Chronic fatigue syndrome (CFS) is syndrome of unremitting fatigue of at least 6 months' duration that causes significant disability. Exercise therapy has a proven track record in medicine and could be effective for some patients with CFS. An updated Cochrane review of eight studies appeared to suggest that exercise helps fatigue symptoms, but with only a small probability of recovery and/or improvement in daily function. Provisional data on acceptability suggest that most patients are willing to participate. However, one key study (PACE), which was well powered and influential in the Cochrane review, has been met with considerable controversy owing to lack of clarity on outcomes. Following release of the PACE study primary data, re-analysis suggested smaller effect sizes than initially reported.

Microdeletion syndrome is an important topic in intellectual disability, associated with various psychiatric symptoms, such as autism, attention deficit, hyperactivity, obsession and compulsion, and psychosis. In this article, we provide a clinical update on the following syndromes and their associated psychiatric disorders: Prader–Willi syndrome, Angelman syndrome, Williams syndrome, Wolf–Hirschhorn syndrome, cri du chat syndrome, DiGeorge syndrome and Rubinstein–Taybi syndrome.

Medications prescribed by psychiatrists are known to elevate serum prolactin levels, but hyperprolactinaemia remains underrecognised, as the adverse effects of an elevated prolactin are mostly not visible. Hyperprolactinaemia can lead to adverse health outcomes, so clinicians need not only to be alert to its symptoms, but to manage the consequences as well. In this article we provide a brief overview of prolactin physiology, regulation and function. We list various factors that can lead to elevated serum prolactin. We discuss the interpretation of blood results and the management of psychotropic-induced hyperprolactinaemia. We include a flow diagram to assist clinicians in decision-making in the clinical management of hyperprolactinaemia.

The adjective ‘comorbid’, and its fellow noun ‘comorbidity’, are used repeatedly in psychiatric practice, but we frequently use them sloppily and ignore what they really mean. Here, I briefly define comorbidity of disorders, and suggest the alternative categories of consanguinity and co-occurrence.

Psychiatry uses some of the most controversial treatments in medicine. This may be partly because several are administered under coercion and opposed to the patient's expressed will, under the protection of the relevant mental health legislation. Electroconvulsive therapy (ECT) is perhaps the archetypal controversial treatment; although it is considered to be effective, the research supporting it is much less impressive than one would expect. The prescription of stimulant drugs for childhood attention-deficit hyperactivity disorder (ADHD) and substitution therapy (such as methadone maintenance) in addictions treatment remain topical and appear to be subject to political interference. ‘Treatment’ for homosexuality and psychosurgery were common in the past but are now rare. These issues are discussed to give insight into how once common controversial treatments can decline and become obsolete. However, seclusion and covert medication remain in practice and are highly scrutinised.

Carer stress is well documented, especially in those caring for individuals with dementia. A recommendation of all national dementia strategies is to provide excellent support and information to informal carers of people with dementia. NICE guidance suggests that a range of tailored interventions, including psychological input, psychoeducation and training courses, should be offered to reduce caregiver burden and stress, although good-quality outcome-based evidence is lacking. On the basis of a narrative review of the literature, we describe individual and multicomponent carer support packages and discuss their evidence base, reflecting on outcomes for carers. Multicomponent interventions have the best evidence for effectiveness.

This article examines the concept of moral responsibility in psychopathy. In doing so it shows how philosophical ideas can be used to help approach a complex issue in psychiatry. Building on a fictitious case, we explore two arguments: the exempting view, which proposes that psychopaths lack any ability to function as moral agents; and the mitigating view, which concedes that there are impairments in moral understanding in psychopathy, but takes these to be insufficient to be completely exempting, instead concluding that such individuals are at least partially morally responsible. Typically, clinicians (and the courts) are more comfortable with a mitigating view, whereas philosophers tend to extol an exempting view. Through discussion of the case, we illustrate the value that philosophy brings to clinical psychiatry and the ways in which psychiatry can enrich philosophical debate.

Parity of esteem means valuing mental health as much as physical health in order to close inequalities in mortality, morbidity or delivery of care. There is clear evidence that patients with mental illness receive inferior medical, surgical and preventive care. This further exacerbated by low help-seeking, high stigma, medication side-effects and relatively low resources in mental healthcare. As a result, patients with severe mental illness die 10–20 years prematurely and have a high rate of cardiometabolic complications and other physical illnesses. Many physical healthcare guidelines and policy recommendations address parity of esteem, but their implementation to date has been poor. All clinicians should be aware that inequalities in care are adversely influencing mental health outcomes, and managers, healthcare organisations and politicians should provide resources and education to address this gap.

Quality improvement (QI) offers a route to transforming care delivery at the scale and pace needed to ensure sustainability in the National Health Service. However, it is a complex endeavour with numerous challenges to consider, and it takes time. There are many ways of understanding quality and QI in healthcare, and it is important for doctors to develop knowledge of the core principles of QI, which increasingly feature in clinical settings and in training curricula for healthcare professionals.