Benzodiazepines are still widely prescribed in psychiatry, mainly for the treatment of anxiety-related disorders. This is not because they are only taken by a hard core component of patients who are addicted and do not need them; it is because they remain the most effective and rapid acting of all drug treatments. Strategies for practitioners to use them more confidently are described.

There is evidence pointing to a bias in the application of the Mental Health Act 1983 (which is in force in England and Wales). One study found that Black people on in-patient units were four times more likely to have been compulsorily admitted than White people. Furthermore, it has been shown that compulsory admissions to secure units are 2.9–5.6 times higher for Black than for White patients. Any understanding of this bias necessitates an examination of the attitudes of mental health professionals towards Africans and African–Caribbeans. Here we discuss possible contributory factors and examine a number of initiatives that have been instituted in order to tackle this problem.

The classification of depression has been debated for decades. The introduction of operational criteria and the category of major depression were significant advances in the 1970s. However, the validity of the major depression category is controversial. The article highlights the limitations of using severity criteria and cross-sectional evaluation to diagnose depression. It recommends the classic typologies (melancholia, dysthymia and adjustment disorder) for clinical presentations of depression, highlighting the need to use longitudinal clinical patterns and context for diagnosis. Major depression owes its success to its loose definition, to the subordinate status of adjustment disorders and dysthymia and to the mechanistic application of the diagnostic hierarchy and criteria. There is a need to focus more on the context of depression (stress, coping and support) and to reduce the medicalisation of distress.

Machines will replace therapists and counsellors. This was the confident prediction made a decade ago. In this article, I discuss the inherent limitations of machines as conversationalists that have prevented the prediction from coming true. Machines can, however, be exploited to assist therapy and I consider the following digital tools: test administration; managing procedural, symptom-relieving cognitive–behavioural therapies; providing virtual environments for immersive behavioural therapies and for e-learning; and assisting training through automated discourse analysis and the use of cognitive maps.

The recruitment and retention crisis in UK nursing puts many reforms outlined in recent health policies at risk. Increasing bureaucratisation of health care, unattractive working conditions, poor pay and the emotionally exhausting nature of the work are associated with high rates of burnout and workplace violence. Some nurses prefer agency work, some leave because they cannot reconcile a caring role with working in the NHS. It seems that health care has become emotionally distant and the profession's longstanding attachment to caring through interpersonal relationships has been overridden by a high-technology, fast-track system of care management. To retain the principles and ethos of nursing at the centre of health developments, attention must be given to the micro-environments in which nurses work.

Several English prisons contain democratic therapeutic communities (TCs) for personality disordered offenders, and addiction TCs for serious substance misusers. This article describes how these are organised and comments on how they are specifically tailored and accredited for use in custodial settings. It also describes ‘psychologically informed planned environments’ (PIPEs), offender pathways for those with personality disorders and psychopathy which provide additional support for psychological treatment. It ends by explaining how ‘enabling environments’ are assessed, since these are now becoming widely adopted in prisons to reverse toxic environments – which affect staff, the prison and the outside world as well as the individual prisoner – and to counter negative learning found in custodial institutions.

Serotonin syndrome (serotonin toxicity or serotonin toxidrome) is a potentially serious and theoretically predictable reaction that appears to be rarely diagnosed in practice in the UK. Some symptoms of serotonin syndrome overlap with features of other presentations in psychiatry and thus may be misattributed to mental illness (‘diagnostic overshadowing’). Further, there may be diagnostic dilemmas in patients on combinations of drugs, those receiving drugs with previously unknown serotonergic properties or where there are drug interactions. Prescriber vigilance and holistic review of the patient, including the pharmacotherapy, may be helpful in avoiding progression of serotonin syndrome to more serious outcomes.

Multicultural societies offer a significant challenge to mental health services. Different groups have different rates of illness, illness models, ideas of what a suitable pathway of care is and what suitable care looks like. Trying to set up services to meet all these needs can be difficult. There may need to be modifications in clinical practice, service configuration and the way services are commissioned. Ethnic minority communities face complex problems and, consequently, strategies to deal with them can be complex, requiring support from the non-statutory sector, social services and other branches of medicine. Service development often needs research, staff training, race-equality schemes and sufficient funding to make change possible. I offer here a scheme for considering how to think through service development in this area as well as introducing the government strategy, Delivering Race Equality.

Psychotic disorders in adolescence are uncommon, but often mark the beginning of a lifetime of contact with mental health services. They pose a challenge and anxiety to sufferers, to their families and to professionals involved in assessment and treatment. Accurate and early diagnosis, coupled with appropriate treatment, is essential to minimise secondary handicaps. However, their rarity means that professionals are frequently unfamiliar with some aspects of presentation or management and that appropriate service provision is not readily available (e.g. admission directly into an in-patient bed in an age-appropriate environment). A lack of age-appropriate provision may also mean that adult psychiatrists are occasionally called on to manage and treat a younger teenager presenting with a psychotic disorder.

Adverse effects of psychotropic medication on breast-fed infants have not been studied in controlled and systematic research. Existing information comes from small case series and single case reports. These limited data confirm that psychotropics are excreted into breast milk and that the infant is exposed to them. In recent decades sufficient data have accumulated to allow psychiatrists to prescribe tricyclic antidepressants, selective serotonin reuptake inhibitors, conventional antipsychotics, carbamazepine and sodium valproate to breast-feeding mothers with safety. There are not sufficient data on atypical antipsychotics to allow women to breast-feed safely. Mothers on clozapine or lithium should not breast-feed. It is good practice to recommend that breast-feeding mothers requiring psychotropic medication be on a low dose of one single drug. Future research taking account of maternal mental health, psychopharmacological factors, infant physiological environment and individualised risk/benefit assessment will yield clearer responses to this complex issue.

Self-harm in adolescents is common and is increasing. It can present to professionals as a symptom of major mental health disturbance or it can form part of a cultural ‘norm’. This article reviews current knowledge about self-harm in 12- to 18-year-olds. Definitions of self-harming behaviour, epidemiological and aetiological factors, risk assessment and management of self-harming in various settings are discussed in terms of pragmatic clinical approaches and evidence-based practice.

This article offers an introduction to advocacy on behalf of people with mental disorders and/or intellectual disabilities. It concentrates mainly on the issues related to independent specialist advocacy, but refers to other forms also. The term is itself contentious, having different meanings in different contexts. Some of these controversies are outlined here. Inevitably, diverse interpretations imply varying practices, and these too are illustrated briefly. Legislation and concordance of expectations are both contributing to a set of standards to which most advocates in the UK and Ireland will adhere. The requirements that such legislation makes of mental healthcare staff working with independent specialist advocates are outlined, and the ethical dimension of mental health advocacy is noted.

Presence of fever in psychiatric patients may signify a number of potentially fatal conditions. Several of these are related to treatments (e.g. neuroleptic malignant syndrome with antipsychotics, serotonin syndrome with serotonergic antidepressants, and malignant hyperpyrexia with anaesthesia used for administration of electroconvulsive therapy) or exacerbated by them (e.g. malignant catatonia with antipsychotics). New classes of drug treatment may be changing the epidemiology of these disorders. We suggest that an initial diagnosis of hyperthermia syndrome is clinically useful as there are some important commonalities in treatment. We outline a systematic approach to identify a particular subtype of hyperthermia syndrome and the indications for more specific treatments where available.

The relationship between anxiety disorders and substance misuse is intimate. Here we concentrate on alcohol, although for completeness we also briefly mention other substances taken for anxiety relief or that cause anxiety.

This issue of Advances carries two articles from Melbourne, Australia, outlining the rationale for, and implementation of, early psychosis services. Their publication provides an opportunity to address some of the more contentious issues relating to the early psychosis intervention movement.

There has been increasing interest in how to assist people to ‘live well’ with advancing and incurable conditions late into life. This article considers the progress made in mental health services for adults of working age which promote active involvement in their care and how these principles can be applied to older adults with dementia. The concept of ‘recovery’ and its applicability to dementia care are discussed. The Wellness Recovery Action Plan (WRAP) and how it could be translated and modified to the needs of people with dementia are explored. This is especially important in light of the UK National Dementia Strategy, which emphasises early diagnosis and intervention to promote improved care and quality of life.

Psychogenic non-epileptic seizures (PNES) have a significant impact on most patients in terms of distress, disability, loss of income and iatrogenic harm. Three-quarters of patients with PNES are initially misdiagnosed and treated for epilepsy. Misdiagnosis exposes patients to multiple iatrogenic harms and prevents them from accessing psychological treatment. In most cases, the patient's history (and witness accounts) should alert clinicians to the likely diagnosis of PNES. Since this diagnosis may be resisted by patients and may involve ‘un-diagnosing’ epilepsy, video-electroencephalogram recording of typical seizures is often helpful. The underlying causes of PNES are diverse: a model combining predisposing, precipitating and perpetuating factors is a useful way of conceptualising their aetiology. The initial step of treatment should be to limit iatrogenic harm. There is some evidence for the effectiveness of psychotherapy.

In 2003 the Department of Health, in conjunction with the National Institute for Mental Health in England, outlined the government's plan for the provision of mental health services for people with a diagnosis of personality disorder. This emphasised the need for practitioners to have skills in identifying, assessing and treating these disorders. It is important that personality disorders are properly assessed as they are common conditions that have a significant impact on an individual's functioning in all areas of life. Individuals with personality disorder are more vulnerable to other psychiatric disorders, and personality disorders can complicate recovery from severe mental illness. This article reviews the classification of personality disorder and some common assessment instruments. It also offers a structure for the assessment of personality disorder.

Funding for mental health services in England faces many challenges, including operating under financial constraints where it is not easy to demonstrate the link between activity and funding. Mental health services need to operate alongside and collaborate with acute physical hospital services, where there is a well-established system for paying for activity. The funding landscape is shifting at a rapid pace and we outline the distinctions between the three main options – block contracts, episodic payment and capitation. Classification of treatment episodes via clustering presents an opportunity to demonstrate activity and reward it within these payment approaches. We discuss the results of our research into how well the clustering system is performing against a number of fundamental criteria. We find that, according to these criteria, clusters are falling short of providing a sound basis for measuring and financing services. Nevertheless, we argue that clustering is the best available option and is essential for a more transparent funding approach for mental healthcare to demonstrate its claim on resources, and that clusters should therefore be a starting point for evolving a better funding system.

Amphetamines, cocaine and methylenedioxymethamphetamine (MDMA, ‘ecstasy’) have been prominent on the UK drugs scene over the past decade. Much cocaine is now in the form of ‘crack’, which produces particularly acute versions of well-known complications including paranoid psychosis, mood disorders and cardiovascular problems. Ecstasy has additional hallucinogenic properties, and the slightly different range of psychiatric effects can be long-lasting. Assessment for stimulant misuse should include drug screening more than is currently common in general settings. Management comprises psychosocial (particularly behavioural counselling) and pharmacological approaches. A wide range of dopaminergic and other medications have been studied in cocaine misuse, and specialised substitute prescribing may be appropriate for heavy amphetamine injecting. There has been recent focus on problems of dual diagnosis, with particular strategies required to address stimulant misuse by people with severe mental illnesses.