Psychiatric out-patient services originated in the early-20th century to enable triage of new referrals to the asylum in order to differentiate between treatable and untreatable cases. They evolved to provide community follow-up of patients discharged from hospital and assessment of those newly referred to psychiatric services. Non-attendance at out-patient appointments represents an enormous waste of clinical and administrative resources and has potentially serious clinical implications for those who are most psychiatrically unwell. The place of out-patient clinics in modern community mental health services is explored with reference to the reasons for, and clinical and cost implications of, missed appointments. An alternative model is described that incorporates recent UK government guidance on the roles and implementation of community mental health teams, liaison with primary care and new roles for consultant psychiatrists.

This article reviews how data on the benefits and hazards of antidepressants have been analysed, and how conclusions drawn from these analyses conflict with the data. Randomised trials of antidepressants have for two decades consistently shown evidence of an increased risk of suicidal acts on active treatment compared with placebo, but an inappropriate application of significance testing has led to this evidence being dismissed. During the same period a minority of antidepressant trials have produced data indicative of benefits that have reached statistical significance at a 95% level. In this case significance testing appears to have led to an unrealistic impression of the likely benefits of treatment in practice. Current approaches to evidence-based medicine risk perpetuating misunderstandings of this type. Against a background of current developments in healthcare delivery, clinicians might need to reconsider how they handle and present clinical trial data.

The author explores key issues related to psychotherapeutic work with people who self-harm. Particular attention is given to the powerful countertransference feelings that practitioners often experience in this work and the importance of managing these. Rather than maintaining a detached distance, therapists should emotionally engage with the patient's experience, creating a unique therapeutic relationship. The common patterns, functions and meanings of self-harm are discussed, with clinical vignettes that highlight the underlying dynamics of the behaviour. Self-harm is a survival stratagem, and methods for helping patients to find other ways to cope are suggested. One such is mentalisation, which can enhance the patient's capacity to think, not impulsively act. If patients learn how to assess more accurately their own and other people's states of mind, less destructive behaviours can emerge.

Behavioural phenotypes are patterns of behaviour that present in syndromes caused by chromosomal or genetic abnormalities. They have both physiological and behavioural manifestations with distinctive social, linguistic, cognitive and motor profiles. Their course is not static. Presentation typically varies according to level of learning disability and a host of environmental, developmental and therapeutic influences, and it changes with increasing age.

Physical symptoms with no medical explanation are commonly experienced by healthy people and those attending clinics. Psychiatrists see such patients in liaison settings and clinics for those with psychotic and affective disorders. The pathophysiology remains obscure; physical investigations are usually performed to exclude pathology rather than elucidate dysfunction. However, modern neuroimaging has allowed the study of nervous system structure and function. Although there are few diagnostically specific findings, patterns of association have emerged: where action is impeded (certain forms of conversion disorder and chronic fatigue syndrome) frontal systems of the brain are often implicated; when subjective awareness of the body is disturbed (passivity phenomena and anorexia nervosa) temporo-parietal cortices appear to be dysfunctional. The caudate nuclei (components of the frontal executive circuit) are implicated in a variety of syndromes (including body dysmorphic disorder, somatisation and chronic fatigue). The brain may be viewed as a cognitive neurobiological entity, crucially oriented towards action (for survival). Psychiatric syndromes that have an impact on bodily awareness signal dysfunction within systems representing that body and its performance in time and space.

The purpose of this first article of four addressing the electronic approaches to psychotherapy (e-therapy) is to introduce the equipment (computers) and systems (the World Wide Web and the internet) involved. I describe some of their many elements (e.g. bits and bytes), uses (such as search engines, email, web mail) and a few abuses (e.g. spam, spyware).

The world wide web has many advantages for the psychotherapist and for the client, but it poses new challenges too. This article considers both in relation to information, disinformation and information overload; openness and availability of information; and the anomalies of being present, and able to meet other presences, in virtual space but with no physical body and with an identity that may be created for the occasion.

This review focuses on screening and assessment in general psychiatric settings, where drug use is unlikely to be known to service providers. It builds on the recurrent finding that psychiatric patients are at high risk of substance misuse. The application of self-report questionnaires and rating scales and more in-depth assessment instruments is outlined, as are biological screening techniques. The use of brief self-completion questionnaires probably offers the most practical approach to routine screening by non-specialist staff in general hospital settings. The importance of implementing such tools lies in reaching an accurate diagnosis, choosing treatments more appropriately and monitoring the management of patients' psychiatric disorders.

With fundamental changes to the way services are commissioned and resourced within the UK's National Health Service (NHS), optimising the efficient and effective use of resources has become a key task for mental health clinicians and managers. A core step in this process is ensuring that resources are optimally allocated across the service. This article outlines steps in resource allocation, including understanding how resources are managed through budgets, the link between resource matching and care delivery, and methods of reallocating resources to improve service performance. Influencing appropriate allocation is a critical role for psychiatrists, working with both managers and commissioners in the decision-making process. Understanding resource allocation from a management perspective should improve the ability of psychiatrists to influence this process more effectively.