The number of in-patient beds for psychiatric treatment in America has declined dramatically over the past 40 years. Public and private policies have encouraged an extremely short-term, crisis-stabilisation model of treatment. This is true on both general and subspecialty units. As a result, readmissions have increased, emergency rooms are crowded, and many patients end up homeless or incarcerated in the criminal justice system. These changes have created a public health crisis in America, and are the greatest challenges that American psychiatry faces today.

This article sets out the history of medical directorship, outlines the authors' view of the current contribution that medical directors can and should be making to the mental health arena and looks forward to the possibilities of this evolving role. The focus of the article is mainly on English policy and healthcare structures, recognising that these vary in the other jurisdictions of the UK. However, certain principles should be of wider interest and application.

Puerperal (postpartum) psychosis – the acute onset of a manic or psychotic episode shortly after childbirth – most commonly occurs in women with a bipolar disorder diathesis who have a vulnerability to a specific childbirth-related trigger. Women with bipolar disorder are at particularly high risk of puerperal psychosis, with a severe affective episode following between 25 and 50% of deliveries. Suicide is a leading cause of maternal death in the UK and it is clear that we must do more to identify and better manage women at high risk of illness related to childbirth. The clinical picture of puerperal psychosis can vary dramatically from hour to hour and can escalate quickly to a true psychiatric emergency. It is vital that clinical services identify women who are unwell and can respond quickly to the severity of illness, delivering treatment in the most appropriate setting for the mother and her baby.

The neurological deficits in sensory and motor function in schizophrenia have been described using a confusing variety of terms, reflecting their uncertain relevance and significance to psychosis. In this article we explore the nature of neurological abnormalities in psychosis, describe their assessment and suggest their potential relevance for clinician and patient. We propose that the assessment of neurological abnormalities and extrapyramidal side-effects should figure in the assessment of any patient with psychosis, particularly at illness onset. Furthermore, we suggest that neurological abnormalities can inform prognostic predictions and help to identify patients with more complex future care needs.

Although psychiatrists in England and Wales are generally familiar with the Mental Health Act 1983 and the Mental Capacity Act 2005, there is a body of law that is available to assist patients in the community with which they are generally less familiar. There are two main reasons for this. The first is that it is a rather confused amalgam of different statutes and case law affecting each other in ways that are less than clear. The other is that the care programme approach (CPA) was meant to cut through all this and make care provision straightforward. In fact, the latter has never been the case and community care law has always sat uneasily alongside the CPA, but in October 2008 the CPA was withdrawn from some patients with mental health problems. This article explains what is meant by community care law and how psychiatrists can use it to help their patients.

Self-harm in adolescents is common and is increasing. It can present to professionals as a symptom of major mental health disturbance or it can form part of a cultural ‘norm’. This article reviews current knowledge about self-harm in 12- to 18-year-olds. Definitions of self-harming behaviour, epidemiological and aetiological factors, risk assessment and management of self-harming in various settings are discussed in terms of pragmatic clinical approaches and evidence-based practice.

This commentary discusses how much we appear to know about self-harm and the circumstances in which it may occur but how little we really know about what works in managing it. It reviews how suggestions for its management conflict with what we know about self-harm and the outcomes of young people. The challenge appears to be how better to identify those at risk of further self-harm and to train frontline staff in this, so that at-risk individuals may be referred to specialist services. Perhaps there is also a need to review the evidence for what actually works in reducing repetition of self-harm.

People detained in prisons, psychiatric hospitals, police custody and immigration detention centres remain a cause of concern, particularly to professionals, politicians and the media. As the number of people detained by the state increases, Courts have been taking an increasing interest in cases in which individuals have died in state custody. Such cases are subsumed under Article 2 of the Human Rights Act 1998 – the right to life. Article 2 case law has elucidated key principles that can be applied in practice. Importantly, it imposes on states not only a negative duty not to take life intentionally or negligently, but also a positive duty to safeguard life. The inherent positive obligations have two aspects: first, there is a duty to provide an effective and impartial investigation in cases of death resulting from the activities of state officials, and second, a duty to safeguard and protect life.

Systemic lupus erythematosus (SLE) is a disorder which can affect the central nervous system and result in a broad range of psychiatric syndromes such as psychosis, mood disorders, acute confusion and cognitive dysfunction. Despite the robust nomenclature of neuropsychiatric SLE (NPSLE), psychiatric syndromes in patients are often non-specific and may be secondary to concurrent non-SLE-related conditions and complications of medical therapies. Although the exact immunopathological mechanism for psychiatric presentation remains elusive, prompt exclusion of other factors contributing to the psychiatric symptoms coupled with effective assessment strategies and management with immunosuppression and psychiatric therapy are imperative. Psychiatrists and rheumatologists must work in close liaison to identify, treat and prognosticate patients with psychiatric syndromes in order to improve their quality of life, vocational aptitude and, ultimately, survival.

This article examines the short story Metamorphosis by the enigmatic Czech writer Franz Kafka, whose work has been the subject of extensive critical discussion. His writings have been seen in the context of existentialism, Jewish mysticism and as a warning of the advent of totalitarianism. Kafka has attracted the attention of psychoanalysts and psychiatrists, who have maintained that his life and work manifest evidence of unresolved Oedipal issues and of schizoid personality. Metamorphosis is open to a multitude of interpretations, but a potentially fruitful approach is to see parallels between the predicament of the story's main character, Gregor Samsa, and that of people with severe mental illness. The story highlights the fate of those who are judged to be different by society and how issues of alienation, impaired communication and rejection arise.

Analysing interpersonal dynamics is an approach through which the multidisciplinary team can develop a shared understanding of their patients. This empirically based method provides an insight into repeated patterns of dysfunctional behaviour, which not only have been evident in the past, but are currently having an impact on the patient's relationships with caring staff. The technique is accessible to any team member with only minimal training required. It provides the team with a coherent map of the patient's relationship patterns that underpins the formulation of an effective strategy for care. The multidisciplinary team is then able to work towards shared goals, supporting all members in their provision of effective interventions within the full range of therapeutic modalities. The approach promotes positive staff–patient interactions and provides an additional dimension to the assessment and management of risk.

Values-based practice is a new approach to working with complex and conflicting values in mental health practice. Theoretically, it argues that many clinical and ethical dilemmas in psychiatry arise because of the different value perspectives taken by the players involved. By exploring the differences in value systems ‘held’ by each player, it may be possible to come to a richer consensus that can incorporate both similarities and differences. In particular, values-based practice suggests that, traditionally, the value perspective of the patient is often either not considered or is ignored, and that by giving it voice, clinical practice will become more patient-centred. In this article, I will compare values-based practice with other types of systemic thinking in mental healthcare and I will discuss some areas of clinical practice where values-based practice may be difficult to apply.