The subdivision of the class of antipsychotic drugs into two discrete groups – ‘conventional’ (or first generation) and ‘atypical’ (or second generation) – has been adopted as standard, with the latter generally accepted as ‘better’ and widely recommended as automatic first-line choices. However, this perception has been thrown into confusion with the results of large pragmatic trials that failed to identify advantages with the new, more expensive drugs, while identifying worrying tolerability issues. This article explores the origins of ‘atypicality’, its construction on the back of a confusing and weak clinical validator (diminished liability to promote parkinsonism) and how even in relation to the archetypical atypical, clozapine, the uncertain boundaries of drug-induced extrapyramidal dysfunction may be contributing to confusion about ‘efficacy’ and ‘tolerability’. It argues that abandoning atypicality would open up clinical practice to all drugs of a single class of ‘antipsychotics’ and allow for individualised risk/benefit appraisal as a basis for truly tailored treatment recommendations.

Men are a numerical minority group receiving a diagnosis of, and treatment for, depression. However, community surveys of men and of their mental health issues (e.g. suicide and alcoholism) have led some to suggest that many more men have depression than are currently seen in healthcare services. This article explores current approaches to men and depression, which draw on theories of sex differences, gender roles and hegemonic masculinity. The sex differences approach has the potential to provide diagnostic tools for (male) depression; gender role theory could be used to redesign health services so that they target individuals who have a masculine, problem-focused coping style; and hegemonic masculinity highlights how gender is enacted through depression and that men's depression may be visible in abusive, aggressive and violent practices. Depression in men is receiving growing recognition, and recent policy changes in the UK may mean that health services are obliged to incorporate services that meet the needs of men with depression.

Adult patients with medically unexplained symptoms (somatisation) in primary care are numerous and make disproportionately high demands on health services. Most of these individuals are open to the suggestion that their illness reflects psychological needs. Empowering explanations from doctors can enable patient and doctor to work collaboratively in managing the problem and can reduce healthcare contacts. Parental medically unexplained symptoms, sexual and physical abuse in childhood and childhood neglect are associated with a greater risk of medically unexplained symptoms in adulthood. The overall prognosis for the majority of primary care patients with medically unexplained symptoms is very good. The two most common approaches to dealing with medically unexplained symptoms in primary care are stepped-care approaches and teaching general practitioners new skills to manage consultations more effectively.

The importance of mental health to our social, financial and physical well-being has gained better recognition in recent years. The work of psychiatry is to understand, prevent and treat mental illness, and should therefore be of compelling interest to the public. Yet few care about the profession or practice of psychiatry other than psychiatrists themselves. The public and the profession would both benefit from a ‘conversation’ about practical, moral and political aspects of contemporary mental health. This should be a dialogue of equals, distinct from didactic approaches to ‘public education’ or from a ‘media psychiatry’ that exists primarily to entertain. This discourse would help to improve care, diminish stigma, promote recovery and improve the status of the profession itself. This article proposes that this kind of ‘public psychiatry’ should take its place as one of four interdependent professional domains.

We consider the value of dialogue between healthcare professionals and mental health service users with severe mental illnesses. Discussion with the service user before, during and after a psychiatric crisis should help services to offer choice even to individuals under compulsory detention.

The management of anxiety and depression in primary care presents significant issues for workload and understanding the patient in terms of a bio-psychosocial model. There is no shortage of policy in this area, but finding effective and innovative ways of implementing that guidance is only just beginning. This article discusses some of the ways that implementation is happening for adults of working age.

A formal therapy for depression, behavioural activation focuses on activity scheduling to encourage patients to approach activities that they are avoiding and on analysing the function of cognitive processes (e.g. rumination) that serve as a form of avoidance. Patients are thus refocused on their goals and valued directions in life. The main advantage of behavioural activation over traditional cognitive–behavioural therapy for depression is that it may be easier to train staff in it and it can be used in both in-patient and out-patient settings. This article describes the theory and rationale of behavioural activation, its evidence base and how to develop a formulation that guides the strategy.

Michael Smith's article considering the present and future of ‘public psychiatry’ assumes the continued existence of psychiatry following a conversation with the public. But what if the public does not want psychiatry?

In all areas of medicine there is increasing awareness that patients need information that is clear, relevant and appropriately timed. This is obviously connected with ethical concerns of patient dignity and autonomy, but it also underpins the principle of informed choice. It is not possible to make an informed choice about how you want a problem to be managed, if you do not have the relevant information. Doctors have, historically, been poor communicators of such information. Although, on the face of it, this seems a straightforward issue to rectify, there are a surprising number of practical problems to be addressed before such communication can become a reality in daily practice.

Do men comprise a minority group whose distress would be better understood by positing a new ‘male depressive syndrome’? Or have gender differences been overemphasised for political reasons that are clinically unhelpful? An unedifying list of mistaken categories of depression advocates caution.

Many health professionals feel ill-equipped to deal with the complex needs of asylum-seekers and refugees. This article offers an overview of the literature, and reviews the demography, epidemiology and causes of mental illness in refugee and asylum-seeker groups. It discusses the types of service configurations and service response that would be appropriate. It highlights the findings of the Royal College of Psychiatrists' consensus team and their position statement on the treatment of refugees and asylum-seekers. It finishes with some thoughts about what clinicians can do to improve their treatment. Clearly, there is a need for more training, education and service development.

Expert witnesses have recently had a bad press but they have long played an important role in the administration of justice. This article begins by drawing attention to the guidance of the UK Academy of Medical Royal Colleges for medical expert witnesses and then sets out the latest guidance for experts in civil cases.

This guide to the neurological disorder cerebral autosomal dominant arteriopathy with subcortical infarcts and leuco encephalopathy (CADASIL) is specifically targeted at psychiatrists. The aims are to enhance awareness, provide educational clinical information and offer practical guidance on management of the disorder. An overview of diagnostic algorithms and recent research is also provided.

From the standpoint of primary care, mental health services in the UK now appear very fragmented. We have to address the problems of working across interfaces as they continue to multiply. There is now a considerable evidence base relating to what works at the interface between psychiatry and primary care. Psychiatrists should consider the challenge of adopting new ways of working in the management of anxiety and depression in partnership with primary care.

He could not die when trees were green,
For he loved the time too well.
His little hands, when flowers were seen,
Were held for the bluebell,
As he was carried o'er the green.

Psychiatrists reporting in criminal cases in England and Wales are now governed by the Criminal Procedure Rules on expert evidence and these will require changes to the format and content of psychiatrists' reports in criminal proceedings. This article sets out the new rules and also draws attention to additional requirements made by the Court of Appeal and, when instructed by the police or the Crown Prosecution Service, by the Crown Prosecution Service. It also draws attention to the report of the Scoping Group on Court Work of the Royal College of Psychiatrists.

How is it possible not to grow hard,
To build a shell around yourself when you
Have to watch so much pain, and hear it too?
Many you see are puzzled, wounded; few
Are cheerful long. How can you not be scarred?

The Disability Discrimination Act, passed by Parliament in 1995 and amended in 2001 and 2005, covers people in Britain with physical or mental impairments that have a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities. The Act has been important in setting a framework for good practice and it can stimulate more systemic change through formal investigations of organisations or whole sectors, and through the Disability Equality Duty, in force since December 2006. The Disability Discrimination Act has implications for people working in mental health services when they are considering employment and educational opportunities for service users, and when they are considering how to redress systemic disadvantage, including inequalities in physical health.

We outline how the values-based approach adopted in training materials supporting the Mental Health Act 2007 for England and Wales will complement recovery-based practice in compulsory psychiatric detention.