We discuss the implications of our systematic review of the evidence regarding current postgraduate psychiatric training methods in the UK. The review found only 24 papers on the topic, 10 of which were research based. None of the papers addressed the reliability and validity of the teaching methods studied. These papers suggest that issues regarding psychiatric training and education in the UK have been addressed only to a limited extent. There is thus an urgent need for more rigorous and scientific evaluation of training methods, especially now that training and assessment are changing in the UK.

The Department of Health is introducing a ‘payment by results’ system for mental health services in the UK. The system is already being used in the acute healthcare sector, but is still under development for application in mental healthcare. This article outlines the concept of payment by results, briefly reports on its use in other countries and describes the pilot study underway in England to define currencies to be used in a payment by results system planned for NHS mental healthcare throughout England and Wales.

Payment by results, a system for paying healthcare trusts, is intended as a fair and consistent basis for hospital funding. It relies on a national tariff structured around a case-mix measure known as healthcare resource groups. It is often argued that if payment by results works as planned, the National Health Service will become more efficient and productive. However, the use of a case-mix measure, the healthcare resource group, which derives from the diagnostic related (or diagnosis-related) group, has attendant problems. These include the risk that the payment structure will be inaccurate, unfair and liable to cause the financial destabilisation of trusts. There is also the risk that healthcare institutions will falsify patient classifications (‘up-coding’) to ensure higher remuneration. It has been argued that payment by results may be particularly unsuited to psychiatry. The ability of healthcare resource groups to accurately predict resource use in psychiatry is doubtful. In conclusion, mental health trusts will need to adapt to payment by results but there will inevitably be losers.

This article focuses on how the general adult psychiatrist, in thinking about everyday clinical problems, may usefully apply attachment theory to gain insight. Fictional case vignettes are used to illustrate the importance of attachment in shaping and understanding the clinician–patient relationship. Ways in which service configurations may be informed by attachment theory are also examined.

The role of psychotherapy for elderly people is the subject of much debate. Yet this has not resulted in a shift of resources towards increasing its availability within the UK's National Health Service. Over the past decade the pessimistic view of psychotherapy for elderly people has diminished owing to the growing evidence base and the commitment of champions in old age psychiatry and psychotherapy. However, there is still very little structured research into psychotherapy in dementia. Supportive psychotherapy is a poorly understood but very practical means of helping people with dementia to adjust to the effects of their illness. Its inherent flexibility enables individual sessions to be tailored to the patient's needs and deficits. An understanding of supportive psychotherapy and its benefits could enable clinicians to improve the quality of life of people with dementia and their carers within the ever-present constraints of limited time and resources. This article explores the use of supportive psychotherapy as a treatment option in dementia.

A significant minority of people who use the internet develop ‘internet addiction’ – a relatively new concept in psychiatry not yet recognised by ICD–10 or DSM–IV. Preliminary research offers interesting insight into predisposing factors and psychosocial treatment options. Mental health professionals need a basic understanding of internet addiction so that they can recognise it early and intervene appropriately. In this article, we present an overview of the aetiological frameworks, assessment and treatments of internet addiction.

The concept of computer addiction is examined and the importance of conceptual and nosological clarity emphasised. The risk of tautology in the construction of such conditions is raised, as is the issue of whether it would be better to classify many affected individuals in terms of the end behaviour rather than the mediating mechanism. Definitional difficulties and sociocultural contexts are explored.

This article considers the contribution that psychodynamics can make to the work of teams providing early intervention in psychosis. Psychodynamic understanding enriches the stress and vulnerability psychosis model; can contribute to resolving the issues involved in relapse prevention; informs individualised formulations; and can make sense of patients' reactions to prescribing in psychosis. A rationale is given for longer-term individual, group and family dynamic psychotherapies within early intervention teams.

A good therapeutic alliance between mental health professionals and patients with psychosis can enhance adherence to medication regimens and improve clinical outcome. This article explores how the therapeutic alliance might be developed with respect to decisions to prescribe antipsychotic medication. It does this by presenting the implications for practice that arise from a recent qualitative interview study with consultant psychiatrists. We consider strategies for strengthening the therapeutic alliance, occasions when it might be appropriate to suspend shared decision-making temporarily, techniques used to enable discussion of symptoms and side-effects, and how issues of adherence are uncovered and addressed. Psychiatrists already possess considerable skills in these areas. The dissemination of these to colleagues forms an important opportunity for CPD.

Catatonia is an important phenomenon in both psychiatry and general medicine. This article provides an overview of the key aspects of catatonia, including clinical features, differential diagnoses, management and prognosis. The different types of catatonia, the position of catatonia in the psychiatric classificatory systems, use of catatonia rating scales and the association between catatonia and neuroleptic malignant syndrome are also covered. Abnormalities that have been hypothesised as being possible underlying mechanisms in catatonia are highlighted. The article aims to provide clinicians with a comprehensive update on the subject, with information derived from an extensive range of relevant references.

The government in England and Wales is promoting policies and initiatives to offer patients choice across all healthcare specialties. This has raised concerns in mental healthcare, particularly if the physical healthcare model of implementation is imposed. However, the ‘choice agenda’ is an opportunity for mental health services to be innovative and act as beacons to other disciplines in healthcare. The south-east London programme introducing choice in mental health services is offered as an example here. There already exists an ‘ethos of choice’ within mental health services, but current practices may require a focused approach and structuring to fit in with national policy. This also might be necessary to influence policy makers to take a different perspective on choice in mental health. The principle of choice goes hand in hand with the drive towards greater social inclusion for people with mental health problems.

The ‘choice agenda’ reflects a key element of the modernisation of public services. There are many conceptual and practical difficulties with the implementation of choice within mental health services, but these are not in any way unique to this client group. Professionals will have to adapt to the new world that will encompass a plurality of paradigms of care and service providers.

Risk assessment forms an integral part of clinical practice. Traditionally, risk has been portrayed as a binary concept, and its assessment regarded as a test that can be correctly or incorrectly classified. However, this article discusses how risk assessments are less straightforward than is commonly perceived and are often complicated by multiple forms of uncertainty. These uncertainties arise where psychiatrists are unsure about their interpretation of information, where information is missing, or where interpretation of the risk situation is open to challenge. They centre on doubts about the accuracy and the defensibility of assessment of patients' risk status and the need for risk containment. Like other professionals, psychiatrists adopt a range of strategies to resolve uncertainties. These strategies, which often involve some ‘risk-taking’, enable the practising clinician to make a more confident decision. There is an argument for including ‘certainty’ as a theoretical feature of risk assessment in psychiatry and for recognising it as a multifaceted phenomenon. There is also an argument for considering with greater precision the manner in which uncertainty is managed within psychiatric risk assessments.