The role of mental health review tribunals is to oversee that standards of care and treatment are maintained for involuntary patients and for those on community treatment orders. This article considers some ways in which the basic principles of psychotherapy can be applied by tribunal members to offer patients a sense of hope, encouragement and optimism and reduce the emotional challenge of the tribunal review.

Many authors have considered the ethical dilemmas of a doctor being both the treating physician and expert witness in litigation. The debate has often focused on the potential for bias and the adverse impact being an expert witness can have on the therapeutic alliance. Much of this debate seems rooted in the ethic of non-maleficence. In this article we attempt to examine the other end of this ethical quandary. Using a pragmatic approach, we explore these conflicts and consider biases from other sources. Ultimately, taking on the mantle of both roles is becoming increasingly unavoidable. Hence we argue that, although there are challenges, embracing this dual role can be an important part of holistic treatment, risk management and the pursuit of the ethical principle of justice.

Recent years have seen a rise in media coverage as well as demand for specialist attention-deficit hyperactivity disorder (ADHD) assessments in adults and children. This article explores the challenges in the diagnostic process for adult ADHD, amidst much misinformation and controversy. In doing so, we look at the social model of ADHD; a glossary of terms to better understand lived experience; underdiagnosis and misdiagnosis; and the fallacy of the ‘high functioning’ label. We propose the use of co-production to bridge the gap between the medical and social models. We conclude with suggestions for future research. The article includes anonymous contributions from doctors with ADHD.

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.

Faster internet speeds and ever-present mobile phones present a new challenge to psychiatric wards – the ability for patients to live stream their in-patient stays. What are the benefits and the risks to the patient streaming and the ward as a whole? This article is to help start a conversation about this unique problem and how health professionals might go about addressing it.

Professionals, patients and patient organisations have advocated for the renaming of ‘schizophrenia’, seeing the term as misleading, stigmatising and a barrier to specialised care. In countries where a name change has occurred (e.g. Japan), the advantages of renaming seem to far outweigh disadvantages. Nevertheless, a name change would be a long and complex process that would not be useful if it were not accompanied by parallel changes in legislation, services and the education of professionals and the public.

This reflection summarises the evidence regarding the management of bipolar II disorder in the perinatal period, compares this to the authors’ clinical experience using case studies and considers the treatment of patients in current clinical practice.

If a Mental Health Act section 136 lapses at 24 h because no in-patient bed is available, the legal grounds to continue holding an individual in the place of safety are dubious. Duty of candour and a senior clinical review are essential. The use of common law and the Mental Capacity Act have limitations, the latter also raising a question about whether deprivation of liberty safeguards would also apply. Clarity of this dilemma is needed through legislation.

Acute behavioural disturbance is relatively common during the perinatal period. The management of agitation in pregnant women is similar to that in the general population, although with some additional considerations, such as modifications to restraint techniques, careful medication selection, monitoring of maternal and fetal well-being and the importance of a debrief. There are benefits of agreeing a pre-determined care plan for women who are at risk.

Rapid retitration of clozapine may be necessary to reduce the known high risk of mental state destabilisation in patients who have had a 48 h treatment break. It may carry a high risk of complications, including seizures and myocarditis. We reflect on the literature on standard and rapid retitration and present a case of rapid retitration in the community. In this case, of a 54-year-old homeless man with treatment-resistant schizophrenia and polysubstance misuse, we safely retitrated clozapine in a community setting four times during a 6-month period; each retitration was completed over 4 days. We used a specific protocol based on his psychiatric history. We are now more confident in delivering clozapine retitration to other patients, thus preventing unnecessary admissions.

Effective communication skills are essential for all healthcare professionals. Specialist teaching on communicating with people with intellectual disabilities is often lacking, resulting in poorer healthcare and worse outcomes than in the general population. Working with professionally trained actors with intellectual disabilities, we developed an interprofessional workshop that sought to provide authentic communication skills training to enable healthcare students from various disciplines to communicate effectively with patients of all abilities. In a survey, students reported that they found the workshops rewarding and confidence-building, and that they learnt more about the roles of their interprofessional colleagues.

Dissociation is a common and often overlooked symptom in traumatised children. Although there is a lack of a scientific consensus as to the nature of dissociation and very limited research about dissociative identity disorder (DID) in children, the authors have seen children given this diagnosis recently referred to their clinic and are concerned about this practice and the parenting approaches that have ensued. The diagnosis of DID in children may be rare or of doubtful validity, but repeated traumatic experiences of an interpersonal nature can have a profound effect on a child's identity, memory and self-organisation. Furthermore, abuse and neglect can increase the risk of dissociative symptoms. This brief article considers dissociation in post-traumatic stress disorder, then outlines developmental factors hypothesised to be associated with dissociation in childhood and early adulthood. It warns that clinicians should keep an open mind about how dissociation may manifest transdiagnostically, and concludes with recommendations for further research.

This brief article describes the main health indicators of Brazil and gives an overview of psychiatric care. It points out the primary pitfalls of the mental healthcare system and presents some suggestions for the future of mental health in the country.

Mind–body dualism is often considered to be incompatible with modern psychiatry for two reasons. First, it is claimed that dualism is falsified by recent advances in neuroscience. Second, dualism is thought to lead to an unhelpful attitude towards patients and their illnesses. I reflect on and challenge both lines of thought and argue that there is no inherent conflict between dualism and psychiatry.

This reflection presents a discussion of some common measures of variability and how they are appropriately used in descriptive and inferential statistical analyses. We argue that confidence intervals (CIs), which incorporate these measures, serve as tools to assess both clinical and statistical significance.

The widespread nature of child sexual abuse is increasingly recognised and in the public domain following high-profile cases. Children and vulnerable people need protecting from such abuse. At the heart of the dilemma facing clinicians is the need to feel supported by the legislative framework to maintain confidentiality and use their clinical discretion in the best interests of their patients, ensuring that they receive the help they need, but also protecting others at risk. There are compelling arguments both for and against strengthening legislation to improve child protection.

Stress is the most important proximal precipitant of depression, yet most large genome-wide association studies (GWAS) do not include stress as a variable. Here, we review how gene × environment (G × E) interaction might impede the discovery of genetic factors, discuss two examples of G × E interaction in depression and addiction, studies incorporating high-stress environments, as well as upcoming waves of genome-wide environment interaction studies (GWEIS). We discuss recent studies which have shown that genetic distributions can be affected by social factors such as migrations and socioeconomic background. These distinctions are not just academic but have practical consequences. Owing to interaction with the environment, genetic predispositions to depression should not be viewed as unmodifiable destiny. Patients may genetically differ not just in their response to drugs, as in the now well-recognised field of pharmacogenetics, but also in how they react to stressful environments and how they are affected by behavioural therapies.

The nature of culpability and agency in patients with a variety of psychiatric diagnoses is complex. In this article, a psychiatry resident (specialty trainee in psychiatry) reflects on a clinical encounter in medical school to demonstrate some of the benefits (including the removal of stigma) and dangers (including the threat to patients’ agency) of using the medical model to conceptualise psychiatric illness.

Debates on dualism continue to plague psychiatry. I suggest that these debates are based on false dichotomies. According to metaphysical physicalism, reality is ultimately physical. Although this view excludes the idea of entities distinct from physical reality, it does not compel us to favour neural over psychological interventions. According to methodological dualism, both physical and mental interventions on the world can be deemed effective, and both perspectives can therefore be thought to be equally ‘real’.

Psychiatrists are wanting in Sweden and many other countries. Among Swedish efforts to improve specialist training in psychiatry and to make a future psychiatric career attractive is a national course-based project named METIS. An evaluation of METIS courses run between 2007 and 2012 revealed that, in parallel with the initiative, the number of doctors obtaining proofs of specialist competence in psychiatry increased by more than a third. This article outlines current specialist training in Sweden and describes how the 40-hour METIS programme fits within it.