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.

Self-injury (self-harm) occurs frequently and is familiar in the accident and emergency departments and surgical and medical wards of ‘acute hospitals’. Despite its common presentation, there are frequent and authoritative reports that patients' experiences of emergency hospital treatment for self-harm are often negative. There is compelling evidence for the need to improve delivery of care for patients who self-harm, and to improve the training, supervision, support and coordination of the staff groups delivering that care.

Herbal remedies are used by many people suffering from anxiety or depression. It is therefore important to know whether they generate more good than harm. A systematic review of the published literature revealed trial data for Ginkgo biloba, Lavandula angustifolia, Hypericum perforatum, Valeriana officinalis, Crataegus oxyacantha, Eschscholzia californica, Matricaria recutita, Melissa officinalis, Passiflora incarnate and Piper methysticum. Only two of these herbal remedies are supported by sound evidence: Hypericum perforatum (St John's wort) for mild to moderate depression and Piper methysticum (kava) for anxiety. Neither is free of risks. Our knowledge of herbal remedies is incomplete and the subject merits rigorous study.

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.