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.

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 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.

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.

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.

In their recent articles in APT Mace & Binyon described a four-level approach to the teaching of the psychodynamic formulation. The fourth level requires development of confidence in the use of an operationalised psychodynamic diagnostics (OPD) manual. Here I critically reconsider the aspects necessary to develop the ability to arrive at a psychodynamic formulation. I argue that as one develops more sophistication and clinical confidence, one needs to move from a manualised to a more open-minded reflective mode.

The history of the concept of the placebo effect and research into its quantification and mechanisms are reviewed, particularly in relation to psychiatry. Research has demonstrated a notable placebo effect in depression: a large proportion of the clinical effect of antidepressant medication is attributable to the effect. Various mechanisms have been hypothesised: anxiety relief, expectation, transference, ‘meaning effects' and conditioning. Recent research from neuroimaging has unveiled that the effect is associated with biological correlates in the brain. Despite the renewal of research into the placebo effect, many questions remain unanswered. This partly reflects philosophical obstacles such as the mind/body dichotomy, which are inherent in conceptualising the effect. However, it also demonstrates the vast scope for further research into this area. Ultimately, an understanding of the processes that underlie the placebo effect should allow a rationalised therapeutic approach to be developed to maximise the clinical benefit of the therapeutic encounter.

People with schizophrenia make a significant contribution to violence in our communities and, in so doing, often lay waste to their own lives. The 10% or so from which will emerge the perpetrators of most of the serious violence are identifiable in advance. A structured programme in which the criminogenic personality and behavioural factors, substance misuse and social dislocation are managed together with the active symptoms of the disorder could prevent the progress to violence. Such systems of care could significantly reduce serious criminal violence and homicide, reduce the number of people with schizophrenia who end up in prison, stop the rising number of forensic psychiatric beds and, most importantly, improve the lives of many of the most disturbed and disadvantaged of those with the disorder.

Clinical records are the most basic of clinical tools. Aggregated, they form a permanent account of individual considerations and the reasons for decisions. Essential for effective communication and good clinical care, they are often accorded low priority, are poorly maintained and not readily available. Independent inquiries, health ombudsmen's reports and the courts have repeatedly criticised the quality of records and the resulting failings of care. Most advice from professional bodies, indemnity organisations and the General Medical Council is extremely brief and confined to individual entries in the record. Patient safety and the demands of clinical governance make change essential. This article draws together standards and concludes with some good practice points for a fit-for-purpose, structured, multidisciplinary record to support good care and protect the interests of patients and clinicians. These principles should be equally applicable to electronic records.

New data have emerged over the past 10 years regarding the efficacy and mechanisms of action of lithium. This article briefly summarises the evidence for the use of lithium to treat affective disorders and psychosis, reviews its putative anti-suicidal effect, highlights new research on its mechanism of action and provides an update on some important side-effects and consequences of its use.

As a gold-standard methodology for the testing of the effectiveness of health treatments, the randomised controlled trial (RCT) continues to evolve to meet the challenges of new contexts and areas of medicine. This article reviews two particular evolving features of RCTs that make them increasingly well adapted to testing psychological interventions in mental health. The first is a new confidence that RCTs can be successfully adapted to test the more complex (often psychosocial) health interventions and technologies. The second is an increasing emphasis on using the RCT method to explore many facets of the process of treatment as well as its outcome. These two developments should help the RCT method to come of age in mental health, increase the face validity of the RCT method for practitioners and aid the effective translation of research work into improvements in practice.

Operational criteria for detecting prodromal, or at-risk, mental states have been developed largely on the basis of individuals seeking help for attenuated or brief, self-limiting symptoms that do not meet threshold criteria for psychotic disorder. These individuals present largely to primary care and other non-specialist mental health settings. Follow-up studies have confirmed that 15–40% will make the transition to full psychosis within 12 months. Cognitive therapy alone or in combination with low-dose atypical antipsychotics has been shown to be efficacious in reducing or delaying the transition to psychosis, as well as in ameliorating the severity of non-psychotic symptoms and distress. Antipsychotic medication alone has not shown significant efficacy, but results are suggestive of some advantage from drug treatment. Further work is needed to clarify the relative merits of these interventions.

If personality disorder is no longer to be a diagnosis of exclusion it needs a conceptual framework that fits both the symptoms of the illness and the behavioural problems that constitute its current diagnostic criteria. In this article, we suggest that personality disorder is best understood as disorganisation of the capacity for affect regulation, mediated by early attachments. We present evidence for this argument based on both developmental and neurobiological research.

The health of family carers may affect not only their own lives but also the lives of the people for whom they provide care. This article describes how the caring role can affect the health and well-being of a carer of a person who has a mental or physical disorder. Suggestions are made about how to recognise and ameliorate some of the detrimental effects of the caring role on the carer's own health.

Over the past few years electroconvulsive therapy (ECT) has come under increased scrutiny in the UK, with the first systematic review of patients' experiences and new national guidelines. Our aim in this article is to translate recent and sometimes confusing research and policy statements into practical guidance that benefits patients. We examined the evidence on the permanent memory and cognitive effects of ECT, with a focus on delineating their nature, understanding how ECT may cause them, informing prospective patients about them, and assessing their impact on former patients. We describe a simple and effective method for assessing retrograde amnesia. Data do not exist at this time to confirm the mechanisms by which ECT exerts its adverse effects, but clinicians should fully inform patients of the possible permanent adverse effects of the treatment, which include amnesia, memory disability and cognitive disability, and should provide follow-up testing using relevant instruments.

John Rawls's theory of justice has been embraced by both the political left and the right, albeit for different reasons. This commentary points out some caveats regarding Rawls's theory as applied to healthcare in general and psychiatry in particular. An alternative political philosophy, the theory of ‘entitlement justice’ as advanced by Nozick, is presented and it is argued that this has more real-life relevance for healthcare ethics than the Rawlsian theory of distributive justice. The reader is invited to determine which theory, if either, is the best fit for psychiatry. The article concludes with some thoughts on the limits to autonomy that mental illness imposes and likens it to the concept of ‘interstitial autonomy’.