In this article we review the evidence base and practical experience supporting the use of psychopharmacological treatments for autism-spectrum disorders across the lifespan. Recent advances in knowledge are highlighted, as are the shortcomings of published data in this field. Psychosocial and educational interventions remain the core of treatment, but there is now evidence that medication management is a good option for certain domains of behaviour. We discuss the evidence in terms of symptom clusters, including the underlying social deficit of autism and common psychiatric comorbidities.

Recommendations by Lord Woolf for the reform of the civil justice system in England and Wales include proposals which are already beginning to influence the provision of expert evidence to the courts. Lord Woolf has himself been instrumental in the establishment of an Expert Witness Institute which has caused some controversy in medical circles. It is no coincidence that all of this is happening at a time when the courts are delivering judgments which are particularly critical of some expert witnesses.

As many as 10% of the population experience post-traumatic stress disorder (PTSD) at some time in their lives. It often runs a severe, chronic and treatment-resistant course. This article reviews the evidence base for typically recommended treatments such as cognitive-behavioural therapy (CBT), eye movement desensitisation and reprocessing and selective serotonin reuptake inhibitors (SSRIs). It tabulates the major randomised controlled trials of SSRIs and trauma-focused CBT and reviews research on novel treatments such as ketamine, MDMA, quetiapine, propranolol and prazosin.

The Department of Health's best practice guidelines on risk management and violence prevention in UK mental health services highlight the importance of transparency and collaboration with service users. The recovery philosophy echoes the importance of service user inclusion and empowerment in treatment. Our experience in a medium and low secure hospital was that patients were largely excluded from the risk assessment process. In this article, we describe a model for achieving inclusion and transparency in the use of risk assessment tools based on structured professional judgement.

Different forms of excessive reassurance-seeking safety behaviours are explored, along with reasons why these unhelpful responses occur across a range of mental health disorders. This short update covers the rationale for reducing and stopping these behaviours and offers interventions to help people understand and overcome the unhelpful impact that excessive reassurance-seeking can have on them and others.

The human search for tranquillity has embraced the use of numerous substances of which alcohol is probably the most widely used. Alcohol acts in part by facilitating neurotransmission at γ-aminobutyric acid (GABA) synapses and until recently the pharmacological treatment of anxiety was based principally on drugs that produce similar actions on this neurotransmitter and its receptor complex (Cowen & Nutt, 1982) (Box 1).

Bipolar depression remains a major challenge for psychiatric therapeutics. It is associated with disability and excess mortality, and accounts for three-quarters of the time spent in morbid states by treated patients with bipolar disorder. Major limitations of research on the treatment of depression in bipolar disorder include a paucity of short-term and lack of long-term trials, probably reflecting concern about inducing mania. In addition, polytherapy with multiple drugs appears to be widespread, but it is virtually untested for efficacy and safety. Here, we summarise the evidence concerning efficacy of treatment of bipolar depression with antidepressants, mood-stabilising anticonvulsants, lithium and second-generation antipsychotics.

Following ground-breaking work by Shepherd et al (1966) and, more recently, Goldberg & Huxley (1992), primary care is now recognised as the arena in which most contact occurs between the National Health Service (NHS) and people with mental health problems. General practitioners (GPs) remain the first, and in many cases the only, health professionals involved in the management of a whole range of conditions, from common anxiety and depressive disorders to severe and enduring mental illnesses.

Heavy drinking poses a significant risk to public health in the UK. Opportunistic screening and brief interventions offer a cost-effective method of reducing the harm related to excessive alcohol consumption at both an individual and a public health level. Given the high prevalence of alcohol misuse among patients attending mental health services and its impact on behaviour and health, professionals need to be skilled in identifying and treating these problems in all areas of mental health. There is also a need for effective joint working between mental health and specialist addiction services. This article describes the principles and evidence base for brief alcohol interventions, and methods of implementation in health settings.

The principal manuals for psychiatric diagnosis have recently been updated (ICD-11 was released in June 2018 and DSM-5 was published in 2013). A common diagnostic quandary is the classification of people with chronic low mood, especially those with repeated self-harm (‘emotionally unstable’ or ‘borderline’ personality disorder). There has been a great interest in use of type II bipolar affective disorder (‘bipolar II disorder’) as a less pejorative diagnostic alternative to ‘personality disorder’, despite the radically different treatment options for these disorders. DSM-5 (but not ICD-11) clearly distinguishes between borderline personality disorder and bipolar II disorder, indicating that intense emotional experiences (such as anger, panic or despair; irritability; anxiety) should persist for only a few hours in people with a personality disorder. Both manuals now use the term ‘borderline personality disorder’ rather than ‘emotionally unstable personality disorder’. The diagnostic criteria for cyclothymic disorder remain confusing.

A growing body of evidence suggests that late-onset depression (depression occurring for the first time in later life) differs from early-onset (recurrent) depression in terms of clinical features, aetiology, neuroanatomical substrates and prognosis. Some evidence suggests that late-onset depression is more associated with somatic symptoms, cognitive deficits, cerebral structural abnormalities, vascular disease (‘vascular depression’) and poorer treatment outcomes than is early-onset depression. Both general adult and old age psychiatrists face the challenges of managing late-onset depression. In this article we attempt to clarify specific issues relating to late-onset depression in terms of clinical features, aetiology, treatment response and prognosis.

Values-based practice is a new approach to working with complex and conflicting values in mental health practice. Theoretically, it argues that many clinical and ethical dilemmas in psychiatry arise because of the different value perspectives taken by the players involved. By exploring the differences in value systems ‘held’ by each player, it may be possible to come to a richer consensus that can incorporate both similarities and differences. In particular, values-based practice suggests that, traditionally, the value perspective of the patient is often either not considered or is ignored, and that by giving it voice, clinical practice will become more patient-centred. In this article, I will compare values-based practice with other types of systemic thinking in mental healthcare and I will discuss some areas of clinical practice where values-based practice may be difficult to apply.

Over the past 20–30 years psychiatry has gradually moved from predominantly hospital-based care to care in the community. Community psychiatry embraces a variety of definitions: it may describe the practice setting, the population served or the philosophy of illness and treatment (Johnston et al, 1995). In discussing the training implications of this shift towards community models of psychiatric care, we will not consider a separate discipline of ‘adult community psychiatry’. We believe that nearly all psychiatric specialities now involve substantial elements of work outside the hospital, and we therefore contend that the new skills, knowledge and attitudes required to meet the challenge of providing both hospital- and community-based care are pertinent to all trainees. Furthermore, the development of these are essential if the consultant of the future is to provide the safe, effective and sustainable service to those with complex mental health needs detailed in the recent National Service Framework (NSF) for Mental Health (Department of Health, 1999). We will also not attempt specifically to assess the merits of the move to community psychiatry, which may be subject to a separate debate.

Seclusion is a tool used by psychiatrists primarily to manage aggressive and disturbed behaviour that is presumed to be due to the patient's mental disorder. In most parts of the world there are guidelines to using seclusion that are designed to maximise a patient's freedoms and protect their liberty while providing a safe environment. Arguments against the use of seclusion revolve around the deprivation of liberty, the potential for misuse and the concept of seclusion as a form of social control, and patients generally report seclusion as a negative, coercive experience. There is little evidence that seclusion provides long-term benefits in terms of treating symptoms or reducing aggression, although the literature is mixed in this regard. Expert opinion recommends a combination of national policy, ward management and patient-centred interventions to reduce seclusion rates.

‘Rapid tranquillisation’ refers to the use of medication to calm highly agitated individuals experiencing mental disorder who have not responded to non-pharmacological approaches. Commonly it is the initial stage in the treatment of severe and enduring illness. Using medication in this way requires particularly robust evidence of efficacy and the management of side-effects. This article attempts to integrate current understanding of the neurochemical mechanisms of underlying illness and drug actions with therapeutic interventions. It distinguishes arousal from agitation, and effects on sedation from tranquillisation. It reviews critically the practice of rapid tranquillisation in the light of new evidence, changes in the NICE guidelines and British National Formulary recommendations and a national audit (POMH-UK). Broader aspects of management, known as ‘restrictive practices’ (such as control and restraint and seclusion), psychological support of team members, incident reporting, risk assessment, monitoring and medico-legal aspects are not covered.

The world wide web has many advantages for the psychotherapist and for the client, but it poses new challenges too. This article considers both in relation to information, disinformation and information overload; openness and availability of information; and the anomalies of being present, and able to meet other presences, in virtual space but with no physical body and with an identity that may be created for the occasion.

The challenge of managing repeated self-harm and the high risk of morbidity and mortality are compounded in forensic patients, where there are additional risks of harm to others, absconding and security breaches. There is an urgent need for clinically sound, practice-based and theoretically grounded strategies for managing these associated risks. This is essential as available UK guidelines appear inadequate for this group of patients. This article promotes a pragmatic approach to assessing the risk of self-harm clinically to arrive at hierarchical risk judgements. It further suggests an algorithmic approach to managing these risks and provides testable strategies that can be adapted for use in various secure institutions.

The Mental Health (Care and Treatment) (Scotland) Act 2003 was implemented in October 2005. This article summarises the main features of the Act and its differences from previous legislation. The Act was intended to provide a more flexible range of interventions, including compulsory treatment in the community. It also introduced a number of new safeguards. These are described and early data on their impact are presented. Some provisions of the Act are time-consuming and cumbersome, but there is evidence that psychiatrists are committed to its principles and this is borne out by early monitoring data. Some aspects of the Act are being reviewed at the time of writing.

Psychiatrists reporting in criminal cases in England and Wales are now governed by the Criminal Procedure Rules on expert evidence and these will require changes to the format and content of psychiatrists' reports in criminal proceedings. This article sets out the new rules and also draws attention to additional requirements made by the Court of Appeal and, when instructed by the police or the Crown Prosecution Service, by the Crown Prosecution Service. It also draws attention to the report of the Scoping Group on Court Work of the Royal College of Psychiatrists.

More than 68 million people worldwide have been forcibly displaced and one-third of these are refugees. This article offers an overview of the current literature and reviews the epidemiology and evidence-based psychological and pharmacological management of post-traumatic stress disorder (PTSD), sleep disturbance and pain in refugees and asylum seekers. It also considers the relationship between sleep disturbance and PTSD and explores concepts of pain in relation to physical and psychological trauma and distress. During diagnosis, clinicians must be aware of ethnic variation in the somatic expression of distress. Treatments for PTSD, pain and sleep disturbance among refugees and asylum seekers are essentially the same as those used in the general population, but treatment strategies must allow for cultural and contextual factors, including language barriers, loss of freedom and threat of repatriation.