The World Health Organization (WHO) has indicated that 8–12% of couples worldwide experience infertility, and in recent years the number seeking treatment has dramatically increased. The diagnosis and therapy put a heavy psychological and physical burden on most patients, female and male. The incidence of depression in couples presenting for infertility treatment is significantly higher than in comparable fertile couples. Anxiety is significantly higher in infertile couples than in the general population. Professionals have become aware of the importance of providing educational interventions to address patients' fears and concerns, and to better prepare patients for the demands of treatment. Health professionals should follow a patient-centred approach to provide for the specific needs of the couple. Women in general have a positive attitude to seeking psychological help in the form of cognitive-behavioural therapy, couples counselling and infertility counselling.

The association of life events with the onset of various psychiatric disorders is well-known. The body of evidence has highlighted the impact of negative or positive life events on the genesis of common mental disorders, especially depression. These findings have been replicated across different cultures, although the impact of different life events varies between cultures. In addition, the roles of chronic difficulties (defined in Life events and psychiatric disorders, below) and resulting ongoing chronic stress have been shown to contribute to vulnerability to certain mental illnesses. However, data on the impact of life events, especially those perceived as racial, on members of minority ethnic groups are rather sparse. The questions that need to be addressed concern the perception of life events as racial, the role of pervasive and perceived institutional and individual racism, and chronic difficulties.

This article reviews the literature on advance statements, including current mental health law and guidance in England and Wales, ethical and practical advantages, disadvantages and barriers to implementation. The idea of planning psychiatric treatment for a time when mental capacity may be impaired is not new. Yet there has been a renewed interest following the introduction of the Mental Capacity Act's 2005 provision of legally binding advance decisions to refuse treatment. In addition to information on treatment refusals, advance statements provide information on treatment preferences and personal care instructions which, although not legally binding, should inform treatment decisions. Advance statements are not yet widely used, but existing limited evidence suggests that they could reduce coercion and improve service users' satisfaction with treatment.

Somatising disorders, characterised by complaints of unexplained physical symptoms, are common presentations in children and adolescents, both in primary and secondary care settings. They have significant impact on the children themselves and on health care resources: as in adults, there is a wide range of severity and resulting handicaps.

Anxiety has reported prevalence rates between 38 and 72% among people with dementia. It has a negative impact on cognitive impairment and is associated with agitation and poor quality of life. The presence of excessive anxiety can be difficult to establish in people with dementia, especially when expressive or receptive speech is impaired. Unfortunately, there is a lack of research on the treatment of anxiety in dementia, and also on the wider issue of the management of anxiety disorders in old age. We explore the prevalence, presentation and diagnosis of anxiety in dementia and discuss the therapeutic options available.

We review key recent research and guidance for staff working with acutely disturbed psychiatric patients. Assessment of aggressive patients and their situation should enable full risk assessment, which may ideally involve the use of advance directives. We discuss appropriate use of the Mental Health Act 1983 and consider benefits and adverse effects of rapid tranquillisation. We present a simple protocol for oral or intramuscular rapid tranquillisation. Staff using physical restraint should be properly trained and consider sensitively issues of the patient's diginity, gender and the most appropriate location for restraint to occur. Simple precautions can improve safety when working with potentially disturbed patients. Staff need support during and after the management of an aggressive incident.

In the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.

Mistakes are inevitable in any branch of medicine, but psychiatry is a particularly risky business (Holloway, 1997). When psychiatrists get it wrong there may serious consequences for their patients, the clinical team and the wider public. The Government introduced a series of initiatives in the 1990s: the Care Programme Approach (1990), the supervision register (Department of Health & Home Office, 1994) and supervised discharge (Secretary of State for Health, 1997). One of the main purposes of this legislation was to minimise the risk psychiatric patients pose to the community. Future service provision will be shaped by clinical governance and the National Service Framework for Mental Health (Secretary of State for Health, 1997), and evaluation and management of risk will become increasingly important.

‘Depot antipsychotics' (‘long-acting injectable antipsychotic medications' or LAIs) are underused in the treatment of schizophrenia (including first episodes) and, possibly, of schizophrenia with comorbid substance use disorders. Patients' and clinicians' beliefs and attitudes, and service barriers, affect best practice and evidence-based care in LAI prescription. Poor medication adherence is a key reason for LAI prescription, but patients receiving LAIs may still relapse or experience significant side-effects. Patients' and clinicians' attitudes towards antipsychotic medication, as well as the quality of their recovery-focused relationship, are key factors in adherence. Clinicians should avoid a dichotomous ‘oral v. LAI’ choice: LAIs may have a place at various stages in the continuum of care and they should be one of the options discussed with any patient requiring long-term treatment, even early in the illness course. Many clinicians need better education about LAIs and greater familiarity with schizophrenia treatment guidelines.

Malingering is the dishonest and intentional production of symptoms. It can cause considerable difficulty as assessment runs counter to normal practice, and it may expose clinicians to testing medicolegal situations. In this first part of a two-article review, we explore types of psychiatric malingering and their occurrence across a range of common and challenging scenarios, discussing presentations that may help delineate true from feigned illness. A framework is provided for undertaking an assessment where malingering is suspected, including recommendations on clinician approach, the use of collateral information, and self-evaluation of biases. The uses, and limitations, of psychometric tests are discussed, including ‘general’, malingering-specific and ‘symptom validity’ scales.

The lack of a medically grounded approach to personality disorder and its management has led to its comparative neglect as a topic by many clinicians in the UK. In this article we present evidence that personality disorders are, like other mental disorders, the social manifestations of a pathological process. This process presents with characteristic clinical features that are developmental in nature. These cause disturbances in arousal, affect and reality testing that have an impact on interpersonal social functioning. Personality disorder may therefore be conceived of primarily as a socioemotional disability, not dissimilar to Axis I conditions.

The targeting of services to groups with special needs is today commonplace in enlightened public health policies. To list men among the ‘minorities’ in need of such special help might have the semblance of satire. This air of levity is not really reduced by listing male's shorter life expectancy, higher infant mortality and higher rates of natural and unnatural deaths in all age groups (Drever & Bunting, 1997; Kelly & Bunting, 1998).

Meta-analysis is the use of statistical techniques to analyse the findings of many individual analyses (Glass, 1977). It covers all aspects of the review process involving formulating relevant research questions, searching the literature, assessing the quality of studies and choosing relevant ones, extracting and combining the data (for review see Henry & Wilson, 1992; Wilson & Henry, 1992). Meta-analysis as part of a systematic review has advantages over a narrative review but there are problems in applying it in practice (Box 1).

This article reviews how data on the benefits and hazards of antidepressants have been analysed, and how conclusions drawn from these analyses conflict with the data. Randomised trials of antidepressants have for two decades consistently shown evidence of an increased risk of suicidal acts on active treatment compared with placebo, but an inappropriate application of significance testing has led to this evidence being dismissed. During the same period a minority of antidepressant trials have produced data indicative of benefits that have reached statistical significance at a 95% level. In this case significance testing appears to have led to an unrealistic impression of the likely benefits of treatment in practice. Current approaches to evidence-based medicine risk perpetuating misunderstandings of this type. Against a background of current developments in healthcare delivery, clinicians might need to reconsider how they handle and present clinical trial data.

Intimate partner violence is associated with significant psychiatric comorbidity. Treatment has focused on male perpetrators but recent studies indicate that this is of limited success in reducing male violence. This article reviews the current available treatments from three perspectives: that of the victim, the perpetrator, and the couple who wish to remain together. It also provides guidelines to assist the general psychiatrist in determining what treatment to offer patients who present with intimate partner violence. Guidelines emphasise the need for assessment of risk factors that indicate a potentially lethal relationship and the importance of the diagnosis and treatment of comorbidity, especially alcohol misuse and dependence.

Aspects of print, broadcast, film and ‘new media’ are related to their interactions with psychiatry. Frequent representations of mental health issues are paralleled by the adoption of psychological theories into media studies. Key areas are covered where psychiatric items diverge from other medical specialities, such as the depiction of suicide, the dominance of ‘human interest’ stories and negative representation of people with mental illness. Although the language of mental disorders is important, the power of the image needs to be examined. Media items also have implications for public mental health (children as vulnerable viewers) and the clinical practice of psychiatry that are not uniformly negative. Television has limitations and clinicians are encouraged to participate in radio and other media. Resources and practical advice for media contact are provided.

Autoimmune encephalitides can present with altered mental states, particularly psychosis and delirium. Psychiatrists need to be particularly vigilant in cases of first-episode psychosis and to look out for other, sometimes subtle, features of encephalitis. Encephalitis related to N-methyl-d-aspartate (NMDA) receptor autoantibodies is the most common autoimmune cause of isolated psychosis, the second being related to voltage-gated potassium channel (VGKC)-complex antibodies. Psychiatrists should note ‘red flag’ signs of seizures, autonomic instability, movement disorders and sensitivity to antipsychotic medication (including neuroleptic malignant syndrome). They should also be aware that, in some cases, encephalitis is a non-metastatic manifestation of malignancy. Treatment primarily involves suppression of immunity and is often successful if delivered early. There is accumulating evidence that isolated psychiatric syndromes can be caused by autoimmunity and this could potentially signal a significant change in the approach to disorders such as schizophrenia. Psychiatrists and neurologists need to work together to diagnose, manage and understand this group of conditions.

Nearly a decade ago, the Department of Health published its strategic development plan for mental healthcare for women. It focused on the ways in which mental health services for women should be configured to take account of the context of women's lives and the complexity of their health needs. This commentary argues that attention to the reproductive and sexual health of women in mental healthcare is at the centre of a gender-sensitive and modern mental health service.

In the first two articles of this series (Williams & Garland, 2002; Wright et al, 2002), we looked at the different areas of human experience that alter during times of mental illness. The Five Areas Assessment model (Williams, 2001; see also Fig. 1 of Williams & Garland, 2002) provides a clear summary of the range of problems and difficulties faced by the individual in each of the following domains:

1. 1 life situation, relationships, practical problems

2. 2 altered thinking

3. 3 altered emotions (moods or feelings)

4. 4 altered physical feelings/symptoms

5. 5 altered behaviour or activity levels.

Since 2000 assertive outreach has been a requirement of community mental health provision in the UK. This has led to rapid proliferation of assertive community treatment teams offering a pure form of clinical case management to people with severe mental illness. The teams provide intensive support in obtaining material essentials such as food and shelter and place a greater emphasis on social functioning and quality of life than on symptoms. People with psychotic illness with fluctuating mental state and social functioning and poor medication adherence are most likely to benefit. Teams are ideally placed to monitor clozapine treatment in the community. Teams require a broad skills mix, and team members need some competence across a wide range of areas. Teams should include a psychiatrist or have regular access to one. Ideal individual case-loads are 10–12 patients. Around-the-clock availability is no longer considered essential, particularly in view of the rise of crisis resolution/home treatment teams.