‘In some few jails are confined idiots and lunatics, –many of the bridewells are crowded and offensive, because the rooms which were designed for prisoners are occupied by lunatics. The insane, when they are not kept separate, disturb and terrify other prisoners. No care is taken of them, although it is probable that by medicines, and proper regimen, some of them might be restored to their senses, and usefulness in life’ (Howard, 1784: pp. 10–11).

In this paper I review some of the ethical dilemmas that arise when psychiatrists are involved in the assessment and treatment of medical colleagues. Special attention needs to be paid to the context of the relationship between the psychiatrist and the doctor-patient, and to the extent to which the patient is seeking help voluntarily or at the request of a third party. Psychiatrists may find themselves uncertain about how to meet the ethical demands of their duties to the patient and their duties to the public, when these conflict.

This article outlines proximate (physical and mental) and ultimate mechanisms of placebo effects. Interpersonal processes contributing to placebo effects are reviewed and illustrated through research into the process of psychotherapy. Evolutionary theories of how and why the capacity for placebo effects might have evolved are described. The components of treatment and placebo effects are defined. It is concluded that maximising therapeutic placebo effects is effective and a valid clinical goal.

Tobacco smoking among people with mental illnesses can be explained by biological, psychological and social factors. The prevalence of smoking in people diagnosed with schizophrenia is higher than in people with other mental disorders and in the general population. This article explores three current hypotheses that explain this higher prevalence of smoking in schizophrenia. The first, the self-medication hypothesis, is increasingly countered by a growing body of evidence indicating that smokers experience more severe symptoms of schizophrenia. Numerous researchers have already identified smoking as a possible risk factor for the development of schizophrenia, which is the second hypothesis. The third hypothesis (shared genetic vulnerability) identifies certain genes that confer vulnerability for both schizophrenia and nicotine dependence. Understanding the reasons behind the higher prevalence of smoking among people with schizophrenia is vital in planning effective primary, secondary and tertiary smoking prevention for these individuals.

Definitions for learning disability vary depending on the context in which they are used (Box 1), as does the terminology (Box 2). In the UK, the term ‘learning disability’ was adopted in 1991 by the Department of Health. The term ‘mental retardation’ is used in the ICD-10 (World Health Organization, 1992). Fryers (1991) has commented on the need for different definitions in order to distinguish the context in which the term is used.

Dual diagnosis is one of several terms used to identify individuals diagnosed with a co-occurring mental disorder and substance use disorder. The existence of a dual diagnosis in adolescents is often associated with functional impairment in various life domains, causing physical health problems, relational conflicts, educational/vocational underachievement and legal problems. Dual diagnosis is difficult to treat and can result in tremendous economic burden on healthcare, education and justice systems. It is essential for clinicians caring for young people to be knowledgeable about dual diagnosis to ensure that it is identified early and treated. This article aims to provide an overview of dual diagnosis, increase its awareness and promote a realistic treatment approach.

Workplace-based assessment (WPBA) is becoming a key component of post-graduate medical training in several countries. The various methods of WPBA include: the long case; multisource feedback (MSF); Mini-Clinical Examination (mini-CEX); Direct Observation of Procedural Skills (DOPS); case-based discussion (CbD); and journal club presentation. For each assessment method, we define what the approach practically involves, then consider the key messages and research evidence from the literature regarding their reliability, validity and general usefulness.

The concept of an ‘at-risk mental state’ for psychosis arose from previous work attempting to identify a putative psychosis prodrome. In this article we summarise the current criteria used to identify ‘at-risk’ individuals, such as the ultra-high-risk (UHR) criteria, and the further identification of important clinical risk factors or biomarkers to improve prediction of who might develop a psychotic disorder. We also discuss important ethical issues in classifying and treating at-risk individuals, current treatment trials in this area and what treatment current services can offer.

This is an overview of epidemiology relevant to mental health problems in old age. We start by reviewing some basic terminology: the definitions of prevalence and incidence; the difference between descriptive and analytical epidemiology; the differences between study designs, including cross-sectional, case–control and cohort studies. We then cover the main epidemiological features of the major psychiatric diseases that affect older people (dementia and its different types, depression, late-onset schizophrenia, bipolar affective disorder, delirium, anxiety-related disorders, eating disorders, alcohol and substance misuse, personality disorders) and suicide.

We end with some descriptive statistics regarding quality of life in older people.

In English Law, an adult has the right to make decisions affecting his or her own life, whether the reasons for that choice are rational, irrational, unknown or even non-existent. This right remains even if the outcome of the decision might be detrimental to the individual (Re T (Adult: Refusal of Treatment), 1992) or to a viable foetus (Re S (Adult: Refusal of Medical Treatment), 1992). However, such a right to self-determination is meaningful only if the individual is appropriately informed, has the ability (capacity) to make the decision and is free to decide without coercion (Grisso, 1986).

Few tests address the types of memory problem commonly reported after electroconvulsive therapy (ECT). Here, we focus on the importance of neuropsychological assessment in ECT-treated patients and describe a number of tasks that may be useful in measuring the everyday memory problems of such patients with ongoing memory difficulties. At the time of writing, no attempts have been made to rehabilitate patients who experience persistent adverse cognitive effects, but clinicians should be aware of the potential beneficial role of cognitive rehabilitation in the treatment and management of these effects.

This article, the first of two on placebo effects, provides a broad overview of placebo in the field of medicine. A brief conceptual history is followed by some basic facts about placebos. Problems of definition are identified. Additive and non-additive models of treatment effects, and problems of measurement of placebo effects are described. The role of placebo in the pharmacotherapy of depression and complementary and alternative medicine is discussed. The ‘efficacy paradox’ (that placebo treatments can have larger effects than ‘evidence-based treatments’) is introduced. Finally, ethical issues are discussed.

Boredom is highly prevalent among general hospital in-patients. Self-help strategies suit some patients, but for others hospitals need to stimulate opportunities for them to experience meaningful relationships and roles and a sense of control. In-patients' well-being and levels of boredom may be affected by no-smoking policies, hospital design, access to natural light, nature scenes and indoor or outdoor gardens. Alleviating boredom in elderly patients with reduced cognitive function may be particularly challenging. Healthcare professionals may face the wider challenge of fully engaging with patients' psychosocial needs, given the biomedical model that privileges the ‘traditional medical history’ over the more holistic communication model. Engaging with patients' psychosocial needs is consistent with managing their experience of 'sickness' rather than focusing on the narrower concept of ‘disease’.

Depression is increasingly recognised as a major public health problem worldwide. The heterogeneity of this condition implies that there may be several neurobiological pathways to depression. This article attempts to explore a pathway that links depression with the inflammatory response. Associations linking inflammation and chronic immune activation with depression have been noted, particularly in the context of (a) medical disorders with inflammatory pathophysiology and (b) immunotherapy for cancer and hepatitis C. Acute coronary syndrome is given as an example of how the inflammatory process might result in depression, and potential mechanisms are discussed. These include: direct action of pro-inflammatory cytokines on the serotonin system, with specific reference to the serotonin transporter; action of cytokines on the hypothalamic–pituitary–adrenal axis; and effects of pro-inflammatory cytokines on neurogenesis in the hippocampus. Reference is made to the potential anti-inflammatory effects of antidepressant drugs and antidepressant effects of anti-inflammatory treatments.

It is hard to disagree with the principles of the care programme approach (SPCR, 1993; Kingdon, 1994) but it has been much harder to agree how to put them into practice. What should be ‘just good practice’ becomes more complex the more it is discussed by clinical teams.

The government in England and Wales is promoting policies and initiatives to offer patients choice across all healthcare specialties. This has raised concerns in mental healthcare, particularly if the physical healthcare model of implementation is imposed. However, the ‘choice agenda’ is an opportunity for mental health services to be innovative and act as beacons to other disciplines in healthcare. The south-east London programme introducing choice in mental health services is offered as an example here. There already exists an ‘ethos of choice’ within mental health services, but current practices may require a focused approach and structuring to fit in with national policy. This also might be necessary to influence policy makers to take a different perspective on choice in mental health. The principle of choice goes hand in hand with the drive towards greater social inclusion for people with mental health problems.

Clinical neuromodulation began in psychiatry with electroconvulsive therapy (ECT), but in recent years several new techniques have been developed: repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), vagal nerve stimulation (VNS), trigeminal nerve stimulation (TNS) and deep brain stimulation (DBS). Each works in a different way, although the principle remains to effect therapeutic change through physically modifying brain activity. Their use in different clinical groups varies between techniques, as does their underlying evidence base. Most support currently exists for rTMS, with a more modest, but growing database for tDCS. Understandably, but problematically, most research in the other techniques has, to date, been in unmasked open trials. This article describes the mechanism of action and current evidence base for each technique, and notes the challenges facing future work in this potentially important field and new clinical avenue.

Research has consistently demonstrated a connection between affect dysregulation and experiences of early childhood neglect, trauma and attachment failure. Without adequate regulation of the infant's distress states, the nervous system and affect-regulating brain structures fail to develop optimally. Affect dysregulation is a component of all mood, anxiety and borderline personality disorders as well as a contributor to addictive and suicidal behaviour. Methods to increase self-regulation are crucial to the effectiveness of any treatment for these problems. Traditional therapeutic modalities that address distorted cognitions or focus on emotional expression attempt to address affect regulation but fail to modify its underlying basis in the nervous system. Sensorimotor psychotherapy, as a somatically oriented therapy, approaches affect dysregulation as a subcortical issue. Its interventions directly address the underlying causes of dysregulation in the body and nervous system.

In this article, we explore the role of attachment in the development of medically unexplained symptoms (MUS) and response to physical illness. We review the evidence that attachment insecurity is common in people with different forms of MUS and certain long-term physical conditions. We discuss a possible developmental model for understanding how MUS develop. We conclude with discussion of potential therapies and implications for services.