Doctor-to-doctor relationships are explored. The impact of the employing organisation on working relationships is considered and methods of analysing problems at the organisational and individual level are described. The application of psychodynamic and systems theory in deepening understanding is discussed, illustrated by vignettes from the work situation. The impact of changes in the work environment are considered and potential sources of support listed.

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.

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.

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.

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.

Children and adolescents with learning disabilities have high rates of mental health problems and behavioural difficulties. Comorbid disorders such as epilepsy, autism and attention-deficit hyperactivity disorder are common. Despite this, many areas in the UK are failing to provide a psychiatric service for these young people and their families. The children suffer as a result and may have to move away from home unnecessarily, at enormous emotional and financial cost. Each area should have a specialised multidisciplinary health team working closely with colleagues from education and social services to assist these complex children and give them the best chance to fulfil their potential.

On average, 49–63% of people with intellectual disabilities and/or autism spectrum disorder (ASD) are prescribed psychotropic medications to treat psychopathology, including psychiatric illness, behaviours that challenge and the core symptoms and associated behaviours of these developmental disorders. In many cases, psychotropics, particularly antipsychotics, are used off-label without a proper indication, particularly to manage behaviours that challenge. The RCTs show moderate evidence supporting the efficacy of low-dose risperidone and some preliminary evidence for aripiprazole in treating behaviours that challenge among children with ASD and/or intellectual disabilities. The RCT-based evidence for the other psychotropics is equivocal, so no definitive conclusions can be made on their efficacy. Polypharmacy and the use of high doses of antipsychotics are prevalent in this population, leading to the risk of adverse events and drug–drug interactions. Despite various national and international guidelines, and government initiatives encouraging reduced psychotropic use, there is little evidence of this happening; on the contrary, the use of antidepressants, mood stabilisers and benzodiazepines may be increasing. A concerted multi-agency effort is urgently needed to address this significant public health concern of the overmedication of people with intellectual disabilities and/or ASD.

Psychodynamic psychotherapy has been criticised as being based on outdated principles of psychoanalysis and lacking an adequate evidence base to convincingly demonstrate its efficacy. This article summarises the recent evidence from high-quality outcome studies to show that psychodynamic psychotherapy is as effective in the treatment of a range of mental disorders as other psychological treatment modalities such as cognitive-behavioural therapy, as well as reviewing process-outcome research aiming to elucidate mechanisms of therapeutic change. A paradigm for psychodynamic psychotherapy research based on attachment theory is introduced, which may inform the development of psychodynamic therapeutic modalities tailored for specific conditions.

The Department of Health is introducing a ‘payment by results’ system for mental health services in the UK. The system is already being used in the acute healthcare sector, but is still under development for application in mental healthcare. This article outlines the concept of payment by results, briefly reports on its use in other countries and describes the pilot study underway in England to define currencies to be used in a payment by results system planned for NHS mental healthcare throughout England and Wales.

Behavioural phenotypes are patterns of behaviour that present in syndromes caused by chromosomal or genetic abnormalities. They have both physiological and behavioural manifestations with distinctive social, linguistic, cognitive and motor profiles. Their course is not static. Presentation typically varies according to level of learning disability and a host of environmental, developmental and therapeutic influences, and it changes with increasing age.

Patients detained at high and medium security reveal significant gender differences in the presentation of psychopathology, mental disorder and social and offending profiles. However, secure mental health services in England, like prisons, generally fail to recognise the core importance of the differing biopsychosocial development in women and the impact of life experiences on women's subsequent biopsychosocial functioning. As a consequence, women are often inadequately provided for in services dictated by the identified needs, risks and responsiveness of men. The lack of clinically appropriate facilities for women may account for the increased frequency with which women are readmitted to medium security and for their longer admissions to both high and medium secure care. New tertiary services are developing as a result of the lessons learnt while providing gender-blind care. However, further development is required to ensure that women receive services of the same quality, range and nature of those received by men.

In health care, the word ‘communication’ covers a wide range of interactions, including interpersonal communication, communication technology, medical education, health policy and mass communication. It takes many forms, from a brief informal talk between colleagues to formalised written documents between professionals. The essence of this verbal and written communication is the sharing of information. To make our information exchange more useful and to give it more meaning, the information communicated needs an appropriate framework. For example, the meaning of the diagnosis ‘schizophrenia’ is greatly enhanced by knowledge of the individual patient within the context (the framework) of his or her past history and family background.

Stress-related disorders are diverse and they may be mental and physical. Often, several body systems and organs are involved simultaneously. The pathophysiology of stress-related disorders involves many factors: an observable or perceived stressor, an individual dynamically evolving vulnerability and maladaptation leading to imbalance, as well as environmental, cultural, gender and life-cycle variables. There is a need to develop a comprehensive quantifiable stress assessment instrument. It would be based on the ‘stress factor’, a dimension that would integrate biological, psychological, social, economic and spiritual parameters and would allow for cultural sensitivity. It would contribute to clinical operational sophistication and would illuminate treatment options and multidimensional well-being interventions. Hopefully, it would facilitate development of culturally sensitive pharmaceutical or biophysiological adaptogens and homeostatic interventions.

Although police surgeons (or forensic medical examiners; FMEs) usually assess fitness to be interviewed by the police (Norfolk, 1996), psychiatrists may also be asked for an opinion (Protheroe & Roney, 1996).

By the 1980s, one-fifth of all general psychiatrists in England and Wales (Strathdee & Williams, 1984) and one-half in Scotland (Pullen & Yellowlees, 1988) were spending some proportion of their time working in primary care. Rather than limit this process, the growth of general practice fundholding fostered it and developments in general practice total purchasing and extended fundholding have encouraged it further (Lee et al, 1999). At the same time, nationally there has been a gradual increase in referrals directly from general practitioners (GPs) to community psychiatric nurses (CPNs). Referrals from GPs constituted 37% of all referrals to CPNs in 1990 and 46% in 1996 (Brooker & White, 1997: further details available from L.G. upon request), even though there has been a trend away from the primary care service base (21% in 1990 compared with 14% in 1996).

Electroencephalography (EEG) is a non-invasive investigation that can aid the diagnosis of psychiatric and neuropsychiatric disorders. A good predictor of an abnormal EEG recording is the presence of an organic factor identified during the clinical assessment. The non-invasiveness and low cost of the procedure and its ability to measure spontaneous brain activity appear to attract clinicians to utilise this investigative tool. However, studies have reported that EEGs arising from psychiatric referrals have the lowest abnormality detection rate. The focus of this article is to improve this by highlighting the current pitfalls and providing recommendations for appropriate utilisation of EEG. We describe specific EEG changes associated with major psychiatric disorders. We conclude by offering pragmatic considerations when referring a patient for EEG, emphasising the fact that the information provided to the neurophysiologist plays a crucial role in interpreting the EEG recording in a diagnostically meaningful way.

Peer review is widely accepted as essential to ensuring scientific quality in academic journals, yet little training is provided in the specifics of how to conduct peer review. In this article we describe the different forms of peer review, with a particular focus on the differences between single-blind, double-blind and open peer review, and the advantages and disadvantages of each. These illustrate some of the challenges facing the community of authors, editors, reviewers and readers in relation to the process of peer review. We also describe other forms of peer review, such as post-publication review, transferable review and collaborative review, and encourage clinicians and academics at all training stages to engage in the practice of peer review as part of continuing professional development.

The risks and benefits of psychopharmacological treatment in pregnancy need careful consideration. Conventional antipsychotics and tricyclic antidepressants are relatively safe for the foetus. Selective serotonin reuptake inhibitors appear to be safe, but mood stabilisers such as lithium, sodium valproate and carbamazepine are associated with increased foetal malformations. Benzodiazepines in the first trimester are teratogenic, and in high dosage can also cause withdrawal symptoms, hypotonia and agitation in the newborn. Women taking atypical antipsychotics should be switched to conventional antipsychotics before they conceive. In women with long-term mental illness necessitating psychotropic medication, effort should be made to stop polypharmacy and non-essential medication (e.g. benzodiazepines) and to decrease the dose of essential drugs, after full assessment. There is rarely a valid reason to stop essential drug treatment during pregnancy.