of psychiatrists and neurologists and FCD encompasses some newly recognised conditions in addition to classic types such as pseudodementia and psychogenic amnesia. The clinical features, neuropsychological findings and treatment are presented and discussed.

Delusional infestation (delusional parasitosis) is a relatively rare condition but it has been of interest to a wide range of professionals, including entomologists, zoologists and dermatologists, as patients predominantly seek help from specialties other than psychiatrists. The illness requires a multidisciplinary approach and a strong bond of trust between the treating clinician and the patient to ensure the best possible outcome. This article discusses how clinicians in all specialties should approach patients presenting with the disorder and outlines differential diagnosis and associated laboratory tests. It considers the evidence base for treatment and the success of psychodermatology clinics that provide a ‘neutral setting’ for consultation to address the problem of patients’ non-engagement. Such clinics are few, and there is a need to develop disease-specific pathways in primary care and hospital settings to improve prognosis.

Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse reaction to drugs. In psychiatric practice, it is mainly associated with antipsychotics. The classic presentation is that of hyperpyrexia, muscle rigidity, mental state changes and autonomic instability. Subtle forms are difficult to recognise owing to symptom overlap with other conditions. This article discusses the clinical presentation of the syndrome, its differential diagnosis and use of supportive care, medication and electroconvulsive therapy in its treatment. It also explores prevention of NMS and reinstatement of treatment after an episode. It is stressed that all but the mildest forms of NMS should be considered a medical emergency that is properly managed in an acute hospital.