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.

Procedures following suicide differ in Scotland from elsewhere in the UK and we describe the investigation of deaths by procurators fiscal and fatal accident inquiries that may ensue. Higher Scottish suicide rates, and possible reasons for these, are mentioned. Suicide risk cannot be accurately quantified in individual patients but psychiatrists should take the view that good management can collectively reduce the risk among all patients. We comment on practical and emotional issues for clinicians who are coping with the suicide of a patient.

Around 7.1 million people in England drink hazardously or harmfully and a further 1.1 million are dependent on alcohol. Motivational interviewing is widely used to treat people with alcohol problems and is probably the best described example of a brief intervention. However, some recent trials have been disappointing. Specialised alcohol treatment services have also suffered from weakness in the evidence base. Investment in treating alcohol misuse has fallen far behind that for drug misuse. The Department of Health's Alcohol Harm Reduction Strategy for England embraces policies that are high-profile and cheap but are ineffective and ignore many effective measures. It recommends stepped care for alcohol treatment, but unlike the equivalent for drugs treatment, it sets no targets and leaves the small (7%) increase in funding to the discretion of local purchasers. UK spending on specialised treatment for drug misuse is estimated to be around £600 million for 2007 – around three times the estimated cost of treatment for alcohol misuse.

Sequenced (stepped) treatment approaches are widely endorsed in the management of depression. Combining antidepressants is a recognised step for those failing to respond to monotherapy. Despite the limited evidence base, this strategy is widely used by clinicians in practice. Not every combination used clinically has a sound neuropharmacological rationale and the use of such combinations may increase the side-effect burden without any additional advantage to the patient. Efficacy of various antidepressant combinations along with the data on side-effect profile and toxicity of such combined treatments are reviewed here. The different combinations are considered by each class of antidepressant available in the UK.

The psychiatric problems of combat returnees are a topical and important issue given the ongoing conflicts in Iraq and Afghanistan. Despite the media prominence afforded to post-traumatic stress disorder, the most common disorders in the UK armed forces post-deployment are depression, alcohol misuse and anxiety disorders. Although the majority of service personnel do well after leaving military life, a minority who leave with psychiatric problems appear to be at risk of social exclusion and ongoing ill health. Reserve veterans are at greater risk as they do not have access to the usual support networks of the regular military. Steps to improve the knowledge and expertise of primary care services about veterans' mental health issues and increasing the availability of treatment options are important and are underway.

Alcohol policy varies in different jurisdictions and is subject to change. Understanding policy development requires an international perspective. Current models of alcohol treatment systems require an understanding of the different impacts of interventions on different patient groups and clarity in the description of interventions and populations. Several systematic reviews have evaluated the outcome of alcohol treatment favourably and shown it to be highly cost-effective.

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.

Making decisions in the context of risk is an integral part of psychiatric work. Despite this, decision-making skills are rarely systematically taught and the processes behind decisions are rarely made explicit. This article attempts to apply contemporary evidence from cognitive and social psychology to common dilemmas faced by psychiatrists when assessing and managing risk. It argues that clinical decision-making should acknowledge both the value and limitations of intuitive approaches in dealing with complex dilemmas. After discussing the various ways in which clinical decision-making is commonly derailed, the article outlines a framework that accommodates both rational and intuitive modes of thinking, with the aim of optimising decision-making in high-risk situations.

The Human Rights Act was introduced into UK law in 2000 and must be considered in all cases, including mental health review tribunals. Article 8 (the right to respect for private and family life) comprises two parts and has embedded in it ‘tests’ that must be applied when assessing any interference with this protected right. A review of Article 8 case law reveals how it is used and how it can be applied in a myriad of clinical situations. Because it involves the right to respect for private life, and is in a sense individualised, it will potentially affect people (both patients and staff) in the mental health services in a variety of ways. Article 8 has implications not only for patients but also for clinicians and healthcare organisations.

Depression is an illness that kills. The links between depression and medical illness are well established and bi-directional, but evidence is mounting that depression increases mortality as well as morbidity in adults, particularly older adults. We examine the evidence that the increase in mortality in depression applies to all-cause mortality as well as cardiac mortality, and describe plausible physiological theories for the association. We conclude that excess mortality arising from depression is a major public health problem that is largely unrecognised and needs to be addressed by a range of clinicians.

Shame and self-criticism are transdiagnostic problems. People who experience them may struggle to feel relieved, reassured or safe. Research suggests that a specialised affect regulation system (or systems) underpins feelings of reassurance, safeness and well-being. It is believed to have evolved with attachment systems and, in particular, the ability to register and respond with calming and a sense of well-being to being cared for. In compassion-focused therapy it is hypothesised that this affect regulation system is poorly accessible in people with high shame and self-criticism, in whom the ‘threat’ affect regulation system dominates orientation to their inner and outer worlds. Compassion-focused therapy is an integrated and multimodal approach that draws from evolutionary, social, developmental and Buddhist psychology, and neuroscience. One of its key concerns is to use compassionate mind training to help people develop and work with experiences of inner warmth, safeness and soothing, via compassion and self-compassion.

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.

Hoarding seems to be a non-specific symptom, as it has been associated with a wide range of psychiatric disorders. Validating hoarding as pathological is controversial and its nosological status remains unresolved. ‘Diogenes syndrome’ has been paradigmatic in this area, but its clinical use seems limited. Hoarding is not explicitly covered in either DSM–IV or ICD–10 and literature suggests that diagnosis of mental illness may consequently be missed in this population. In the context of these theoretical uncertainties, clinicians still need to accurately assess and treat patients who show hoarding behaviour. To this end, we summarise the available evidence, and present assessment and management algorithms together with a multicomponent psychological intervention that aims to teach patients to successfully apply the three Rs (reduce, recycle, reuse).

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.

Assessment is key to the educational process and plays a significant role in looking at the progress trainees make as a result of training and personal development. Recent developments in curricula have led to substantial changes in assessing progress and attainment throughout postgraduate medical education in the UK. This article outlines the framework used to develop the postgraduate curriculum in psychiatry and describes the nature and purpose of the assessment programme that forms part of this new curriculum. The article considers the principles of medical education that are essential for the success of assessments, not only centrally in the development of the assessment system, but also locally in the delivery of these assessments. The overall context of developments in medical education, as well as the relationship between workplace-based assessments (WPBAs) and formal examinations, are described with specific references to developments in psychiatric training, its curriculum and assessments.

Violent behaviour in people with a psychiatric disorder causes great public concern and leads to stigma for people with mental illness. There is good evidence for a correlation between schizophrenia and increased rates of violence but any association between mood disorders and violence has been comparatively overlooked. It appears that there may be more evidence relating mood disorders and violence than many clinicians realise. This article highlights the difficulties in assessing this, summarises what is known and discusses what this means for clinical practice.

UK guidelines for treating people diagnosed with schizophrenia currently emphasise the primacy of antipsychotic medication, with or without psychosocially based interventions as circumstances dictate. We now see increasing calls, most notably from mental health service users, for the provision of ‘whole-person-based’, minimal-medication approaches to treating people with this diagnosis. This article is intended to locate the development of such approaches within the history of modern and pre-modern psychiatry and, in doing so, summarise the available evidence base that underpins their efficacy.