Conversion disorders tend to be poorly understood and diagnosis can be difficult. In this article, we aim to clarify what conversion disorders are and how they can be distinguished from other psychiatric disorders that involve physical symptoms. Prevalence, prognosis and relationship to organic disease are controversial areas; we outline what is known about them and provide some historical context. Aetiological theories and management strategies are discussed, the latter with the aid of case vignettes.

For nearly three decades, closure of large psychiatric and learning disability hospitals has continued and more people with mental health needs remain in the community. With this continuing decrease in hospital provision, there has been an increased focus on the development of systems of safe care and effective treatment for people with significant mental health problems living in the community. Attempts to make this a central plank of mental health care have been reflected in legislation and guidance produced by the Department of Health. The Care Programme Approach (CPA) was introduced in 1991 after the publication of HC (90) 23/LASSL (90) 11 and subsequent guidance from the White Paper Caring for People (Department of Health, 1990).

Homeless families are defined as all adults with dependent children who are statutorily accepted by local authorities (housing departments) in the UK, and are usually accommodated for a brief period in voluntary agency, local authority or housing association hostels. This period varies from a few days to several months, although the target for rehousing is usually around 4 to 6 weeks. Some housing departments, particularly in London, also use bed and breakfast accommodation.

During the past decade, increasing attention has been paid to the primary care level of service for children and adolescents with mental health problems. In particular, a number of national reports have advised service commissioners and providers to increase the amount of specialist child and adolescent mental health services (CAMHS) support to primary care colleagues (Department of Health/Department for Education/Social Services Inspectorate, 1995; National Health Service (NHS)/Health Advisory Service (HAS), 1995; Audit Commission, 1999).

General principles of management of patients with personality disorders admitted in crises to the in-patient unit are discussed. The role of the acute ward in the overall plan of care, the clinical thresholds to consider in deciding whether admission is appropriate and the main elements of the in-patient care plan are outlined. The management of patients with borderline personality disorder, who constitute the majority of such admissions, is discussed in detail.

This article is intended to update prescribers of electroconvulsive therapy (ECT) on the key points of the revised edition of the Royal College of Psychiatrist's ECT Handbook (due to be published in 2005). The two most important tenets that influenced the revision were that evidence from systematic reviews and appraisals was balanced with expert judgement based on clinical experience, and that both prescribers and practitioners should strive to reduce further the cognitive adverse effects of treatment. The article concentrates on revised guidance regarding the indications for ECT, important elements of the process of informed consent, and the prescription of treatment, i.e. choice of electrode placement and the frequency and total number of treatments.

Mental health professionals regard the assessment of suicide risk as part of normal clinical practice, but most shy away from assessment of risk of interpersonal violence, either doubting that such predictions are possible, or, if possible, are part of their role. In part, this fastidiousness reflects the influence of a consensus which emerged in the 1970s to the effect that there was no substantial relationship between mental illness and violent behaviour. The only basis for risk assessments which remained were those factors in the general population known to be associated with criminality. Even here, however, the accuracy of predictions made by clinicians had been subject to considerable critical scrutiny, which undermined any claims the profession may have had to expertise (Monahan, 1981; Brizer, 1989). There seems to have been wide acceptance that psychiatrists were doubly disabled in the business of predicting violence by having no relevant specialist knowledge and by being poor at applying knowledge gleaned from other disciplines such as criminology.

In the interest of road safety, driving license holders who suffer from a medical condition likely to affect fitness to drive must notify the Driver and Vehicle Licensing Agency (DVLA) and not drive. The Secretary of State for the Environment, Transport and the Regions (of the Department for the Environment, Transport and the Regions, DETR) has the responsibility, via his Medical Advisers at the Drivers Medical Unit of the DVLA, to ensure that all licence holders are fit to drive.

Effective pharmacological management of depression resistant to antidepressant medication is best carried out in the context of a supportive and collaborative relationship, following a mutually agreed care plan. Simpler pharmacological approaches such as switching antidepressant classes are tried first, then augmentation is used if needed. New classes of antidepressants have made antidepressant combination a popular augmentation strategy, but lithium addition has most supporting evidence. The use of atypical antipsychotics as augmenting agents is increasing. For patients unresponsive to these strategies, monoamine oxidase inhibitors and electroconvulsive therapy remain important. Large randomised pragmatic trials are needed to help clinicians and patients make better treatment choices.

Against the backdrop of a tight financial climate, a new method of funding mental health services is being rolled out in England's National Health Service. Called payment by results (PbR), it represents a fundamental change to the way providers of psychiatric services are paid for care of patients. The Mental Health Clustering Tool has been developed to capture activity which reflects the relative needs of patients, and cluster costs are being collected by service providers. The ultimate goal is the creation of a national tariff or fixed price for each cluster. This article describes the incentives generated by PbR and gives evidence on PbR in acute physical care services where it has been in operation for a decade, with respect to efficiency, quality, volume of activity, administrative costs, upcoding or gaming, equity of provision, and cross-subsidisation. It explores the challenges for mental health services as PbR is introduced.

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.

All psychiatrists should be able to construct a psychodynamic formulation of a case. A key advantage of formulation over diagnosis is that it can be used to predict how an individual might respond in certain situations and to various psychotherapies. This article looks in some depth at what psychiatric trainees need to be taught about psychodynamic formulation. We introduce formulation in terms of four levels, each level corresponding to a different degree of theoretical and clinical sophistication and therefore to different trainees' needs. We use a case vignette to illustrate how a clinical situation might be formulated at each of these levels.

Epidemiological evidence has identified key strategies that may be used in the prevention of both Alzheimer's disease and vascular dementia. These strategies may be loosely divided into three areas: treatment of vascular risk factors, neuroprotection and increasing neuronal reserves. Evidence from randomised controlled trials already exists for treatment of hypertension but results for statins have been disappointing. Most of the intervention trials currently in progress focus on one or two risk factors and include cognition or dementia only as a secondary outcome. The potential of intervention strategies awaits confirmation by randomised controlled trials that target multiple risk factors in at-risk people with mild cognitive impairment, with incident dementia as the primary outcome.

Medically unexplained somatic complaints are among the most common clinical presentations in primary care in developing countries and they are a considerable burden for patients and the healthcare system. They are assumed to be the result of psychosocial factors, and the process by which symptoms are experienced is termed somatisation. Common mental disorders, somatoform disorders and socio-economic adversities are the major risk factors for these complaints. There is evidence suggesting that cognitive–behavioural therapy, which has proven efficacy for somatoform disorders in the developed world, can be used in developing countries with some adaptations (e.g. by simplifying the content so that it can be applied in primary care by non-specialist health practitioners; using culturally appropriate analogies; and delivering the intervention over fewer and shorter sessions). The main components of such an intervention are presented in this article.

Hyperprolactinaemia is a common endocrine disorder that can be associated with significant morbidity. Antipsychotic medications are frequently linked to hyperprolactinaemia. This disorder usually presents as menstrual problems in women and sexual problems in men, which affect the patients' quality of life and adherence to antipsychotic treatment. In the past, treatment for hyperprolactinaemia was recommended only for symptomatic patients. However, it has become clear that persistent asymptomatic hyperprolactinaemia can be associated with long-term physical morbidities such as osteoporosis and possibly breast cancer. Hence, it is imperative that hyperprolactinaemia is managed even if asymptomatic when initially detected. This article discusses the various management options, such as reducing the dose of antipsychotic medication, switching to a prolactin-sparing antipsychotic and adding aripiprazole to the treatment regimen.

The proportion of children affected by chronic illness is relatively high, approximately 10–12%. For these children, there is no available cure and the best that medical care can currently offer is relief from symptoms and the opportunity to participate in normal life as far as possible. Epidemiological work suggests that many of the children experience relatively few restrictions on everyday life, but about 1–2% of the total population of sick children have more severe conditions (Gortmaker & Sappenfield, 1984).

This article outlines common psychodynamics in psychosis. We consider psychosis as a response to unbearable aspects of reality and illustrate how psychodynamic concepts of psychological defence can be used as a framework for understanding this. We also present a psychodynamic approach to understanding the development of psychosis, using the stress–vulnerability model, and discuss interpersonal dynamics in psychosis, particularly their relevance to therapeutic relationships and to interactions between patients and their families. The perspectives presented are intended to complement and enrich other frameworks rather than compete with them.

Medication non-adherence is a major obstacle to translating treatment efficacy in research settings into effectiveness in clinical practice (Dickson & Kendall, 1986; Scott, 1995). Randomised controlled trials indicate that brief interventions such as cognitive-behavioural educational packages for depression, cognitive therapy for lithium clinic attenders and compliance therapy for people with schizophrenia may be beneficial (Cochran, 1984; Katon et al, 1995; Kemp et al, 1996). However, clinical psychiatry has been surprisingly slow to investigate individual risk factors for medication non-adherence or to use strategies to enhance adherence that have been used extensively in other chronic illness populations.

Home treatment as an alternative to acute adult in-patient care is part of the National Health Service Plan for mental health services in the UK. As a form of crisis intervention, it benefits from an understanding of, and ways of working with, the social systems relevant to the patient in crisis. This article reviews relevant terminology and background theory, and considers the social factors associated with psychiatric admission.

The health of family carers may affect not only their own lives but also the lives of the people for whom they provide care. This article describes how the caring role can affect the health and well-being of a carer of a person who has a mental or physical disorder. Suggestions are made about how to recognise and ameliorate some of the detrimental effects of the caring role on the carer's own health.