This article examines how madness is depicted in the work of Dostoyevsky. It gives a brief account of Dostoyevsky's life before looking at the many ways in which he portrayed insanity. It suggests that he provided a sophisticated and complex picture of mental illness which has relevance for how contemporary clinicians conceive of psychiatric illness.

Buprenorphine, a partial μ-opioid agonist and κ-opioid antagonist, is recommended as safe and effective maintenance treatment for opioid dependence. It offers the possibility of management in primary care settings. However, its prescription has led to diversion for illicit recreational use and resulted in medical complications and, rarely, fatal overdose in combination with other sedatives. The outcome of buprenorphine maintenance programmes varies from country to country and it is determined by the local therapeutic traditions, regulatory restrictions and existing service provision for opioid misusers. This article addresses the pharmacology of buprenorphine, the benefits and drawbacks of its prescription, service provision for opioid misuse around the world, policy recommendations, and prescribing training requirements.

Feedback is an essential part of the learning process. Feedback can be positive or negative, constructive or destructive, minimal or in depth. It must always occur and should never be ignored. The role of effective feedback is critical in the modern postgraduate medical educational process in the UK, with its emphasis on competency-based curricula and workplace-based assessment. Feedback is not new in medical education and has been shown in research to be effective in bringing about change, particularly improvement in clinical performance. There are clear principles and features of good and bad feedback and these are highlighted, along with descriptions of models for use in daily practice.

This commentary discusses how much we appear to know about self-harm and the circumstances in which it may occur but how little we really know about what works in managing it. It reviews how suggestions for its management conflict with what we know about self-harm and the outcomes of young people. The challenge appears to be how better to identify those at risk of further self-harm and to train frontline staff in this, so that at-risk individuals may be referred to specialist services. Perhaps there is also a need to review the evidence for what actually works in reducing repetition of self-harm.

A series of psychoanalytic theorists and clinicians have suggested that conflicts about anger play a central role in the development of depression. Research data have supported the notion that patients struggle with the experience and expression of angry feelings. Anger in people with depression often stems from narcissistic vulnerability, a sensitivity to perceived or actual loss or rejection. These angry reactions cause intrapsychic conflicts through the onset of guilt and the fear that angry feelings will disrupt relationships. These conflicts lead to anger being directed inwards, further lowering self-esteem, creating a vicious cycle. Defence mechanisms that are triggered, including passive aggression, reaction formation, denial and identification with the aggressor, are ineffective at managing these conflicts and further prevent the appropriate expression of anger. This article discusses how to identify and detoxify angry feelings and fantasies using a psychodynamic approach.

Over 95% of cases of dementia are attributable to Alzheimer's disease, vascular, Lewy body and frontotemporal dementia, and a few other common causes. In this article we consider some of the rare and unusual causes that account for the remaining 5%. Categorising them according to aetiological group (degenerative, vascular and infectious causes, and human prion diseases), we discuss the presentation of these forms and reasons for variations in estimated prevalence rates in the general population.

Paranoid personality disorder is a neglected topic in clinical psychiatry, and is often the subject of diagnostic confusion and therapeutic pessimism. This article presents a summary of the key diagnostic issues relating to paranoid personality disorder and describes various psychological and social processes mooted to be central to the genesis of paranoid thinking and behaviours. The evidence relating to paranoid personality disorder and risk of violence is summarised and clinically useful guidance for the safe treatment of people with the disorder is outlined.

This commentary questions evidence put forward in support of minimal-medication approaches to the treatment of schizophrenia. Psychiatrists should indeed seek to minimise the amount of medication that they use in order to reduce the incidence of side-effects. However, there is strong evidence that antipsychotic medications do help people with psychosis towards recovery. In practice, psychiatrists do not rigidly follow guidelines recommending medication, but rather work with and support individuals in a broad-based way to make informed choices about their mental healthcare.

Binge eating occurs across the entire range of eating disorders. It is required for a diagnosis of bulimia nervosa but it is also seen in some cases of anorexia nervosa and in many cases of eating disorder not otherwise specified (usually referred to as eating disorder NOS or atypical eating disorder). This article focuses on the management of those eating disorders in which binge eating is a prominent feature.

Plants have been used for medicinal purposes for centuries, treating everything from non-specific ailments such as backache and colds to serious conditions, including depression and cancer. In this review, a few commonly known plants with psychotropic effects (St John's wort, Ginkgo biloba, kava, ginseng and valerian) are discussed by way of illustration. The readers' attention is brought to important interactions between herbal remedies and conventional drugs. A background to the constituents of herbs, possible mechanisms of action and an explanation of their antioxidant properties is given.

The classification of depression has been debated for decades. The introduction of operational criteria and the category of major depression were significant advances in the 1970s. However, the validity of the major depression category is controversial. The article highlights the limitations of using severity criteria and cross-sectional evaluation to diagnose depression. It recommends the classic typologies (melancholia, dysthymia and adjustment disorder) for clinical presentations of depression, highlighting the need to use longitudinal clinical patterns and context for diagnosis. Major depression owes its success to its loose definition, to the subordinate status of adjustment disorders and dysthymia and to the mechanistic application of the diagnostic hierarchy and criteria. There is a need to focus more on the context of depression (stress, coping and support) and to reduce the medicalisation of distress.

People detained in prisons, psychiatric hospitals, police custody and immigration detention centres remain a cause of concern, particularly to professionals, politicians and the media. As the number of people detained by the state increases, Courts have been taking an increasing interest in cases in which individuals have died in state custody. Such cases are subsumed under Article 2 of the Human Rights Act 1998 – the right to life. Article 2 case law has elucidated key principles that can be applied in practice. Importantly, it imposes on states not only a negative duty not to take life intentionally or negligently, but also a positive duty to safeguard life. The inherent positive obligations have two aspects: first, there is a duty to provide an effective and impartial investigation in cases of death resulting from the activities of state officials, and second, a duty to safeguard and protect life.

Depression in schizophrenia has been a neglected field for some time, but much evidence exists as to the common occurrence of affective disturbance in so-called non-affective psychosis. Depression is related to poor outcome in terms of functional recovery, relapse rate and suicide, and there is increasing evidence that it also precedes the onset of first-episode psychosis for many individuals. This article reviews recent steps forward in the evidence base for depression in schizophrenia in terms of prevalence, importance, assessment and treatment implications, with the aim of providing useful information for practising psychiatrists.

This article offers an introduction to advocacy on behalf of people with mental disorders and/or intellectual disabilities. It concentrates mainly on the issues related to independent specialist advocacy, but refers to other forms also. The term is itself contentious, having different meanings in different contexts. Some of these controversies are outlined here. Inevitably, diverse interpretations imply varying practices, and these too are illustrated briefly. Legislation and concordance of expectations are both contributing to a set of standards to which most advocates in the UK and Ireland will adhere. The requirements that such legislation makes of mental healthcare staff working with independent specialist advocates are outlined, and the ethical dimension of mental health advocacy is noted.

Cinema is at once a powerful medium, art, entertainment, an industry and an instrument of social change; psychiatrists should neither ignore nor censor it. Representations of psychiatrists are mixed but psychiatric treatments are rarely portrayed positively. In this article, five rules of movie psychiatry are proposed, supported by over 370 films. Commercial and artistic pressures reduce verisimilitude in fictional and factual films, although many are useful to advance understanding of phenomenology, shared history and social contexts in psychiatry. Acknowledging some negative representations, three areas are explored where cinema gets it mostly right: addictions, bereavement and personality disorder. Although there are excellent representations of psychosis on film, film-makers have more often portrayed it violently – ultimately demonising people as psychokillers in more than 100 films cited. When people with mental illness are stigmatised through stereotypes, examining unwelcome depictions can uncover important truths. Psychiatrists' engagement with film will ensure professional and artistic gains.

Antipsychotic medication is the primary form of treatment offered to people diagnosed with schizophrenia or psychosis, but it is associated with severe adverse effects, it is often experienced as unpleasant and its benefits may have been overstated. Therefore, it is important to evaluate research into approaches that aim to minimise the use of this medication. Existing studies suggest that such approaches can be successful and result in avoidance of antipsychotics in a high proportion of clients.

Systemic lupus erythematosus (SLE) is a disorder which can affect the central nervous system and result in a broad range of psychiatric syndromes such as psychosis, mood disorders, acute confusion and cognitive dysfunction. Despite the robust nomenclature of neuropsychiatric SLE (NPSLE), psychiatric syndromes in patients are often non-specific and may be secondary to concurrent non-SLE-related conditions and complications of medical therapies. Although the exact immunopathological mechanism for psychiatric presentation remains elusive, prompt exclusion of other factors contributing to the psychiatric symptoms coupled with effective assessment strategies and management with immunosuppression and psychiatric therapy are imperative. Psychiatrists and rheumatologists must work in close liaison to identify, treat and prognosticate patients with psychiatric syndromes in order to improve their quality of life, vocational aptitude and, ultimately, survival.

Dementia is is stereotypically associated with older people. However, in a significant minority it can affect people in their 40s and 50s, or even younger. Currently there is a lack of awareness, even among healthcare professionals, and there is a dearth of appropriate services for such patients. Despite the attention given to this condition by National Institute for Health and Clinical Excellence guidelines, provision of specialist early-onset dementia services in the UK remains patchy. Carers and patients often find themselves being passed ‘from pillar to post’ between psychiatry and neurology, and also between adult, old age and liaison psychiatry. The responsibility for identifying available and appropriate help is often left with carers. This leads to unnecessary delays, causes undue distress to patients and places an added burden on carers.