The four main Indian religions – Hinduism, Buddhism, Jainism and Sikhism – have several shared concepts about self and suffering, which are salient to the world-view of the followers of these faiths. Understanding the concepts of mind, self and suffering in these faiths can help clinicians build better rapport and gain deeper understanding of the inner world of patients of these faiths. This article highlights the broad cultural and religious beliefs of these groups, with the hope that increased knowledge among clinicians might lead to better therapeutic engagement.

Managing isolation protocols for distressed, cognitively impaired COVID-19-positive patients presented a range of new challenges to our liaison psychiatry for the elderly service. In this article we present some of the scenarios we have experienced, our own reflections on the needs of this specific group and how this has challenged us in terms of tolerating risk, prescribing off-label, collaborating with distressed colleagues, professional boundaries and being creative in non-pharmacological interventions.

Triage wards were introduced as a new model of psychiatric in-patient care in 2004. However, there is limited evidence comparing them with the traditional in-patient models of care. This article reviews the history of triage wards, their principles, the evidence for this model (e.g. length of in-patient stay, readmission rates, staff and patient satisfaction) and the development of assessment wards based on the triage model of care. The evidence shows that the triage model has higher rates of rapid discharge, with a greater proportion of ‘acute care’ performed in the community with the support of home treatment teams. This leads to lower bed occupancy in the triage wards without increased rates of readmission or a worse patient experience of in-patient care. However, overall staff experience was better in the traditional model, given that staff satisfaction rates were lower on locality wards in settings with triage systems in place. Future research should explore the potential impact on home treatment teams, and the rates of serious incidents due to the high number of acutely unwell patients on triage wards.

Debates on dualism continue to plague psychiatry. I suggest that these debates are based on false dichotomies. According to metaphysical physicalism, reality is ultimately physical. Although this view excludes the idea of entities distinct from physical reality, it does not compel us to favour neural over psychological interventions. According to methodological dualism, both physical and mental interventions on the world can be deemed effective, and both perspectives can therefore be thought to be equally ‘real’.

Electroconvulsive therapy (ECT) for depression is a controversial treatment with highly polarised views about the balance between therapeutic benefits and adverse effects. Studies investigating whether ECT is more effective than a placebo treatment started in the 1950s, with the most important randomised controlled trials carried out about four decades ago in which ECT was compared with sham ECT (SECT) involving anaesthesia but no electrically induced seizure. Subsequently the data have been pooled in a number of meta-analyses which have found that ECT is an effective treatment. However, a recent review of the quality of the SECT-controlled studies, and the meta-analyses based on them, concludes that their quality is too poor to allow assessment of the efficacy of ECT and that, given its risks (permanent memory loss and death), the use of ECT should be suspended. This commentary critically discusses the methodology of this review and its conclusions.

Forensic psychiatry services have grown and become more complex in structures, processes and pathways. Legacy customs, practices and changing policy are now organised into formal models of care. These are written accounts of how a health service is delivered, outlining best practice and services for patients progressing through the stages of their condition and the care and treatment available. This article explores the four key elements of a model of care: goals; pathways and processes; treatment programmes; and systematic evaluation. It describes the most common model of care in forensic services, which builds on structures of stratified therapeutic security. It also considers variations on this basic or standard model matched to needs arising from the complex interrelationship with other parts of the mental health service for the population served and with criminal justice, primary care and physical health, housing and welfare agencies.

It is generally believed that the physiological consequences of stress could contribute to poor outcomes for patients being treated for cancer. However, despite preclinical and clinical evidence suggesting that stress promotes increased cancer-related mortality, a comprehensive understanding of the mechanisms involved in mediating these effects does not yet exist. We reviewed 47 clinical studies published between 2007 and 2020 to determine whether psychosocial stress affects clinical outcomes in cancer: 6.4% of studies showed a protective effect; 44.6% showed a harmful effect; 48.9% showed no association. These data suggest that psychosocial stress could affect cancer incidence and/or mortality, but the association is unclear. To shed light on this potentially important relationship, objective biomarkers of stress are needed to more accurately evaluate levels of stress and its downstream effects. As a potential candidate, the neuroendocrine signalling pathways initiated by stress are known to affect anti-tumour immune cells, and here we summarise how this may promote an immunosuppressive, pro-tumour microenvironment. Further research must be done to understand the relationships between stress and immunity to more accurately measure how stress affects cancer progression and outcome.

Stress is the most important proximal precipitant of depression, yet most large genome-wide association studies (GWAS) do not include stress as a variable. Here, we review how gene × environment (G × E) interaction might impede the discovery of genetic factors, discuss two examples of G × E interaction in depression and addiction, studies incorporating high-stress environments, as well as upcoming waves of genome-wide environment interaction studies (GWEIS). We discuss recent studies which have shown that genetic distributions can be affected by social factors such as migrations and socioeconomic background. These distinctions are not just academic but have practical consequences. Owing to interaction with the environment, genetic predispositions to depression should not be viewed as unmodifiable destiny. Patients may genetically differ not just in their response to drugs, as in the now well-recognised field of pharmacogenetics, but also in how they react to stressful environments and how they are affected by behavioural therapies.

As we age, there are characteristic changes in our thinking, reasoning and memory skills (referred to as cognitive ageing). However, variation between people in the timing and degree of change experienced suggests that a range of factors determine individual cognitive ageing trajectories. This narrative review considers some of the lifestyle factors that might promote (or harm) cognitive health. The focus on lifestyle factors is because these are potentially modifiable by individuals or may be the targets of behavioural or societal interventions. To support that, the review briefly considers people's beliefs and attitudes about cognitive ageing; the nature and timing of cognitive changes across the lifespan; and the genetic contributions to cognitive ability level and change. In introducing potentially modifiable determinants, a framing that draws evidence derived from epidemiological studies of dementia is provided, before an overview of lifestyle and behavioural predictors of cognitive health, including education and occupation, diet and activity.

Bed management and the transfer of patients is an area of clinical care that is frequently overlooked. Often, the lack of discussion leads to the patient perspective being ignored and to transfers to new hospitals without appropriate handovers, both to the detriment of patient outcomes. This article reflects on the real-world consequences of the bed management systems used within the UK's National Health Service (NHS), using the example of a patient in psychiatric services.

This article gives an update for practitioners on recent developments in the use of electroconvulsive therapy (ECT) and related treatment modalities in the contemporary treatment of depression in the UK. Details are provided on new information on the efficacy and side-effects of ECT both in research studies and in the real world, together with recent research on ECT's mode of delivery. There is a focus on the safe administration of ECT in clinical practice. An update on the regulatory framework for ECT in the UK is provided, together with up-to-date information on the legal situation regarding its prescription. Finally, brief summaries of the current position for other neuromodulatory treatment modalities are given.

Significant developments in schizophrenia psychopathology are ready to be incorporated into clinical practice. These advances allow a way forward through the well-described challenges experienced with current diagnostic and psychopathological frameworks. This article discusses approaches that will enable clinicians to access a wider and richer spectrum of patient experience; describes process-based models of schizophrenia in the domains of both the brain and the mind; and considers how different levels of analysis might be linked via the predictive processing framework. Multiple levels of analysis provide different targets for varying modalities of treatment – dopamine blockade at the molecular level, psychological therapy at the level of the mind, and social interventions at the personal level. Psychiatry needs to align itself closer to neuroscientific research. It should move from a symptom-based understanding to a model based on process. That is – after having asked about a patient's symptoms and experience clinicians need to introduce steps involving a consideration of what might be the brain and mind processes underlying the experience.

Resilience is broadly defined as the ability to bounce back from adversity or trauma. Recent advances in resilience research have shifted away from merely describing individual characteristics towards focusing on the complex interactions between individuals and their dynamic personal, community and cultural contexts. It is clear that resilience involves both neurobiological and cultural processes. Neurobiological contributions include genes, epigenetics, stress-response systems, the immune system and neural circuitry. Culture helps to elucidate collective systems of belief and accepted positive adaptations. Importantly, resilience can also be affected by evidence-based interventions and deliberate practice on the part of the individual. This review seeks to understand resilience as a complex and active process that is shaped by neurobiological profiles, developmental experiences, cultural and temporal contexts, and practical training. It uses the COVID-19 pandemic as a case example to better understand individual and group responses to tragedy. We suggest practical recommendations to help populations around the world cope and recover from the global threat of COVID-19.

Despite record-breaking numbers of opiate related deaths in the UK in 2019, pharmacological management of opiate dependence has evolved little since the advent of methadone in 1965. Along with harm minimisation and psychosocial interventions, the mainstay of pharmacological treatment remains opioid substitution therapy (OST) using methadone or buprenorphine, with many patients receiving OST for many years. Even with these treatments, opiate users continue to face mortality risks 12 times higher than the general population, and emerging evidence suggests that individuals who remain on long-term OST present with a range of physical and cognitive impairments. Therefore, with a growing ageing opiate dependent population who would benefit from detoxification from OST, this article provides an overview of the current state of opiate dependence in clinical practice, explores the reasons why availability and acceptability of detoxification pathways are declining, and discusses emerging pharmacological therapies that could provide benefit in relapse prevention.

Sleep is essential for survival and humans spend approximately one-third of their life asleep. Adequate sleep is needed to maintain both physical and psychological health. Routinely getting less than the recommended amount of sleep for your age can have profound negative effects on health, such as increasing the likeliness of psychiatric illness, diabetes, cardiovascular disease and stroke. In children and adults with neurodevelopmental disorders, the prevalence of sleep disorders is significantly higher than in the general population. Given the relationship between sleep and psychiatric disorders, it is essential that psychiatrists have knowledge of the principles of sleep medicine. In this article, we focus on the common sleep disorders found in those with attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) and give an overview of screening, diagnosis and management.

In this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.

Stratified medicine has been successfully used in many areas of medicine, perhaps most notably oncology. There is now both a growing evidence base and mounting enthusiasm, supported at a governmental level and across industry, academia and clinical medicine, to apply this approach to neurodegenerative illnesses, including dementia, as these provide the greatest clinical and social challenge of our times. In this article we consider definitions of stratified medicine, look at its application in other medical specialties, review the national context in the UK and consider the current state, future potential and specific considerations of applying stratified medicine to dementia.

Early detection and specialised early intervention for people at high risk for psychotic disorders have received growing attention in the past few decades, with the aim of delaying or preventing the outbreak of explicit psychotic symptoms and improving functional outcomes. This article summarises criteria for a diagnosis of high psychosis risk, the implications for such a diagnosis and recommendations for treatment.

Trauma-informed approaches emerged partly in response to research demonstrating that trauma is widespread across society, that it is highly correlated with mental health and that this is a costly public health issue. The fundamental shift in providing support using a trauma-informed approach is to move from thinking ‘What is wrong with you?’ to considering ‘What happened to you?’. This article, authored by trauma survivors and service providers, describes trauma-informed approaches to mental healthcare, why they are needed and how barriers can be overcome so that they can be implemented as an organisational change process. It also describes how past trauma can be understood as the cause of mental distress for many service users, how service users can be retraumatised by ‘trauma-uninformed’ staff and how staff can experience vicariously the service user's trauma and can themselves be traumatised by practices such as restraint and seclusion. Trauma-informed mental healthcare offers opportunities to improve service users' experiences, improve working environments for staff, increase job satisfaction and reduce stress levels by improving the relationships between staff and patients through greater understanding, respect and trust.

Funding for mental health services in England faces many challenges, including operating under financial constraints where it is not easy to demonstrate the link between activity and funding. Mental health services need to operate alongside and collaborate with acute physical hospital services, where there is a well-established system for paying for activity. The funding landscape is shifting at a rapid pace and we outline the distinctions between the three main options – block contracts, episodic payment and capitation. Classification of treatment episodes via clustering presents an opportunity to demonstrate activity and reward it within these payment approaches. We discuss the results of our research into how well the clustering system is performing against a number of fundamental criteria. We find that, according to these criteria, clusters are falling short of providing a sound basis for measuring and financing services. Nevertheless, we argue that clustering is the best available option and is essential for a more transparent funding approach for mental healthcare to demonstrate its claim on resources, and that clusters should therefore be a starting point for evolving a better funding system.