Triage wards were introduced as a new model of psychiatric in-patient care in 2004. However, there is limited evidence comparing them with the traditional in-patient models of care. This article reviews the history of triage wards, their principles, the evidence for this model (e.g. length of in-patient stay, readmission rates, staff and patient satisfaction) and the development of assessment wards based on the triage model of care. The evidence shows that the triage model has higher rates of rapid discharge, with a greater proportion of ‘acute care’ performed in the community with the support of home treatment teams. This leads to lower bed occupancy in the triage wards without increased rates of readmission or a worse patient experience of in-patient care. However, overall staff experience was better in the traditional model, given that staff satisfaction rates were lower on locality wards in settings with triage systems in place. Future research should explore the potential impact on home treatment teams, and the rates of serious incidents due to the high number of acutely unwell patients on triage wards.

Intra-hospital transmission of COVID-19 is a major concern. To mitigate this risk, ‘COVID-triage’ psychiatric wards were implemented by some in-patient service providers in the UK. Although the effectiveness of this model has not been investigated, there are questions about the benefits and detriments of this model of care for patients and staff. This reflection draws from the experiences of clinicians who were redeployed from their planned clinical posts (and training rotations, in the case of trainees) to staff a newly established COVID-triage ward at a large urban mental healthcare provider, between August 2020 and March 2021.

In an earlier article we reviewed the latest research on the relationship between religious involvement and mental health, the effects of religiosity on mental health and well-being over time and the impact of religious interventions. Here we focus on clinical applications that may be useful to psychiatrists and other mental health professionals. We discuss general clinical applications relevant to all patients (e.g. taking a spiritual history, supporting/encouraging religious beliefs, referring to clergy), violations of clinician–patient boundaries and the need to ensure that religious/spiritual interventions are patient-centred. We describe evidence-based religious interventions and how to identify appropriate patients for this approach. Finally, we explore situations in which religious beliefs and practices may be a problem, not a resource, and make recommendations on how to address such cases. Case vignettes illustrate clinical situations that mental health professionals are likely to encounter. Although the focus is on the North American context, we note how practice and culture in the UK may differ.

Antipsychotics are the cornerstone of schizophrenia management but they are not adequate in treating the negative and cognitive symptoms of the illness. The Cochrane review discussed in this commentary examines the safety and effectiveness of the wakefulness-promoting agent, modafinil, as an adjunct to standard care in the mitigation of negative and cognitive symptoms of schizophrenia. Add-on modafinil, compared to add-on placebo and standard treatment, did not result in a clear benefit. Due to the heterogenous body of evidence, the quality of which ranged from very low to moderate, the review's conclusions are equivocal.

Electroconvulsive therapy (ECT) for depression is a controversial treatment with highly polarised views about the balance between therapeutic benefits and adverse effects. Studies investigating whether ECT is more effective than a placebo treatment started in the 1950s, with the most important randomised controlled trials carried out about four decades ago in which ECT was compared with sham ECT (SECT) involving anaesthesia but no electrically induced seizure. Subsequently the data have been pooled in a number of meta-analyses which have found that ECT is an effective treatment. However, a recent review of the quality of the SECT-controlled studies, and the meta-analyses based on them, concludes that their quality is too poor to allow assessment of the efficacy of ECT and that, given its risks (permanent memory loss and death), the use of ECT should be suspended. This commentary critically discusses the methodology of this review and its conclusions.

The four main Indian religions – Hinduism, Buddhism, Jainism and Sikhism – have several shared concepts about self and suffering, which are salient to the world-view of the followers of these faiths. Understanding the concepts of mind, self and suffering in these faiths can help clinicians build better rapport and gain deeper understanding of the inner world of patients of these faiths. This article highlights the broad cultural and religious beliefs of these groups, with the hope that increased knowledge among clinicians might lead to better therapeutic engagement.

Psychiatrists live and work in complex, clinically challenging times. Their paperwork is geared increasingly towards defensive practice, key performance indicators and risk assessment forms. Somewhere in the process, detailed understanding of patient experience and clinical formulation based on key psychiatric expertise and skill in mental state examination have taken a backseat. I review the history behind the Present State Examination, the realisation in the 1980s of the need for a common psychiatric language internationally and the current position on phenomenology in psychiatry curricula in the UK. I conclude that it is time to think seriously about a return to basics in psychiatric phenomenology and psychopathology.

Psychostimulants (dexamphetamine, methylphenidate, modafinil) reduce fatigue, promote alertness and wakefulness, and have possible mood-enhancing properties. In modern psychiatric practice, their use has been limited to attention-deficit hyperactivity disorder and sleep disorders such as narcolepsy. Despite this, research has continued into psychostimulant use in general psychiatry, especially in the treatment of depression and fatigue. This article reviews the recent literature regarding psychostimulant use in general and consultation-liaison psychiatry. Although psychostimulants continue to attract clinical research, there is currently not enough evidence to recommend their routine use for general psychiatric conditions.

Therapy for sexual problems is not solely based on findings from scientific studies; much of it has to do with intuitive knowledge that comes from personal and clinical experience. The author suggests that an ideal way to begin education about helping with patients' sexual identity, sexual function and relational concerns is to consider why sex is important. Answering this question illuminates the subtle roles sexual behaviour play in our lives. These roles are explained by providing clinically based responses to twelve questions: How are adults nurtured in sexual relationships? How is psychological intimacy created? What is learnt over time through sex? What accounts for the pleasures of sex? Why is sex important? Why is sexual experience unstable? What is a couple's sexual equilibrium? What is sensuality? Is a life of sexual pleasure possible? What is sexual health? What are the sources of distress about sex? How do these concepts facilitate therapy?

In response to an article on recent advances in the use of ECT for depression, this commentary supports earlier and more extensive use of the treatment. It challenges the belief that ECT is associated with a higher risk of cognitive deficits and mortality and points out its rapid effect compared with antidepressant medication. It calls for clinicians to remain up to date regarding ECT and consider its opportune use in severe depression.

No recent pandemic has had such a severe socioeconomic impact as COVID-19. Significant economic uncertainty and social restrictions have led to increased levels of stress for many. There has been increased social isolation, financial stress and alcohol intake, all of which can increase domestic abuse and other forms of household abuse. Increases in abuse in the home found in other public health emergencies and economic recessions can be seen now – reported UK domestic abuse rates have increased since the start of COVID-19. This article focuses on how COVID-19 and its anticipated aftermath exacerbate the risk factors for domestic abuse in the general population and discusses clinical implications for mental health practitioners in the UK. It aims to provide a point of learning based on previous disease outbreaks and recessions, with a focus on specific factors, such as unemployment and alcohol misuse, and how these contribute to increasing incidence and severity of abuse – and more importantly, how mental health professionals can mitigate these for patients, 1 in 3 of whom are estimated to have already experienced abuse before the COVID-19 pandemic.

Psychosis is a recognised feature of several psychiatric disorders and it causes patients significant distress and morbidity. It is therefore important to keep knowledge of possible risk factors for psychosis up to date and to have an overview model on which further learning can be structured. This article concludes a three-part series. It gives a review of evidence regarding common pathways by which many risk factors come together to influence the development of psychosis and finalises our suggested overview model, a psychosis risk timeline. The three primary pathways considered are based on the major themes identified in this narrative review of recent literature and they focus on neurological, neurochemical and inflammatory changes. We link each back to the factors discussed in the first and second parts of this series that alter psychosis risk through different mechanisms and at different stages throughout life. We then consider and summarise key aspects of this complex topic with the aim of providing current and future clinicians with a model on which to build their knowledge and begin to access and understand current psychosis research and implications for future preventive work.

Despite much research, environmental influences that can be said to cause a schizophrenic illness remain elusive. When the effects of an (often prolonged) prodromal syndrome are taken into account, the first episode appears to come from nowhere. However, over the past couple of decades a number of factors have emerged that can be argued to influence, and not merely reflect, the illness onset. The possible effects of season and geography of birth, urbanisation, immigration, substance misuse, prenatal influenza, famine and other stresses, and obstetric complications are summarised. These varied findings, often of small effect and borderline significance, present a challenge to clinicians attempting to make sense of their patients' life experiences. Any hard conclusions still depend largely on how one formulates the illness.

The phenomenon of acute behavioural disturbance (ABD) (also known as acute behavioural disorder or excited delirium) is an underrecognised and potentially life-threatening syndrome, and an emergency in psychiatric settings. Causes are discussed and the pathophysiology explained. The challenges faced by practitioners are highlighted, including how ‘standard’ control and restraint can exacerbate symptoms. Initial treatment strategies are suggested.

This commentary gives a very brief overview of depression in epilepsy (prevalence, risk, associations between the two conditions, antidepressant medication) and assesses the quality and results of a Cochrane Review comparing antidepressants with placebo and psychotherapy in managing the condition. Although antidepressants were not shown to be more effective than other interventions and no link between antidepressants and increased seizure frequency was observed, the low-quality evidence obtained cannot provide conclusive answers.

I comment on a new overview of the treatment of delusional infestation. I focus on the challenges of communicating with a patient who has delusions and evaluate practical advice. I look at philosophical models to explain those communication problems as well as theories of delusional formation, and examine how these may help clinicians to understand and overcome those challenges.

We consider some advances in relational and affective neuroscience and related disciplines that attempt to resolve some fundamental aspects of the mind–brain problem. We consider the key role of affect in generating consciousness and in meeting our essential survival needs; the neural correlates of relating; how self and other are represented in the brain and awareness of self and other is generated through interoceptive predictive processes. We describe some leading models of the generation and purpose of consciousness, linking theories of affective and cognitive consciousness. We discuss psychiatric and psychotherapeutic innovations arising from this research, new integrated biopsychosocial interventions and the obstacles to be overcome in applying these models in practice.

Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse reaction to drugs. In psychiatric practice, it is mainly associated with antipsychotics. The classic presentation is that of hyperpyrexia, muscle rigidity, mental state changes and autonomic instability. Subtle forms are difficult to recognise owing to symptom overlap with other conditions. This article discusses the clinical presentation of the syndrome, its differential diagnosis and use of supportive care, medication and electroconvulsive therapy in its treatment. It also explores prevention of NMS and reinstatement of treatment after an episode. It is stressed that all but the mildest forms of NMS should be considered a medical emergency that is properly managed in an acute hospital.

Neurosurgery for mental disorder (NMD) is currently performed in the UK for cases of severe depressive disorder and obsessive–compulsive disorder refractory to treatment, under stringent regulations as set out under the Mental Health Act 1983. These surgical procedures appear to be effective for a proportion of individuals in this particularly treatment-resistant cohort. The two ablative procedures currently in use in the UK are anterior cingulotomy (ACING) and anterior capsulotomy (ACAPS). After briefly outlining these procedures, their evidence base and how they compare with other neurosurgical procedures, we suggest two ways in which they could be enhanced in terms of precision, namely the use of stereotactic (Gamma Knife®) radiosurgery guided by magnetic resonance imaging as well as a detailed and expanded standardised psychopathological and neuropsychological assessment both before and after surgery. The latter should involve extended long-term follow-up. We then reflect on how such psychopathological and neuropsychological assessments could help to understand why and how these procedures relieve patients’ suffering and distress.