Baillon et al’s Cochrane review included 430 participants with agitation in dementia from five randomised controlled trials. Overall, the reviewers found that valproate was no better than placebo for the treatment of agitation in people with dementia; however, the quality of the studies included was very variable. Adverse effects and events were higher in the treatment group compared with the controls, although these finding were largely based on low-quality data with incomplete reporting; thus, valproate's safety profile is of concern. This review demonstrates that there is insufficient evidence to change current treatment guidelines.

Many persons with intellectual developmental disorders and/or autism spectrum disorder presenting problem behaviours undergo pharmacotherapy without receiving an appropriate psychiatric assessment and diagnosis. Instead, prescription of psychotropic medication should have specific aims and involve interdisciplinary assessment, personalisation and patient and family participation. Current knowledge about pharmacological management of problem behaviours in this population is limited, necessitating extreme caution in clinical practice and more research into the complex interrelated factors that affect presentation, course and treatment response.

As the age at which psychiatrists leave the National Health Service falls, and as the importance of CPD grows, there is an increasing urgency to assist the professional development and the licensing of portfolio practitioners. A survey undertaken to gain an impression of the experiences of this group of members of the Royal College of Psychiatrists highlighted considerable difficulties for some. Recommendations are made here both for individual members and for the CPD structures within the College. In particular, it is suggested that the College help with the appraisal of members who are outside managed organisations and that enhanced responsibilities be given to regional CPD coordinators. Individual members should see the peer group as the centre of their CPD activities, take a flexible approach to their own CPD, and advise other members of their peer group accordingly.

Sir Arthur Conan Doyle trained as a doctor and practised in a number of areas, but found real success only as an author. He is best known as the creator of the Sherlock Holmes stories. This article considers the individuals in Doyles' life that seem to have inspired the character of Holmes, a flawed genius with dark aspects (including intravenous drug use and instability of mood).

In response to an article on recent advances in the use of ECT for depression, this commentary supports earlier and more extensive use of the treatment. It challenges the belief that ECT is associated with a higher risk of cognitive deficits and mortality and points out its rapid effect compared with antidepressant medication. It calls for clinicians to remain up to date regarding ECT and consider its opportune use in severe depression.

People with intellectual disability can have a range of common mental health difficulties that sit at the interface of two psychiatry subspecialties: intellectual disability and general adult psychiatry. Clinical presentations, comorbidities and complexities can affect the setting of boundaries between the two disciplines. This article touches on current concepts, drives for inclusion of people with intellectual disability in mainstream psychiatry services and some of the difficulties at the interface. It focuses on potential solutions for managing this interface between the two subspecialties.

Malingering is the intentional feigning of illness for external gain. The author has written several papers on the epidemiology, assessment, testing and reporting of this. However, practice in this field can raise considerable challenges, not least the inability to determine motivation for lying, and potential damage from ‘false positives’, where individuals fabricate some aspects of their testimony, yet still have underlying psychiatric problems. This brief article lays out the author's reflections on this complex area.

A wide variety of neurological conditions may present first to a psychiatrist and it is important to be aware of these in differential diagnosis. A careful history, examination and a broad differential diagnosis can help set up an appropriate management plan – with room to change if things change in unexpected ways. In this article we explore common ground shared by psychiatry and neurology and show how incorporation of neurological knowledge can improve the practice of psychiatry. Using four fictional case vignettes of altered mental status we explore important neurological differential diagnoses which could present to the Psychiatrist.

The National Service Framework for Mental Health (NSF–MH), published by the Department of Health in 1999, set an ambitious 10-year agenda for improving mental healthcare for working-age adults in England, based on seven quality standards covering all major services. The NSF–MH was supported by a series of other policy documents published by the government. This article illustrates a means of modelling the government's policy for adult mental health services to produce figures for the necessary services, staffing and financial resources required to meet the policy objectives. The findings of a report recently published by the Sainsbury Centre for Mental Health, which undertook a detailed assessment of what needs to be done to deliver these standards in terms of service provision, staffing and funding, is summarised and its implications examined.

This article focuses mainly on issues regarding doctors' clinical performance (capability) and behaviour (conduct), and is aimed at medical managers who deal them. It covers identifying problems and how to manage them, describes typical underpinning (disciplinary) frameworks and sets out the role of the UK's National Clinical Assessment Service and other external bodies in more serious cases.

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.

Eye movement desensitisation and reprocessing (EMDR) is a psychological therapy that addresses trauma, stress and emotional distress. It has been successfully used in the management of various psychiatric disorders. This article shows that it may also be safely used to manage the psychological distress arising from a variety of physical health conditions and in so doing, reduce the illness burden from conditions such as various cancers, traumatic childbirth, tokophobia, pre-eclampsia, myocardial infarction, haemodialysis in end-stage renal disease, and acute postoperative pain. It can be a stand-alone treatment for hyperemesis gravidarum and tinnitus. The article examines the rationale and evidence for its use in these conditions and suggests areas where more research is needed. Adding EMDR therapy to the range of available interventions in general hospitals has the potential to improve the health and well-being of patients in these settings.

A job plan is part of a modern contract, informing employee and employer what they are paid to do. It is not a mandatory, inflexible tablet of stone, but frequently National Health Service (NHS) clinicians find themselves working, to their detriment, in excess of what they have agreed to do, by bridging the gap between resources and demand. So what do we do when we are persistently going above and beyond and there is no more left to give: how can we fix the system, and who really gets left behind?

Patricia Casey's papers (2003a, b, this issue) cover the situation regarding expert witnesses in England and Wales and in Ireland. The situation in Scotland is outlined below.

There is considerable work being carried out in neuroscientific laboratories to delineate the mechanisms underlying single-gene disorders, particularly those related to intellectual disability and autism spectrum disorder. Many clinicians will have little if any direct experience of this type of work and so find the procedures and terminology difficult to understand. This article describes some of the laboratory techniques used and their increasing relevance to clinical practice. It is pitched for clinicians with little or no laboratory science background.