Aggression is common in older people with mental illness, with 15–43% of community referrals to old age psychiatry services and 44–65% of older people with Alzheimer's disease living in the community exhibiting such behaviour. In psychiatric in-patient units, assaults on staff are most common on wards for elderly people with organic mental illness. There is little high-quality research into the management of aggressive behaviour in dementia. We consider the available literature, which has shown certain behavioural measures and different classes of medication to be of benefit. We discuss factors associated with violence in elderly people with mental illness and potential management options.

There are four high-security hospitals in the UK: Broadmoor Hospital in Berkshire (founded in 1863), Rampton Hospital in Nottinghamshire (1914), Ashworth Hospital in Merseyside (1990), which opened following the amalgamation of Park Lane (1974) and Mosside Hospitals (1913), and the State Hospital at Carstairs in Lanarkshire (1948). The first three are known as the special hospitals and serve England and Wales. The latter offers a special security service, combining high and medium secure care, for the whole of Scotland and Northern Ireland – there is no form of medium secure psychiatric provision in these countries. All four hospitals provide care for patients with mental disorders and dangerous, violent or criminal propensities. There are approximately 1550 beds in these facilities and all patients are formally detained under mental health or criminal legislation. The special hospitals are currently administered by the high-security psychiatric services commissioning team, managed locally as individual authorities, although in the future it is intended to integrate them more fully into the National Health Service (NHS) and to organise both high and medium secure services at a regional level. Carstairs is administered by the State Hospital Board for Scotland which has the status of a special health board.

The National Institute for Health and Care Excellence (NICE) informs us that the first-line treatments for behavioural and psychological symptoms of dementia (BPSD) are non-pharmacological. Although psychotropics used to be the main strategy in the management of behaviours that challenge, there has been an increase in the use of biopsychosocial formulations since 2010, and there are now over a dozen to choose from. However, many are overly focused on obtaining information about the agitation, and less specific about providing details of the actions required to manage the behaviours. The NICE guidelines too fail to provide specific guidance on which non-pharmacological approaches to use. This article argues for giving equal weight to both the collection of meaningful information and the development of ‘informed actions’, because it is the actions that lead to change. The article outlines a management programme providing a framework for the assessment, formulation and treatment of agitation in dementia. The work draws on theory, evidence-based practice and practice-based evidence to provide a model with sufficient structure and flexibility to be useful for clinicians across a range of settings and professional groups.

Early intervention services were established on the basis of a number of fundamental principles, including the notions that intervening in the early stages of psychosis alters illness trajectory and prognosis, that multicomponent interventions promote psychosocial recovery and reduce iatrogenic damage, and that early targeting of non-responders reduces treatment resistance. There is growing evidence of the benefits of specialised early intervention services. These include improved clinical, social and vocational outcomes, reduced in-patient stays and better engagement. Early intervention services can also significantly reduce the risk of a second episode and are highly valued by service users and carers. Duration of treatment appears to determine long-term outcome and there remains uncertainty about how long such intensive intervention should last and whether all patients need the same length of care. Budgetary constraints are pervasive and are particularly likely to affect prodrome clinics and community awareness programmes.

Cognitive linguistics is a new development in one of the basic sciences of psychiatry. It takes a novel approach to metaphor that is having an impact on philosophy and cognitive neuroscience, offering a perspective on questions about the development of language and the embodiment of mind that may have an impact on psychiatry. Likewise, our expertise in mental pathology may be required for further development in cognitive linguistics (Lakoff, 1997).

Recent research has highlighted the fact that a significant number of patients with bipolar affective disorder have a poor outcome (Cole et al, 1993). The most common poor outcome is the development of rapid or ultra-rapid cycling, but mixed states, prolonged depression and severe mania are also associated with poor outcome. It is estimated that approximately one-third of patients with bipolar affective disorder do not respond fully to lithium and a significant number of patients discontinue lithium (Post, 1990) which may itself cause further problems.

This article examines the notion of personhood and shows how it offers a robust conceptual underpinning to person-centred care. We use a fictitious case vignette to clarify the nature of personhood. Mental health professionals need a broad view of personhood, which we feel is best captured by regarding the person as a 'situated embodied agent'. Using this characterisation, we aim to demonstrate how it can underpin the notion of person-centred care and show the practical implications of this in connection with our fictitious case. The broad view supports a specific approach to people with dementia, but also shows the challenges that face the implementation of good-quality dementia care. Discussion of this case shows both the relevance of philosophy to clinical practice and the ways in which clinical practice can enrich the debates of philosophy.

In this issue of APT Mountain & Shah seek to reconcile the currently fashionable ‘recovery’ paradigm of mental healthcare with the distinctly unfashionable ‘medical model’ of psychiatric practice. I argue that their article raises more questions than it answers – not least whether the recovery concept is amenable to empirical analysis.

The last 20 years have witnessed a surge of interest in assertive community treatment (ACT) for the severely mentally ill (Drake & Burns, 1995). ACT aims to help people who would otherwise be in and out of hospital on a ‘revolving door’ basis live in the community and enjoy the best possible quality of life. Services based on the ACT model seek to replace the total support of the hospital with comprehensive, intensive and flexible support in the community, delivered by an individual key worker or core services team. They are organised in a way that optimises continuity of care across different functional areas and across time.

Since the introduction of lithium therapy 30 years ago it has become a major weapon in psychiatrists' armamentarium. It is the drug of first choice for the prevention of recurrent mood disorders, and it is estimated that about one person in every thousand people in Britain receives lithium at any one time. It therefore behoves doctors to be familiar with its use. This article is not a comprehensive account of the pharmacology of lithium (for this the reader is referred to Johnson (1987) and Peet & Pratt (1993)) but concentrates on its clinical use in practice and some less well known, but important, phenomena.

In a recent article (Davies et al, 2000) we covered the background to and clinical presentation of the neuropsychiatric consequences of chronic exposure to organophosphates. In particular, we dicussed a syndrome that appears to develop in about 10% of chronic exposees: chronic organophosphate-induced neuropsychiatric disorder (COPIND). In this article we consider the diagnosis and management of patients with this condition, and related issues.

The traditional disease model, still dominant in psychiatry, is less than ideal for making sense of psychological issues such as the effects of early childhood experiences on development. We argue that a model based on evolutionary thinking can deepen understanding and aid clinical practice by showing how behaviours, bodily responses and psychological beliefs tend to develop for ‘adaptive’ reasons, even when these ways of being might on first appearance seem pathological. Such understanding has implications for treatment. It also challenges the genetic determinist model, by showing that developmental pathways have evolved to be responsive to the physical and social environment in which the individual matures. Thought can now be given to how biological or psychological treatments – and changing a child's environment – can foster well-being. Evolutionary thinking has major implications for how we think about psychopathology and for targeting the optimum sites, levels and timings for interventions.

Although the older adult population makes up only a small percentage of mentally disordered offenders, there is a clear need for forensic mental health services for older people. However, these services to date have developed ad hoc and with no coordination. In this article we discuss the evolution, current provision, future direction and therapeutic implications of such services. Although the epidemiology, criminology and clinical characteristics of older people are sufficiently different from those of younger people to warrant such service specificity, we suggest that the provision of care should be geared to services based on older people's multiple and complex needs, rather than on arbitrary age cut-offs.

With an ageing population and more drivers on the road, the number of drivers with dementia is due to grow exponentially over the next 50 years. Although decisions regarding possession of a driving licence in the UK are made by the Driver and Vehicle Licensing Agency (DVLA), psychiatrists have a duty to advise patients who are unfit to drive to cease driving and to inform the DVLA of patients who pose a risk to the public by continuing to drive when advised not to. This article offers a review of the literature on dementia and driving and summarises the evidence and advice for navigating this minefield. The use of psychological test batteries in clinical practice is discussed, along with the most useful questions to ask in memory clinics. Legal guidance for various countries is considered, as is the important (but often overlooked) issue of helping older people prepare for retirement from driving.

Irrespective of whether one considers official statistics, the proliferation of clinical referrals, research initiatives, review articles or even media attention, the problem of children and adolescents who sexually abuse other children has become a subject of increased attention. Given the proportion of young abusers who are themselves victims of sexual abuse, understanding the continuities between sexual victimisation and sexually abusive behaviour has been important. Despite the paucity of reliable evidence, it is clear that the majority of children who are sexually abused do not become abusers. Moreover, we know that around half of all young abusers have not themselves been victims of abuse. This paper sets out to consider these issues and highlight potentially important factors in understanding the origins and development of sexually abusive behaviour at an early age.

All people with learning disabilities should be able to choose from a variety of residential placements as a way of achieving greater community integration. However, many are still placed away from their borough of origin, resulting in complex consequences for them, and their families and for clinicians. This article explores the nature of the problem, defining the current issues, and examining the role of the stakeholders and the implications for psychiatrists working in this field.

Interprofessional education, learning which brings together different professional groups, helps to prepare practitioners for effective team-based collaborative practice and is now included in all undergraduate training programmes in the health professions. We explore the merits of team-based interprofessional learning, drawing on learning theory and mental health policy. We endorse the use of a practice-based interprofessional education model involving patients in which students experience the complexity of team working and the clinical team gain a more detailed analysis of team processes, which can enhance the quality of patient care. The model has been replicated for undergraduate education in mental healthcare and could easily be used for postgraduate staff. Interprofessional education at postgraduate level could foster the ongoing team-based reflective learning needed to enable mental health services in the UK to adapt to the dramatic changes both in their organisation and in the roles and responsibilities of individual professions.

Recent developments in medical education and in UK government policy for the training and service commitment of junior doctors have highlighted the need to examine clinical teaching. There is growing evidence of the effectiveness of more structured approaches to patient-based teaching. The scope of what can be taught includes the three domains of knowledge, skill and attitudes. There are proven models to deliver teaching not only of patient assessment and management but also of all aspects of the doctor–patient relationship. The application of patient-based teaching is entirely consonant with the rigours of the outcome-based approach to curriculum planning and delivery. The successful, thoughtful adoption of patient-based teaching is part of the ‘professionalisation’ of education in psychiatry that in turn begs questions about the learning, accreditation and reward of those involved as teachers at all levels.