The Royal College of Psychiatrists is well on the way to introducing its new curriculum and revised Membership (MRCPsych) examinations and assessments, in line with the requirements of the Postgraduate Medical Education and Training Board. The new structures might encourage trainees to ask themselves how and why they are studying and learning. Organisers of local MRCPsych courses will need to tailor their courses to fit these new structures, and this might be an optimum time for the College to consider whether it should take a more formal role in approving courses and judging trainees' participation in them.

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.

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.

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.

This article describes the establishment of a clinician as a referral coordinator to manage referrals into a typical mental health service for older adults. The referral coordinator model, which include risk assessment at the point of referral and accurate comprehensive collection of referrer data, is compared with other traditional and more recent models of referral management. The importance of thorough collation of clinical information to produce a preliminary risk assessment and the stages of development of an algorithm as a core requirement to guide the coordinator and ensure consistency over time are described. An initial analysis of local referrer data and trends over a period of 3 years is presented to emphasise the educational opportunities offered by taking control of referral management.

We outline the huge literature on the potentially negative impact on children of growing up with a parent who has an alcohol or drug problem, the risk factors that can exacerbate this effect, and resilience and the protective factors that can reduce it. Clear ways that practitioners can intervene to reduce risk and to increase resilience are discussed. All practitioners have a responsibility to work in holistic ways if damage to children and families is to be avoided, and we summarise the key common skills needed to work with individuals (children as well as adults) and families. The differences between a resilience and a deficit approach are outlined.

Dangerous and severe personality disorder (DSPD) services have a relatively short history but are increasingly involved in the implementation of therapeutic programmes. We describe the background to the DSPD initiative in England and consider issues that arise in planning and delivering treatment services. Two bodies of evidence are particularly relevant: previous research into personality disorder and its treatment, which we suggest is as yet of limited value, and research into the outcomes of offender treatment programmes. The latter is clearly relevant but greater consideration of adapting programmes for the patient population and of breadth of treatment is required in the DSPD setting. The important task is to integrate components for the treatment of personality disorder and offending behaviour in a holistic manner. We describe three further challenges in delivering treatment and suggest that ongoing evaluation of treatments is critical in this area of practice, given the impoverished knowledge base.

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.

This article is aimed at organisers of courses for the Royal College of Psychiatrists' membership examinations (MRCPsych) and College tutors preparing trainees for the MRCPsych. Running revision courses requires planning and a good deal of work but should be possible for most MRCPsych preparation courses. The theoretical background of assessments is explained. An overview of the type of examination used in the MRCPsych is provided and advice as to how trainees can best prepare for them given. Advice is given on the recruitment and retention of examiners for mock clinical exams, how to deal with simulated patients and what equipment is useful to buy for the use of trainees. We also explain how trainees can practice for the written papers and how feedback is best given to them. The new MRCPsych formal examination and workplace-based assessment programme are also discussed.

Although the physical health of doctors is largely better than that of the general population, they continue to have high levels of stress, depression and substance misuse. These aspects of mental ill health are particularly elevated in psychiatrists, and in a number of studies psychiatrists have also been found to be those doctors most likely to face disciplinary proceedings. This article explores the individual and organisational causes of these problems and the ways they may interact within the psychiatrist's work role, and suggests a variety of possible interventions to improve the mental health of doctors in psychiatry.

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.

Few tests address the types of memory problem commonly reported after electroconvulsive therapy (ECT). Here, we focus on the importance of neuropsychological assessment in ECT-treated patients and describe a number of tasks that may be useful in measuring the everyday memory problems of such patients with ongoing memory difficulties. At the time of writing, no attempts have been made to rehabilitate patients who experience persistent adverse cognitive effects, but clinicians should be aware of the potential beneficial role of cognitive rehabilitation in the treatment and management of these effects.

Palliative care is an approach that stands well with the aims of person-centred dementia care. There is no doubt that the standards of care for many people with advanced dementia are poor. There is a lack of good-quality evidence, however, to support any particular approach for palliative care in dementia. Still, there are a number of areas in relation to caring for people with severe dementia where a palliative approach might be beneficial. In general, the relevant decisions have to be made on an individual basis but within a palliative framework. Advance care planning is likely to be crucial in encouraging this process. There is certainly a moral imperative behind the idea that care at the end of life for people with dementia should be improved.

Working with people who have criminal convictions for endangering others is certainly challenging. The place of psychiatric or psychological intervention is still uncertain but for some people, for example those who have a background of physical or sexual abuse, it seems reasonable to provide them with access to interventions that seem to benefit those who do not have such convictions. The dangerous and severe personality disorder (DSPD) system provides an environment to do this. However, if it is ever to be successful in enabling future safe community placements, it has to address issues of stigmatisation.

Fabricating or inducing illness in children (previously called Munchhausen syndrome by proxy) is a form of child abuse in which a caregiver falsifies illness in a child by fabricating or producing symptoms and presenting the child for medical care disclaiming knowledge of the cause of the problem. The behaviour has attracted considerable interest and controversy, and some have questioned its existence. In this article, we assess the prevalence of the behaviour, describing behaviours that have been reported and identified, and discuss its psychopathology. We consider the role of psychiatric expertise in the investigation of such behaviour and in the assessment of those who carry it out, based on what is known to date about their psychopathology. We also outline an approach to management with special reference to the characteristics in the mother that may allow for reunification with the child after the abuse has been established.

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.

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.

Subscribers to the medical model of the causation of madness and distress emphasise the role of genes and can severely underestimate the impact of traumatic events on the development of the human mind. This bias persists despite the worldwide popular wisdom that mental illness arises when bad things happen to people. Childhood physical and sexual abuse and neglect are extremely common experiences among those who develop serious mental health problems. Unfortunately, victims are typically reluctant to disclose their histories of abuse and practitioners are often reluctant to seek it. We explore the nature and extent of the problem and the apparent reasons for the pervasive neglect of this important area of care. Then, on the basis of our experience in New Zealand, we provide guidelines on asking patients about childhood abuse and describe an ongoing initiative in the UK to further advance our understanding of the impact of abuse and our skills to detect it and treat survivors.

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’.

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.