The Royal College of Psychiatrists' Annual General Meeting in Edinburgh in June 2007 witnessed the launch of the joint position statement from the College, the Care Services Improvement Partnership and the Social Care Institute for Excellence ‘A Common Purpose: Recovery in Future Mental Health Services’ as part of its opening session. This is now available as a stimulus and a guide for clinicians and teams to consider how to engage in the recovery agenda and whether to make it their common purpose also.

Evidence for the effectiveness of treatment or secondary prevention of psychotic illness such as schizophrenia is often disappointing. This situation reflects our limited understanding of the aetiology of psychosis. There is good evidence that both genetic and environmental factors are implicated but the precise identity of these is unclear. Cannabis use is one candidate as a possible, modifiable environmental influence on both incidence and prognosis of psychosis. Evidence supporting this candidature is exclusively observational, and its strength has perhaps been overestimated and problems related to its interpretation underestimated by some. Nevertheless the possibility that cannabis does cause psychosis remains. Because of this, and because there are other good public health reasons to prevent cannabis use, interventions targeting use need to be evaluated. This evaluation, along with other imaginative approaches to future research, is needed to further our understanding of the determinants of mental illness and how we can most effectively improve the population's mental health.

Epidemiology is the study of why, how and how often diseases occur in given populations. There is now a sufficiency of epidemiological evidence for psychiatrists to warn that cannabis use could increase risk of psychosis in later life. The policy impact of this accumulated epidemiological evidence is difficult to predict. There is a strong need to develop models of mental health policy-making that incorporate careful interpretation of epidemiological evidence.

Drug treatment is an essential part of much of psychiatric practice, in patients from a wide age range, across many diagnostic groups and in a variety of settings. Despite the availability of many classes of psychotropic drug, significant numbers of patients remain troubled by distressing and disabling symptoms even after a succession of licensed pharmacological treatments. Psychiatrists may then consider the prescription of a psychotropic outside the narrow terms of its licence, as part of an overall management plan. This article reviews the nature and extent of this aspect of prescribing, outlines when it may be appropriate and makes recommendations for a suggested procedure when prescribing medication ‘off-label’.

Patients miss about 20% of scheduled appointments for mental health treatment, almost twice the rate in other medical specialties. Up to 50% of patients who miss appointments drop out of scheduled care. Many who miss appointments because of slips and lapses later rearrange their appointments without adverse consequences. Those that do not are at risk of further deterioration, relapse and hospital readmission. Predictors of non-attendance are complex and linked with the predictors of missed medication. Service barriers and administrative errors are common but are often overlooked in the absence of feedback from patients. Of prime importance are the therapeutic alliance and degree of ‘helpfulness’ of the clinician but again these are rarely measured routinely. Useful markers of engagement include patient-rated trust, satisfaction and degree of perceived participation in treatment decisions. Much can be done to improve attendance in most services. Simple measures such as offering prompt, convenient appointments, offering reminders and augmenting with telephone contact have a reasonable evidence base. Scales to assess therapeutic alliance are now available. Complex interventions need to be evaluated carefully in order that the overall benefits outweigh costs. We suggest that clinicians consider accessibility, discharge policies and patient feedback when examining local rates of non-attendance.

In this issue of APT Mitchell & Selmes present an article detailing why patients miss appointments and how clinicians should respond. Many of the papers quoted relate to the psychiatric out-patient clinic. In this commentary as well as picking up on some of the themes that emerge from their article, I explore the attachment that psychiatrists seem to have to this particular model of patient contact.

In the UK, the National Institute for Health and Clinical Excellence's guidelines on obsessive–compulsive disorder (OCD) recommend cognitive–behavioural therapy, including exposure and response prevention, as an effective treatment for the disorder. This article introduces a cognitive–behavioural model of the maintenance of symptoms in OCD. It discusses the process of engagement and how to develop a formulation to guide the strategies for overcoming the disorder.

Antidepressant discontinuation symptoms occur with all classes of antidepressant. A well-described discontinuation syndrome occurs with the selective serotonin reuptake inhibitors, common symptoms including dizziness, headache, nausea and lethargy. Rare antidepressant discontinuation syndromes include extrapyramidal syndromes and mania/hypomania. All these syndromes, even isolated discontinuation symptoms, share three common features that facilitate diagnosis; abrupt onset within days of stopping the antidepressant, a short duration when untreated and rapid resolution when the antidepressant is reinstated. Clinicians need to be familiar with strategies for the prevention and management of such symptoms. Preventive strategies include warning patients about the possibility of discontinuation symptoms, encouraging good antidepressant adherence and tapering antidepressants at the end of treatment. Most symptoms are mild and short-lived. Consequently symptoms that follow planned termination of an antidepressant can often be managed by providing an explanation and reassurance. More severe symptoms should be treated symptomatically or the antidepressant restarted, in which case symptoms usually resolve within 24 h. More cautious tapering can then follow.

The cognitive behavioural analysis system of psychotherapy (CBASP) is a new therapy specifically designed to treat chronic depression. Conceptually the bio-psychosocial signs and symptoms of chronic depression are viewed as the result of either arrested maturational development at a Piagetian preoperational stage (in early-onset patients) or heightened emotionality and general functional regression (in late-onset patients). In this therapy, patients learn how their cognitive and behavioural patterns produce and perpetuate interpersonal problems and how to alter maladaptive patterns of interpersonal behaviour. The focus is primarily on interpersonal interactions, including with the therapist, through the latter's disciplined personal involvement. In this article we outline the therapy process and key mechanisms of change using examples to illustrate specific techniques. We also outline the theoretical model underpinning CBASP and summarise the evidence from a large clinical trial.

Much has changed in the National Health Service in the UK in the past 10 years and consultant roles need to adapt accordingly. This article describes the drivers for change in consultant roles, including enhanced roles for other mental health professionals, increased expectations of users and carers, changes in junior doctors' work patterns and the new consultant contract. The recommendations of the report on New Ways of Working for Psychiatrists are reviewed, with suggestions for changes in the consultant role in out-patient clinics, community teams and acute care. Enhanced roles for other mental health professionals and the increasing trend to specialisation are also discussed.