Consultant psychiatrists are often called to work in teams that are functioning suboptimally. This is a major challenge, both professionally and personally. This article gives advice and strategies for working with struggling teams. It recommends combining objective-, data- and procedure-driven approaches to technical challenges with ‘softer’ person-centred and relational strategies matched to the learning needs of the team.

The article discusses the issues and challenges for mental health services in providing care for adults with attention-deficit hyperactivity disorder (ADHD). Based on work developed in Sheffield (UK), it describes the contribution that services integrated into community mental health teams may be able to provide. Given the likely increase in numbers of referrals of adults with ADHD (both ‘graduates’ from children's services and adults seeking diagnosis) and the pressures on resources, it is unlikely that current specialist services will be able to address the growing demand. A local service that can link with other mental health services and that has close links to primary care is most likely to provide a sustainable service model, but there are still considerable training needs for this model to be put into practice.

Deafness does not in itself cause emotional/behavioural or cognitive problems or psychiatric disorders. However, children with hearing impairment are at greater risk of developing emotional/behavioural problems and neurodevelopmental disorders. The incidence of both seems to be higher in deaf children from hearing families. Most prelingual deafness is caused by recessive genes; hence, most deaf individuals come from hearing families, the majority of whom do not use sign language. Numerous studies, in both hearing and deaf populations, show how the lack of access to language has an impact on the emotional development of children. This article focuses on the mechanisms by which early language deprivation mediates emotional/behavioural difficulties and consequent emotional dysregulation, and may produce behaviours and symptoms that can be misdiagnosed as neurodevelopmental disorders in deaf children and adolescents (from infancy to 18 years of age).

Philosophy both influences and is influenced by clinical and legal practice relating to suicide. This article begins with a brief history of attitudes in the UK and Europe towards those who attempt suicide. It describes the main philosophical positions regarding suicide, including the principle of respect for life, the utilitarian position, the theological principle, and the principles of autonomy and duty to others. It concludes that short-term interventions are justified in most cases, for example when the suicide attempt is a ‘cry for help’ and/or the individual is ambivalent in their attempt or likely to have a mental illness.

Gender identity disorders are not common. The most frequent is dual-role transvestism, but it rarely needs medical attention. The least frequent is transsexualism. Transsexualism is not usually indicative of serious psychopathology. Diagnoses should be made by a gender identity clinic and never by the patient, and a clear change of gender role should precede any hormone treatment. Patients must have lived and thrived entirely in their new gender role for at least 2 years before any genital surgery is undertaken. However, bilateral mastectomy might be considered for females after a year of life in a male role. With these selection criteria, the outcomes of surgery are generally good. In the UK, individuals may legally change their recorded sex, usually after gender reassignment treatment.

Psychiatry has had a significant influence on both Hollywood and world cinema. In turn, psychiatrists' fascination with psychiatric themes in films has inspired scores of books and bibliographies about films and psychiatry. Advances in medical education have led to the development of core-competency-based curricula for both undergraduate and postgraduate students. Learning objectives underpin such competencies. However, teaching competencies in the workplace is hampered by practical and ethical issues, especially in the case of psychiatric patients. Medical educationalists have found films to be a useful teaching tool with their larger-than-life vivid portrayals. In this article we demonstrate, with examples, the use of films and discrete film clips to achieve specific learning objectives that can be incorporated easily into most undergraduate and postgraduate teaching programmes in psychiatry.

Payment by results (PbR) for mental health services is currently being piloted with the aim of arriving at a national tariff for mental health by 2013/2014. The Department of Health has also established two pilot sites to consider applicability of PbR for learning disability services. This article outlines the concept of PbR in learning disability services and describes the progress of the pilot work being undertaken in this area.

The evaluation of treatment effects is important to both the clinician and the patient. However, outcomes in randomised trials are often difficult to apply to the clinic. The number needed to treat (NNT) is one method that facilitates the interpretation of clinical trials in a meaningful way. When combined with the number needed to harm (NNH), the balance between the risks and benefits of a particular treatment can be appreciated. We illustrate the use of these concepts by focusing on recent large pragmatic studies of antipsychotics, including CATIE, EUFEST and CUtLASS.

The 2007 amendments to the Mental Health Act 1983 and their accompanying Code of Practice produced new guidance on the limits of parental influence over young people's ability to consent. Previously, professional practice on decision-making and consent was guided by a combination of the Mental Health Act 1983 Code of Practice, the Family Law Reform Act 1969 and evolving English and Welsh case law. The 2007 amendments to the 1983 Act take heed of such influences and the Code of Practice specifically includes reference to European case law. What was previously left open to balanced professional interpretation has now been formalised into statute law. A central facet of this is the introduction of the concept of the zone of parental control, which derives largely from European case law. This article considers the derivation from case law of this novel concept and in particular its relationship with the European Convention on Human Rights.

Research that should change clinical practice is often ignored for years. Fifty-five new trials are reported in medicine every day. Psychiatrists need to have some way to sift, digest and act on new research to benefit their patients. This article outlines the key elements of evidence-based psychiatry in an attempt to address these needs. Initially, an evidence-based approach is about asking an answerable question, searching for the evidence and then critically appraising the available information for its validity and relevance. The fourth step involves integrating the evidence with clinical expertise and the patient's values. The whole idea is to improve real-life patient care. This article outlines a number of the tools needed to overcome some of the common problems that psychiatrists face when trying to find and use published research results to help solve patients' problems.

Acceptance and commitment therapy (ACT) is a descendant of cognitive-behavioural therapy (CBT). The model draws techniques from a wide variety of sources and unites them within a philosophical and scientific framework to create a principle-driven therapy. Psychopathology is understood as a narrowing behavioural repertoire that develops over time through maladaptive strategies to cope with unwanted private events. The six core components of the therapy remain consistent across a wide range of clinical conditions. The approach combines processes of acceptance and mindfulness with those of commitment and behavioural change to produce increased psychological flexibility and an expanded behavioural repertoire. Since its introduction in 1999 an increasing number of trials show promising results for a wide range of conditions.

This case illustrates a clinical management problem in which a terminally ill psychiatric patient racially abuses the Black staff caring for him. The clinical team has to tread a fine line between supporting staff victimised by the patient and ensuring his quality of life and care. It is important that patients' (and staff's) sensitivities relating to race and ethnicity are openly discussed at an early stage, so that appropriate clinical management can be negotiated.

This article outlines how MRCPsych courses have developed historically and gives an account of the factors that are currently driving changes in postgraduate psychiatric education. A brief description of educational theory that is applicable to the teaching of these courses is given, followed by a description of the teaching methods used. We also describe the different elements of an MRCPsych course, from the resource requirements to the way the course is structured and delivered. The principles described and examples given may be of interest to experienced course organisers and may be helpful to those taking on the role of course organiser for the first time.

Body dysmorphic disorder is a distressing and often disabling condition characterised by a preoccupation with imagined or slight physical defects in appearance. It has been recognised as a mental disorder for many years (and named body dysmorphic disorder since 1980), but epidemiological studies and clinical trials have been few. To a large extent, the disorder has been ignored by the mental health community, who often fail to elicit the diagnosis. This article reviews the diagnostic criteria for the disorder, its validity and its relationship to other disorders such as obsessive-compulsive disorder, anorexia nervosa, social phobia and somatisation disorders. The course of the illness, its aetiology and treatment approaches are discussed. As research is growing alongside an increase in patient presentations, body dysmorphic disorder requires a coherent response from healthcare services.

Hope has long been considered a relevant variable in medical disciplines, but little attention has been paid to the concept, and its clinical and research implications, in psychiatry. This article illuminates the topic of hope from four different perspectives relevant to psychiatric research and practice. The four authors discuss hope from the viewpoint of their specific area of expertise, providing an overview of philosophical, conceptual, research and recovery-related reflections concerning hope in psychiatry.