Psychiatry faces a number of external and internal challenges. At the heart of its difficulties is an identity crisis and attempts to resolve this have so far split the specialty. British psychiatry has in recent years taken an increasingly ‘neurophobic’ stance. This article argues that, despite the current situation, opportunities remain for a medicine of the mind to thrive. Neuroscientific advances in our understanding of psychiatric disorders need to be made more explicit in training and in the structure of mental health services.

This overview explains antipsychotic-induced hyperprolactinaemia and offers guidance on the management of this common and underestimated problem in general psychiatric practice.

High-dose antipsychotics are sometimes used in clinical practice when patients fail to respond to treatment at standard doses. Owing to the potential physical complications associated with this, strict adherence to physical health monitoring is essential. Challenges arise for clinicians when patients refuse to cooperate with this monitoring. We discuss different interventions to overcome this problem, many of which are coercive in nature, and consider their professional, ethical and legal implications. We include a flow diagram to assist clinicians in their documentation and decision-making in these circumstances as well as case vignettes showing when monitoring under restraint is and is not justifiable.

In this article, we explore the role of attachment in the development of medically unexplained symptoms (MUS) and response to physical illness. We review the evidence that attachment insecurity is common in people with different forms of MUS and certain long-term physical conditions. We discuss a possible developmental model for understanding how MUS develop. We conclude with discussion of potential therapies and implications for services.

Cognitive—behavioural therapy (CBT) provides a structure to inform safe and effective practice. It can be helpful for understanding and working with patients, but it can have a wider potential benefit, offering clinicians and teams a self-reflective approach to how they respond to the challenge of working in busy clinical and managerial environments.

Attention-deficit hyperactivity disorder (ADHD) is a heterogeneous neurobehavioural syndrome, complex in aetiology and presentation. It is characterised by symptoms of inattention, hyperactivity and impulsivity of varying combinations and degrees of severity. This article seeks to elucidate the different components of the assessment and diagnosis of ADHD in comparison with various differential diagnoses that must also be considered. Despite its complexities, ADHD can be effectively managed using a comprehensive approach advocated by the National Institute for Health and Care Excellence (NICE). The article discusses the combination of medication, psychoeducation and parental handling that has been shown to be effective in containing the problematic symptoms of ADHD. It also highlights the difficulties that can persist into adulthood and potential strategies to improve prognosis.

Persistent major depression that does not respond to adequate first- or second-line treatment is a common problem in psychiatry. This article updates evidence on recommended treatment strategies and reviews the prospects of more experimental approaches. The main pharmacological development in recent years has been the demonstration that several atypical antipsychotic drugs are effective adjunctive agents in improving symptoms in depression unresponsive to selective serotonin reuptake inhibitors, although their adverse effect burden is high. There is optimism about novel pharmacological strategies based on glutamatergic and anti-inflammatory mechanisms. It is important to combine drug and psychological treatments whenever possible. With persistent therapeutic engagement, the majority of patients remit eventually, but subsequent relapse remains a problem. Clinicians should pursue an active and collaborative treatment plan that makes use of all effective therapeutic modalities and continues into the relapse-prevention phase.

This article sets out the complicated and confused law on automatism and identifies the role of the psychiatrist, including paradoxically a role in cases of non-psychiatric disorder where the law requires evidence from a doctor approved under section 12 of the Mental Health Act. Legal definitions of automatism are introduced. The internal/external distinction, evidential burden, burden of proof, standard of proof, prior fault, intoxication and the degree of impairment illustrate how the courts limit the defence. Detailed accounts are given of cases in which the defence of automatism has been based on psychiatric disorder and on the effects of psychotropic drugs. Suggestions are made for approaches to assessment and medicolegal reporting.

This article summarises internet-mediated approaches to conducting quantitative and qualitative cross-sectional mental health research, and describes aspects of research design to consider for optimising scientific rigour and validity as well as response. Rapid adoption of internet-mediated approaches risks compromising the quality of the methods used. Not only can it cause distress to participants, but methodological problems may lead to inappropriate inferences being made from research findings. In this article the advantages of using internet communication for research purposes are balanced against the disadvantages, using examples of recent internet-mediated research (IMR) studies to illustrate good practice.

The past three decades in the UK have seen a prolonged experiment in community mental healthcare that has attempted to address the problem of the disgorgement of institutional psychiatry into a poorly prepared community service. The effectiveness of new ‘functionalised’ service models is considered, together with a reminder of the fundamental components of community mental healthcare and a statement of the principles that should inform future service models.

‘Depot antipsychotics' (‘long-acting injectable antipsychotic medications' or LAIs) are underused in the treatment of schizophrenia (including first episodes) and, possibly, of schizophrenia with comorbid substance use disorders. Patients' and clinicians' beliefs and attitudes, and service barriers, affect best practice and evidence-based care in LAI prescription. Poor medication adherence is a key reason for LAI prescription, but patients receiving LAIs may still relapse or experience significant side-effects. Patients' and clinicians' attitudes towards antipsychotic medication, as well as the quality of their recovery-focused relationship, are key factors in adherence. Clinicians should avoid a dichotomous ‘oral v. LAI’ choice: LAIs may have a place at various stages in the continuum of care and they should be one of the options discussed with any patient requiring long-term treatment, even early in the illness course. Many clinicians need better education about LAIs and greater familiarity with schizophrenia treatment guidelines.

Recent years have seen a dramatic increase in the advances and applications of medical imaging techniques. Tools with familiar acronyms such as MRI, EEG/MEG and PET/SPECT have provided invaluable information not only about the brain structure and function associated with psychiatric disorders, but increasingly about the mechanisms underpinning these disorders. This evolving understanding of the specific pathophysiology of mental disorder paves the way for improvement in the diagnosis, treatment and prognosis of the disorders managed in everyday clinical practice. This article gives an overview of the main neuroimaging approaches, contemporary applications of this technology to psychiatric disorder and signposts to the exciting possibilities for the future.

Diabetes is an increasingly common health problem, especially in the West, where there is an emerging epidemic of type 2 diabetes, closely related to the epidemic of obesity. Many people with diabetes struggle to optimise their diabetes control, often because they also have mental illnesses or psychological and social problems. Poor diabetes control has significant consequences for the individual, and if not addressed will result in complications that include blindness, kidney failure and even amputations. There are also consequences for health services resulting from increased admissions and emergency department presentations with diabetes-related difficulties. In the long-term, the costs associated with complications such as renal failure and amputation are high. Addressing the psychiatric and psychological barriers to good glucose control can help reduce the burden of diabetes and its complications on both the individual and the health service.

Torture remains an ongoing global problem. Many individuals who have migrated from areas of conflict and political instability have suffered some form of torture. Survivors of torture can present significant challenges to general practitioners, voluntary bodies and mental health services. This article describes the many physical, psychological and social effects of torture. An understanding of these will hopefully aid comprehensive assessment of survivors of torture by local mental health teams. Also described are the current treatment options and their evidence base.

Tolstoy's life and work illustrate resilience, the transcendence of trauma and the enduring impact of childhood loss. I have chosen the famous oak tree passage from War and Peace to illustrate recovery from the self-preoccupation of depression and the theme of ‘eco-spirituality’ – the idea that post-depressive connectedness and love apply not just to significant others but also to nature and the environment.

Most individuals who have lived in foster homes, residential care or adoptive families for substantial periods (‘people affected by public care or adoption’) show normal psychological adjustment as adults, although rates of mental disorders, hospital admission and suicide are increased. Research focusing on the experiences of this group of people can help professionals better understand their behaviour and attitude towards help. Psychiatric symptoms can be multifaceted, including complex trauma presentations. The specific mental health needs of this population are increasingly being recognised in child and adolescent mental health services but less so in adult services. In this article we describe life experiences of people affected by public care or adoption, examine the lifelong impact of these experiences on mental health and functioning, and offer practical suggestions for clinical work with them.

Over the past decade, important research has been performed into the therapeutic use of dihydrocodeine, injectable opioids (diamorphine) and supervised disulfiram in addiction treatment. There have also been interesting developments regarding baclofen for alcohol problems and use of stimulants in adult Attention-deficit hyperactivity disorder (ADHD). However, evidence for the effectiveness of medication to promote alcohol abstinence remains modest at best.

Serotonin syndrome (serotonin toxicity or serotonin toxidrome) is a potentially serious and theoretically predictable reaction that appears to be rarely diagnosed in practice in the UK. Some symptoms of serotonin syndrome overlap with features of other presentations in psychiatry and thus may be misattributed to mental illness (‘diagnostic overshadowing’). Further, there may be diagnostic dilemmas in patients on combinations of drugs, those receiving drugs with previously unknown serotonergic properties or where there are drug interactions. Prescriber vigilance and holistic review of the patient, including the pharmacotherapy, may be helpful in avoiding progression of serotonin syndrome to more serious outcomes.