This second of two articles on the ‘typical’ (‘first-generation’) antipsychotics covers non-phenothiazines: thioxanthenes (flupentixol and zuclopenthixol), butyrophenones/diphenylbutylpiperidines (including one-time world market-leader haloperidol, and pimozide) and sulpiride, for many years the only substituted benzamide available in the UK. Several tolerability issues ascribed specifically or more frequently to older antipsychotics are also discussed.

Despite the guidance published in revised Codes of Practice and by the Royal College of Psychiatrists, implementation of Section 136 of the Mental Health Act 1983 is still variable. Government funding in England to establish places of safety in psychiatric facilities has been effective but custody suites are still used excessively, especially for those who are brought in intoxicated. Patients feel criminalised by this use of custody suites and by the use of police vehicles rather than ambulance transport for conveyance to the place of safety. There is often a delay in commencing the assessment and the first doctor does not always have Section 12 approval as recommended in the Codes of Practice. The importance of the local Section 136 group tasked with developing and overseeing the implementation of local policy and monitoring is highlighted. There is a need for monitoring locally, but ideally in a form that can be used nationally for benchmarking and research.

Of all the controversies over the different medications used in psychiatry, there is probably least dispute about the effectiveness of antidepressants in controlling depressive illness. However, the choice of which antidepressant to use is bedevilled by the spectre of potential toxicity from adverse effects, interactions and overdose. The unwanted effects may vary from mild and tolerable to potentially lethal. At one time it was relatively easy to become familiar with the problems surrounding the original two main groups of antidepressants – the tricyclic antidepressants (TCAs) and the monoamine oxidase inhibitors (MAOIs). Recent years have seen the introduction of a number of newer drugs, with a wide range of chemical structures and differing pharmacological activities. They also have a new spectrum of adverse effects and interactions. It is worth reviewing the major differences between old and new antidepressants, and to identify the areas in which clinical caution must be exercised in order to avoid pitfalls and maximise clinical benefit.

Jealousy has traditionally been treated by offering medication, support, or various forms of individual psychotherapy or counselling. However, jealousy is usually a condition which has a profound effect on the sexual partner of the jealous person, and they may actually suffer more from the condition than the person him/herself. While accepting that medication and other individual approaches have their place in the management of jealousy, there seem to be several advantages in seeing the problem from the standpoint of the couple relationship. Firstly, couple therapy reduces the almost inevitable labelling of the jealous person as a psychiatric case. Secondly, one might argue a priori that any changes which take place as a result of two people changing their behaviour are likely to be more stable and long-lasting than if just one person changes. There is another consideration, namely that, since the relationship is bound to be affected by the jealousy, it will need attention regardless of the means used to treat the jealousy itself.

The extraordinary events of 1994 in Rwanda touched the world, and the extent and brutality of the atrocities committed scarred it (Anderson, 1998). There are no simple explanations or solutions for such human tragedy. Societies are shattered by war, and societal interventions are required to heal the physical and psychological wounds. The final outcome of such interventions is, however, difficult to predict. Psychiatric involvement in Rwanda's suffering has been small and examination of the literature reveals a paucity of data. Most of the data that are available are qualitative, as that is the only way of understanding what happened. Everyone involved in Rwanda in 1994 was changed by their experiences. Rwanda was a catastrophe.

The impending regulatory changes for all medical professionals in the UK will make it necessary for doctors to be relicensed and, in the case of specialists, to be recertified. This editorial argues strongly in favour of recertification and proposes that continuing professional development is one of the main planks on which recertification of psychiatrists should be based. We present cogent reasons for this, as well as evidence that improved learning contributes positively to healthcare. We also recommend that psychiatrists should make learning objectives more clinically focused as well as properly resourced.

Much the most common type of seasonal affective disorder at temperate latitudes is recurrent winter depression, which probably affects around 3% of adults in the UK to a clinically significant degree. In this article, diagnosis and presentation are discussed and symptoms are contrasted with those of non-seasonal depression. Aetiology and epidemiology, with regard to age, gender and latitude of residence, are described. Sufferers are often treated with light therapy, and this is described in some detail, with mention of effectiveness, prediction of outcome, timescales of response, side-effects, use of lightboxes and alternatives to lightboxes. Other general aspects of the management of seasonal affective disorder, including the use of antidepressant medication, are also outlined.

Violence towards psychiatrists has been recognised as an occupational hazard for many years. With the development of community care it is increasingly likely to be encountered outside the hospital. To maximise personal safety in the community, psychiatrists need to be working in trusts in which an infrastructure to establish and maintain safety standards is in place.

Nitrous oxide (N2O) misuse is widespread in the UK. Although it is well-known that it can cause devastating myeloneuropathy, psychiatric presentations are poorly described. There is little understanding of who it affects, how it presents, its mechanism of action and principles of treatment. We begin this article with a case study. We then review the literature to help psychiatrists understand this area and deal with this increasing problem, and make diagnosis and treatment recommendations. We describe a diagnostic pentad of weakness, numbness, paraesthesia, psychosis and cognitive impairment to alert clinicians to the need to urgently treat these patients. Nitrous oxide misuse is a pending neuropsychiatric emergency requiring urgent treatment with vitamin B12 to prevent potentially irreversible neurological and psychiatric symptoms.

This article is a brief review of the teaching role of psychiatrists and is directed at psychiatrists in the UK National Health Service who teach medical undergraduates. It reviews the responsibility of delivering teaching, the delineation of teaching duties, and the teaching roles of the psychiatrist in the changing environment of medical education. Application of good principles of clinical teaching and delivery of tomorrow's doctors in line with the General Medical Council's recommendations are discussed. The article also describes a recommended core curriculum in psychiatry for undergraduates, which lays out what should be taught.

The prevalence of tattoos is higher among people with mental disorders and those likely to come in contact with mental health services. The motivations for acquiring a tattoo are varied and tattoos can give clues to the presence of particular psychiatric conditions and to the inner world of patients. Psychiatrists need to be aware of the health and safety issues surrounding the tattooing procedure and be able to give appropriate advice to their patients if they wish to acquire a tattoo. The issue of capacity must be considered. This may be particularly relevant for clinicians working with adolescents, the most common age group for acquiring tattoos. Owing to the high proportion of adults who subsequently regret their tattoos and the associated psychological and social distress, clinicians should be aware of methods of tattoo removal.

Those who work with older adults will inevitably find themselves working with families. Indeed assessment of an older person is often difficult if members of their family and social network are not involved. Referrals to social and psychiatric services are often precipitated by family changes. Ratna & Davis (1984) described 142 consecutive referrals to a community old age psychiatry service and found retirement, family conflict, departure of or illness of a carer, or bereavement precipitated 60% of referrals. Thus, work with older adults will often necessitate work with families, although it may not be seen in those terms.

This article summarises new research, together with core features, course and outcome of schizophrenia with onset in childhood and adolescence, and investigates its neurobiology and continuity into adult life. It concludes that, in conformity with other disorders of childhood, adult-based diagnostic criteria have validity in adolescence. Sadly, the disorder has a poorer outcome when onset is in youth.

Most professions have recently realised that basic undergraduate and postgraduate training is not enough to maintain high standards of practice throughout a long career. Continuing professional development (CPD) has become a feature therefore of the working life of these professions, and medicine, which was in the forefront for undergraduate and postgraduate education, has somewhat lagged behind in this. The failure of consultants to keep up to date in their professional knowledge and attitudes is clearly detrimental to patients, to the doctors themselves, and to the Health Service.

Buprenorphine, a partial μ-opioid agonist and κ-opioid antagonist, is recommended as safe and effective maintenance treatment for opioid dependence. It offers the possibility of management in primary care settings. However, its prescription has led to diversion for illicit recreational use and resulted in medical complications and, rarely, fatal overdose in combination with other sedatives. The outcome of buprenorphine maintenance programmes varies from country to country and it is determined by the local therapeutic traditions, regulatory restrictions and existing service provision for opioid misusers. This article addresses the pharmacology of buprenorphine, the benefits and drawbacks of its prescription, service provision for opioid misuse around the world, policy recommendations, and prescribing training requirements.

Reform of mental health legislation has been under consideration for several years in England and Wales (Department of Health, 2000a), where the Mental Health Act 1983 is in force, and in Scotland (Millan Committee Secretariat, 2001), which is governed by the Mental Health (Scotland) Act 1984. The Mental Health (Northern Ireland) Order 1986 is also under review, although the findings have yet to be published.

Structured professional judgement risk management schemes such as the Historical, Clinical, Risk Management - 20 (HCR-20) can be described as clinical guidelines produced by a collaborative process between mental health clinicians and researchers. The purpose is to provide clinicians with a framework to guide interventions designed to manage specific risks such as violence against others. The use of evidence-based clinical methods, especially in a multidisciplinary setting, is now commonly considered a best-practice approach when managing violence and related risks. This article describes some of the practical implementation challenges that may arise when using schemes such as the HCR-20 in multi-disciplinary team meetings.

Sleep medicine is a truly multidisciplinary field that covers psychiatric, neurological and respiratory conditions. As the field has developed it has become increasingly clear that there is a great deal of overlap between sleep and psychiatric disorders and it is therefore essential for psychiatrists to have some knowledge of sleep medicine. Even those disorders, such as obstructive sleep apnoea, that may seem to be outside the remit of psychiatry can have complex and important interactions with psychiatric conditions. In this article we give a brief overview of the range of sleep disorders a psychiatrist might encounter, how they are recognised, investigated and treated, and how they relate to psychiatric conditions.

Issues of sexual reproduction lie at the core of evolutionary thinking, which often places an emphasis on how individuals attempt to maximise the number of successful offspring that they can produce. At first sight, it may therefore appear that individuals who opt for gender-affirming medical interventions are acting in ways that are evolutionarily disadvantageous. However, there are persuasive hypotheses that might make sense of such choices in evolutionary terms and we explore these here. It is premature to claim knowledge of the extent to which evolutionary arguments can usefully be applied to issues of gender identity, although worth reflecting on the extent to which nature tends towards diversity in matters of sex and gender. The importance of acknowledging and respecting different views in this domain, as well as recognising both the uncertainty and likely multiplicity of causal pathways, has implications for clinicians. We make some suggestions about how clinicians might best respond when faced with requests from patients in this area.

A judgement may be defined as an assertion made with evidence or good reason in a context of uncertainty. In psychiatry the uncertainty is inherent in the professional context and the evidence derives from academic literature and scientific studies as they are applied to a specific patient. The nature of the uncertainty and the factors that should inform professional judgement are explored in this article. Professional judgement currently faces two serious challenges: an obsession with numbers, which comes from within medicine, and the ‘patient choice’ agenda, which is politically inspired and comes from outside medicine. In this article we strive to defend professional judgement in the clinic against both challenges.