Although in agreement with their conclusions about the importance of clinical judgement, this commentary criticises the way that Downie & Macnaughton defend it in their article. I argue that their defence is both overly limited in its account of the role of judgement and that it employs unnecessarily contentious arguments. I outline the ineliminable role that judgement plays in determining which general diagnostic concepts fit individual patients given their individuality and specificity.

Akathisia is a common and distressing side-effect of antipsychotic medication. The treatment of this condition is difficult and options are limited. This review of the literature was performed to develop an evidence-based algorithm for the management of antipsychotic-induced akathisia. There is limited high-level evidence to support the use of anticholinergics. Centrally acting β-adrenergic antagonists are potential treatments, although their use is limited by troublesome side-effects. Long-acting benzodiazepines and mirtazapine are potential well-tolerated treatments for the acute management of akathisia.

This refreshment summarises some of the ways in which ‘insight’ has been understood in psychiatric practice and offers some critical thoughts about the notion.

The 1988 US Surgeon General's Report entitled Nicotine Addiction reviewed the mass of evidence on the role of nicotine in tobacco consumption and came to three main conclusions, shown in Box 1.

The true incidence and prevalence of sexual abuse against children is difficult to ascertain. Differing sampling methods, definitions of sexual abuse and methods of information-gathering have a significant effect on the rates reported. General population studies (Morrison et al, 1994) in the USA and Europe reveal a rate between 0.7 and 1.83 per 1000 children. Data from prevalence studies (Morrison et al, 1994) highlight large differences, with rates varying from 7 to 62%; meanwhile, only between 2 and 17% of sexual assaults are reported to the police. Many of the reported offenders are not prosecuted because of difficulties with the child's statement. Some offenders are cautioned, others are charged with specimen charges or have their charges downgraded. Despite an increase in the reporting of sexual offences since the 1970s, they account for only approximately 3% of all offenders on probation and 8% of male offenders in prison even though the number and length of prison sentences for sex offenders has increased since the 1970s. Convicted female offenders remain a very small group with only 23 convicted female sex offenders in custody in 1989.

The deprivation of liberty safeguards apply to England and Wales. In Scotland, trends and uncertainties in the use of welfare guardianship (the equivalent action under Scottish law) provide a useful comparison. In both jurisdictions, there are risks to the rights of individuals.

The Defence Mental Health Services (DMHS) provide an occupationally focused service for the UK armed forces when deployed and when at home. Although much of the work is similar to that carried out by National Health Service community mental health teams, there are many unique aspects to working with the military. Although carrying out operational duties is a key function of the armed forces, the majority of cases managed by the DMHS are not related to traumatic exposures; instead, adjustment, mood and substance use disorders form the bulk of the case work. However, DMHS personnel carry out a considerable amount of psychological education and command liaison functions to support the concept that the psychological welfare of troops is primarily a chain of command responsibility. This article outlines the structure and function of the DMHS and its approach to risk management.

The humane treatment of prisoners has long been considered a mark of a civilised society. Early prison reformers such as Elizabeth Fry and John Howard campaigned vigorously for the improvement of conditions for inmates and for institutions to be focused as much on reform and rehabilitation as on punishment. This progressive improvement in conditions for those imprisoned has been further advanced by the European Convention on Human Rights and its incorporation into UK law. The Human Rights Act 1998 is playing an ever-increasing role in determining the standards of treatment of those detained by the state. Article 3 of the Act – freedom from torture and inhuman and degrading treatment – is of particular importance for those detained in prisons, hospitals and other institutions. As Article 3 case law has evolved, so its interpretation has broadened to include a thorough scrutiny of prison conditions, prison healthcare and the treatment of prisoners in general.

When those whom the law terms ‘secondary victims’ – i.e. the passive and unwilling witnesses of injury, or of the threat of it, to others – seek compensation through the courts for the psychiatric injuries that they have suffered (traditionally but confusingly referred to as ‘nervous shock’ claims), there would in theory be the potential for a virtually limitless number of claims. For this reason, the courts have developed and apply a number of, to a large extent, arbitrary ‘control mechanisms’ as floodgates. This article describes these control mechanisms and other relevant law using recent illustrative cases and with particular reference to the assistance that the courts can expect of psychiatrists as to diagnosis and causation.

Balancing risk and safety in long-term care settings can be challenging while providing and respecting patients’/residents’ needs and rights in terms of sexual expression. We look at factors affecting the expression of sexuality, including staff attitudes and reactions, and the lack of policies governing sexuality. We review the various statute and case law, other legislative and quasi-legal provisions governing sexuality and sexual expression. Finally, we consider the need for clear policies and training for both staff and family members.

This article discusses dopamine partial agonism, which is the main mechanism of action of the psychiatric drugs aripiprazole, brexpiprazole and cariprazine. It outlines the principles of receptor theory and the structure of dopamine receptors; characterises agonists, antagonists and partial agonists; and summarises the dopamine hypothesis of psychosis and the role of dopamine and serotonin in depression.

Clinical research suggests that empathy is associated with better clinical outcomes in various areas of medical care, raising the question of whether a similar effect occurs in psychiatry. The aim of this review is to explore philosophical, neuroscientific and psychological perspectives on the concept of empathy in the context of the day-to-day work of clinical psychiatrists. The definition of empathy is outlined and sociodemographic factors, working conditions and psychiatrists’ beliefs that can potentially affect empathy in clinical encounters are explored; educational and training aspects are also reviewed. The review concludes suggesting that research on empathy is needed to understand contextual, training and relational factors that could benefit mental healthcare as well as the working conditions of clinical psychiatrists, both inextricably linked.

The problems associated with alcohol and drug misuse are diverse and make a major impact on the health of the nation (Anderson, 1991; Royal College of Psychiatrists, 1992). A recent survey showed that the prevalence of alcohol dependence in the population (aged 16–64 years) was 47 in 1000 and of drug dependence 22 in 1000. (This compares with a prevalence for functional psychosis of 4 in 1000) (Office of Population Censuses and Surveys, 1994).

The legal decision on whether a defendant can fairly take part in a criminal trial in England and Wales is currently based on the leading case of R v Pritchard (1836), which despite subsequent case law updates does not embrace the concept of mental capacity or effectively identify defendants who are unable to meaningfully participate. Further to an extensive consultation process, the Law Commission published recommendations for reform in 2016, with a proposed new test of capacity to participate effectively in a trial and detailed suggestions for statutory reform of court procedures for managing defendants found unable to participate. Here we review the proposals and consider practical implications and suggestions regarding their implementation.

Draper & Rogers (2005, this issue) have put an important subject under the ethical microscope. They have demonstrated that the current, fairly simple, rules applying to the publication of case studies and dissemination of patient information in teaching are inadequate and need revision. This is particularly important because such forms of communication are likely to increase in the future. Many journals, including the British Journal of Psychiatry, generally frown upon case studies as representing little value to science: case studies unnecessarily focus on the particular; their message is only valuable when it is general. However, they aren't going to go away because their educational value is obvious, as anyone who looks at the handling of almost any scientific subject in the mass media will testify. Experts can pontificate on hypotheses, proportions, means and significance to little effect and the real message comes home from a sufferer or successfully treated patient who adds human flesh to a dry factual skeleton. This need to particularise is necessary in all parts of teaching.