This article reports the results of a synthesis of qualitative research articles about lay perspectives on prescribed psychotropic medicines. It updates and elaborates on a model of medicine-taking developed by Pound and colleagues. In this model, the concept of resistance refers to the various ways in which people take prescribed medicines while trying to minimise their intake. The synthesis included 12 papers published since 1992. The findings are presented at the societal level, in terms of the social meanings of mental health problems and medication, and at the individual level; the latter covers active engagement and lay evaluation, as well as the outcomes of evaluation, including the doctor–patient relationship. Although it can be difficult to achieve in the current clinical environment, there is much scope for developing more concordant relationships with patients in relation to prescribing and using psychotropic medicines.

There has been a resurgence of interest in the role of childhood trauma in the aetiology of psychosis. In this review, recent findings on the association between childhood trauma and a continuum of psychotic symptoms are presented. Evidence of the association between specific childhood trauma subtypes and psychotic symptoms is examined, with a brief discussion of some current hypotheses about the potential mechanisms underlying the associations that have been found. Some practice implications of these findings are also highlighted.

Mental health services are increasingly expected to engage in a process of cultural change to fulfil guiding values and hopes for choice, personalisation, self-determination, social inclusion and personal recovery. It is unclear how this will be achieved. This transformational agenda also engages with an ambition for progressive change in practice across mental health professions to support people in self-care and self-management, based on a new relationship between practitioners and users of mental health services. There is little consistent guidance on the content of recovery-oriented and socially inclusive practice and what may be the new competencies and skills that would most effectively support recovery outcomes. Life coaching to support recovery for people with mental health needs is emerging as a creative possibility with considerable potential to support this ambition. This is an exploratory article which offers an overview of experience so far, suggests further routes for development and, in line with the College's Fair Deal campaign, underlines the need for evaluation.

This paper will describe the increasingly important role of the community psychiatric nurse (CPN) in the treatment and management of people with schizophrenia, and draw attention to new training programmes which have a focus on skills acquisition in evidence-based methods. However, before describing the way in which these programmes of training improve CPN skills, it is worth examining the history of community psychiatric nursing.

The most important psychiatric implication of experiencing trauma during war is post-traumatic stress disorder (PTSD). The core symptoms of PTSD are intrusive re-experiencing of traumatic events, hyperarousal in reaction to minor stimuli and avoidance of trauma-related triggers. In this paper we describe the phenomenon of intrusive reexperiencing, of which the post-traumatic nightmare (PTNM) is an impressive manifestation that causes considerable distress (Mellman et al, 1995; Schreuder, 1996; Ørner & de Loos, 1998; Schreuder et al, 1998).

Diversion from custody is a policy supporting the removal of people with mental disorders from the criminal justice system to hospital or a suitable community placement where they can receive treatment. There are three principal reasons why such a policy is necessary. First, when those with mental disorders fall through the net of psychiatric services they tend to gravitate towards the criminal justice system; second, the standard of health care provided in prison is, generally speaking, poor; and third, because prison health care centres are not recognised as hospitals for the purposes of the Mental Health Act (MHA) 1983, treatment for mental disorder cannot be given against a prisoner's will unless this can be justified under common law.

The concept of borderline personality disorder (BPD) seems to include, almost by definition, the idea that people described by the term are difficult to help. The broad picture portrayed by the diagnostic criteria (Box 1) is likely to be familiar to most clinicians and to cause the hearts of many to sink. A core issue for those with BPD is difficulty of relationship, and this will inevitably – even especially – include clinical and therapeutic relationship. It is all too common for distress to be met with much therapeutic effort but for little to change. Indeed, there is often a nagging sense that attempts at treatment may be making matters worse. The care of people with BPD presents an important challenge to mental health services. At the individual level, the patient continues to be at risk and to suffer and the clinician feels frustrated. At the service level, substantial resources may be expended to little apparent benefit.

Patients with severe and enduring eating disorders (SEED) may constitute a specific group. It is proposed that patients with anorexia nervosa (SEED-AN) or bulimia nervosa (SEED-BN) that requires the regular attention of a multidisciplinary team and is of a duration known to have a low recovery rate should be included in the SEED group. These patients present with a combination of severe symptoms and long-term illness, and may experience serious chronic physical sequelae (e.g. osteoporosis and renal failure), marked social isolation and stigma. Their carers suffer from the stress of caring for them over a prolonged period. Symptoms, treatment and crisis management of SEED-AN are discussed. SEED is a relatively recently described area of eating disorders psychiatry that requires research and service development so that patients and carers are helped to cope with very serious chronic, but not incurable, conditions.

Attention-deficit hyperactivity disorder (ADHD) is a commonly diagnosed childhood psychiatric disorder. Debate over its diagnostic validity, aetiology, presentation and treatment has extended from the clinical to the public domain. As children with ADHD diagnoses reach adulthood there is increasing interest in ‘adult ADHD’. Cohorts followed up show poorer outcomes as adults than do controls. Self-referred adults, sometimes relatives of children with ADHD, are also of interest regarding adult ADHD. Innovative work is being done examining issues of aetiology, treatment, outcomes and comorbidity in these groups, but heterogeneity among those diagnosed with ADHD and changes in classification systems and diagnostic criteria over time complicate comparison of research findings. The diagnostic validity of adult ADHD remains uncertain and needs further study.

Traditionally, delusions have been viewed as false, unshakeable beliefs which arise out of internal morbid processes and are out of keeping with a person's educational and cultural background (Hamilton, 1978). Primary delusions appear to arise without understandable cause, and secondary delusions appear more understandable in relation to the prevailing affective state or cultural climate (Sims, 1995), for example. However, during the cognitive therapy process we would expect that even primary delusions might become more understandable as the patient's life history and belief profile are gradually disclosed.

Depression, as a heterogeneous collection of disorders, is likely to include subgroups that are more genetic in origin. In common with other neuropsychiatric disorders such as schizophrenia, Alzheimer's disease and Huntington's disease, earlier age at onset in depression is associated with higher genetic loading and poorer long-term outcome. Adolescents and young adults with depression are also at high risk of developing a bipolar illness. This article reviews depressive illnesses that occur for the first time in adolescence and young adulthood. Case studies are used to discuss atypical presentations and the evolving concept of bipolar-spectrum disorders.

This article outlines the majority of the adverse physical effects that have been described secondary to the consumption of alcohol at levels above recommended sensible limits. These conditions are cited according to the organ system they belong to. Only brief descriptions are provided because of the vastness of this topic. The underlying pathophysiology of tolerance and withdrawal is touched upon as this is of relevance to the psychiatrist. Definitions of the terms used describing alcohol misuse, and sensible upper limits of alcohol consumption are also mentioned.

Acute mental disturbance associated with physical illness is well described in early medical literature, but it was not until 1 AD that Celsus coined the term ‘delirium’ (Lindesay, 1999). Although delirium has many synonyms that are applied in particular clinical settings (Box 1), all acute disturbances of global cognitive functioning are now recognised as ‘delirium’, a consensus supported by both ICD–10 (World Health Organization, 1992) and DSM–IV (American Psychiatric Association, 1994) classification systems. Delirium is a complex neuropsychiatric syndrome that typically involves a plethora of cognitive and non-cognitive symptoms, resulting in a broad differential diagnosis dominated by mental disorders. Psychiatrists' skills in assessing cognitive function and psychopathology, coupled with their knowledge of psychotropic agents, make them well suited to improving detection, coordinating management and facilitating research into this understudied disorder.

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.

Supervision is a key feature of professional development in a wide range of professions. The Royal College of Psychiatrists, in its ‘Statement on approval of training schemes for basic specialist training for the MRCPsych’ (available on request from the Postgraduate Educational Services Department of the Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG) dictates that each basic specialist trainee should have a “protected hour per week” with his or her educational supervisor. This time should belong “exclusively” to the trainee and be “for the benefit of the trainee”. The Higher Specialist Training Handbook (Royal College of Psychiatrists, 1998) also emphasises the central importance of supervision as part of higher training for specialist registrars. Training consultants are expected to be “readily available” to trainees, and to provide a “regular, weekly, timetabled supervision session”. Supervision is obviously perceived by those responsible for standard-setting in psychiatry as a key activity. However, there is a marked lack of clarity as to what constitutes good and effective supervision and there are often few opportunities for learning how to supervise. Hayes (1996) writes about research supervision but his comments are equally applicable to other forms of supervision. He suggests that quality supervision, where it exists, is often by accident rather than by design. It is likely to have been acquired experientially and not without some past hurt to either supervisor or supervised or both. He argues that too much attention has been paid to the quality control of supervision and not enough to quality assurance, with insufficient attention paid to all the possible roles of a supervisor and the key personal attributes necessary to fulfil these roles.

Young offenders with a learning disability may encounter a variety of different psychiatrists, most of whom do not claim any particular expertise in helping them. Child and adolescent psychiatrists, learning disability psychiatrists and forensic and prison psychiatrists may all see young offenders referred to them who have a learning disability –that is, ‘mental retardation’ as defined in ICD–10 (World Health Organization, 1992) (Box 1). Many of these psychiatrists do not see such referrals as a core part of their role, and perhaps because of this, surprisingly little is known about this group of young offenders. They frequently fall into the borderlands between different types of service provision, and as a result can become marginalised. This is of particular concern since recent work has suggested that young offenders with a learning disability may have substantial mental health needs. This article aims to summarise what is known about this group and describe how some of their mental health needs might be met.

In May 1999, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness published its first major report since it was reestablished at the University of Manchester (Appleby et al, 1999a). Entitled Safer Services, it presented findings from a two-year sample of suicides and an 18-month sample of homicides occurring in England and Wales, and on the basis of these put forward 31 recommendations for mental health services (Appleby, 1999b; Shaw et al, 1999). This article, modified from a chapter in Safer Services, discusses how services might deal with the risk of suicide and homicide or serious violence.

Community psychiatric teams are an integral part of modern mental health services. The development of such teams has allowed the care of patients to be transferred from institutions to the community. A Cochrane review of community-based programmes showed that community team-based psychiatric services led to a reduction in suicide rates, improved patient engagement and were more acceptable to patients (Tyrer et al, 1999). Community care also reduces the number of days patients stay in hospital, but not the number of admissions (Marshall et al, 1995). However, community mental health teams (CMHTs) have been criticised for their ambiguous and overambitious aims, and their tendency to neglect people with the most challenging health- and social-care needs (Patmore & Weaver, 1991; Sayce et al, 1991). All mental health workers are not necessarily eager, or skilled, to work effectively in teams. Building and maintaining an effective team requires commitment, clarity of purpose, a shared vision and frequent review of team operations. In a previous issue of APT, Burns & Guest (1999) described the adaptation and running of an assertive community treatment team in an inner-city area. Here I examine the attributes of effective CMHTs (Box 1), enumerate barriers and challenges to team-working (Box 2) and suggest strategies for improving team effectiveness (Box 3).

Up to a third of patients with schizophrenia develop treatment resistance. Clozapine has been established as the most effective antipsychotic medication for treatment-resistant schizophrenia. However, it is significantly underutilised in this population. Possible reasons include clinicians' lack of experience with the drug and negative attitudes towards it. African-Caribbean patients are less likely to be treated with clozapine compared with their White counterparts and more likely to have treatment discontinued due to perceived risk of agranulocytosis. This paper discusses the current evidence relating to the underuse of clozapine and factors responsible for this.

Critical psychiatry has often been confused with what is widely known as ‘anti-psychiatry’. In this article the distinction is clarified and the particular contribution critical psychiatry makes is outlined. That contribution is constructive criticism: of the relationship between medicine and mental health practice, of the way drug and psychotherapeutic treatments for mental health difficulties might be better understood. These have implications for everyday clinical practice and there is much to be gained by openly embracing the controversies critical psychiatry highlights.