Shared care in mental health is now a policy imperative in England and Wales, yet its meaning, form and function are still open to debate. In this article, I discuss the benefits of and barriers to a shared care approach, explain how policy is currently driving practice in this area, discuss recent shared care initiatives and highlight some of the tensions inherent in the approach, particularly from the viewpoint of patients. I also give some of the key factors that need to be in place within a ‘whole systems' approach to ensure that shared care moves from the rhetoric of the statute book to everyday practice.

Alzheimer's disease is the most common cause of dementia in older people, with about half a million people affected in the UK. Its effects are devastating and far-reaching for sufferers, their carers and society in general – the Audit Commission estimated the annual cost of dementia care for 1998–1999 at £6.1 billion (Audit Commission, 2000). There is no cure and it is terminal within 3 to 7 years of diagnosis. Given an estimated doubling of dementia cases over the next 50 years (Melzer et al, 1997), the burden of care is set to increase substantially.

Treatability is a confused and confusing concept in psychiatry. In its legal sense, it is a measure that limits the involuntary admission of patients with some particular types of mental disorder. The legal term itself has generated considerable discussion and dissent (e.g. Mawson, 1983; Grounds, 1987), and the Government's White Paper on reforming mental health legislation in England and Wales proposes to abolish it (Department of Health, 2000).

A significant proportion of people live and work in rural areas, and rural mental health is important wherever psychiatry is practised. There are inherent difficulties in conducting rural research, due in part to the lack of an agreed definition of rurality. Mental health is probably better in rural areas, with the exception of suicide, which remains highest in male rural residents. A number of aspects of rural life (such as the rural community, social networks, problems with access, and social exclusion) may all have particular implications for people with mental health problems. Further issues such as the effect of rural culture on help-seeking for mental illness, anonymity in small rural communities and stigma may further affect the recognition, treatment and maintenance of mental health problems for people in rural areas. Providing mental health services to remote and rural locations may be challenging.

With the launch of the Fair Deal for Mental Health campaign in 2008 the Royal College of Psychiatrists made a commitment to ensuring that ‘training for psychiatrists promotes the recovery approach’. National guidance emphasises the universal applicability of the recovery values for anyone of any age who has a significant mental health problem. Yet there has been little thinking as to whether the recovery approach is applicable to old age psychiatry and particularly to dementia care. This article explores the striking similarities between a recovery-oriented approach and person-centred care, the particular challenge posed in dementia care and the benefits of a collaborative approach in pursuit of common purposes.

Choice, responsibility, recovery and social inclusion are concepts guiding the ‘modernisation’ and redesign of psychiatric services. Each has its advocates and detractors, and at the deep end of mental health/psychiatric practice they all interact. In the context of severe mental health problems choice and social inclusion are often deeply compromised; they are additionally difficult to access when someone is detained and significant aspects of personal responsibility have been temporarily taken over by others. One view is that you cannot recover while others are in control. We disagree and believe that it is possible to work in a recovery-oriented way in all service settings. This series of articles represents a collaborative dialogue between providers and consumers of compulsory psychiatric services and expert commentators. We worked together, reflecting on the literature and our own professional and personal experience to better understand how choice can be worked with as a support for personal recovery even in circumstances of psychiatric detention. We were particularly interested to consider whether and how detention and compulsion could be routes to personal recovery. We offer both the process of our co-working and our specific findings as part of a continuing dialogue on these difficult issues.

Asperger syndrome is an uncommon condition, but probably more common than classic autism (the only published population study estimated prevalence at 36 per 10 000 children for Asperger syndrome and 5 per 10 000 for autism (Ehlers & Gillberg, 1993)). Misdiagnosis or delayed diagnosis of this disorder is a serious problem, and the average age at diagnosis is several years later than for autism (Gillberg, 1989). Obviously, this can be traumatic for individuals and families; furthermore, the most effective intervention programmes begin early, and establishing management strategies at an early age can minimise later behavioural problems (Howlin, 1998).

One in four people with mental health problems in Britain report debt or arrears, which is nearly three times the rate among individuals without similar conditions. Although health professionals commonly encounter debt among patients, some report that they lack basic knowledge to effectively intervene and that patient debt is often not acted on until a crisis emerges. Our aim in this article is to improve psychiatrists' knowledge and confidence in dealing with patient debt. We provide basic definitions of debt and problem debt; outline the impact that debt can have on patients' health, social and financial well-being; identify the stages and signs that a patient may be accruing problem debt; describe how psychiatrists should respond; and review the instruments available to assess patients' mental capacity to make financial decisions. We do not expect psychiatrists to become ‘debt experts’, but provide working knowledge for engaging more effectively with this problem.

Psychotropic literature in recent years has become very concerned with the cardiac safety of certain psychotropic medication. This paper reviews some of the cardiac factors to be considered in the safer selection of psychotropic drugs for the vulnerable patient in everyday clinical practice.

Forensic psychiatry services have grown and become more complex in structures, processes and pathways. Legacy customs, practices and changing policy are now organised into formal models of care. These are written accounts of how a health service is delivered, outlining best practice and services for patients progressing through the stages of their condition and the care and treatment available. This article explores the four key elements of a model of care: goals; pathways and processes; treatment programmes; and systematic evaluation. It describes the most common model of care in forensic services, which builds on structures of stratified therapeutic security. It also considers variations on this basic or standard model matched to needs arising from the complex interrelationship with other parts of the mental health service for the population served and with criminal justice, primary care and physical health, housing and welfare agencies.

Over the past decade attention to the provision of healthcare for individuals with personality disorder, particularly those who pose a risk to others, has substantially increased. Keeping pace with such developments with a suitably trained, consistent and motivated workforce, interfacing health and criminal justice systems where necessary, presents an enormous challenge. Staff must be experts in managing conflict at every level, while sustaining an optimistic and therapeutic orientation. Boundaried relationships provide the context for recovery for patients. Key principles and practices likely to promote resilience in personality disorder services, with a focus on the role of supervision, are outlined in order to support staff in keeping themselves afloat, their patients safe, and their services on target.

The use of plant essential oils in aromatherapy has been recorded for thousands of years, but until recently there was very little formal evidence regarding the use of these treatments in people with dementia. Over the past few years a number of clinical trials have compared aromatherapy, principally using either lavender (Lavandula angustifolia or Lavandula officinalis) or lemon balm (Melissa officinalis), with inactive treatment. All of these studies demonstrated a significant impact on behavioural problems in patients with dementia, with negligible side-effects. However, there is still not sufficient evidence to recommend widespread use in clinical practice and the key question of whether these treatments can provide a viable alternative to existing pharmacological agents needs to be addressed.

There is great concern about the access of ethnic minority clients to appropriate healthcare and the treatment they experience once they gain access to services. There have been recent calls for training in cultural diversity to be prioritised for mental healthcare professionals, including psychiatrists. In this article we discuss the term ‘cultural diversity’ and consider its relevance to psychiatrists. We then briefly review some of the training currently available, discussing related issues and problems, including the lack of evaluation. We suggest how psychiatrists may need to change their approach to this subject.

Depression in old age is a pathological process, not a normal reaction to growing older. The majority of people cope with ageing, and many feel happy and fulfilled. However, there is a bias among health professionals and the community in general to accept lower functioning and more symptoms in older people (Alexopoulos, 1992). Depression tends to be denied by the current generation of elderly people, many of whom were raised in an atmosphere where showing feelings was discouraged, and this adds to diagnostic difficulties. Comorbid medical conditions, the tendency of patients to somatise, cognitive deterioration, and multiple life events, often of loss (e.g. bereavement, retirement, moving to smaller housing), all further complicate the diagnostic process.

Research evidence has shown that morbidity and mortality rates are higher in psychiatric patients than in the general population. This article describes factors that affect the physical health of psychiatric patients living in institutions and the steps that can be taken to review, monitor and improve their physical health. The physical health care of long-stay patients should reach the same standards as those expected in the general population.

By focusing therapeutic effort on the early stages of psychotic disorders, effective early intervention should improve short- and long-term outcomes. Strategies include pre-psychotic and prodromal interventions to prevent emergence of psychosis, detecting untreated cases in the community and facilitating recovery in established cases of psychosis. The evidence base for each of these strategies is currently limited, although several international trials are under way. The Department of Health in the UK has announced the intention of setting up 50 early intervention services nationally, several of which are already operational. In this article, we briefly discuss the differing ways in which early intervention is conceptualised, summarise the evidence supporting it in established cases of psychosis, suggest appropriate service models and describe two early intervention services in south-west London.

Cognitive analytic therapy (CAT) was formalised in 1984 by Anthony Ryle. It facilitated the clinical integration of psychodynamic therapy and personal construct/cognitive psychology. It is a brief, user-friendly relational therapy, applicable to the wide range of psychological problems typically seen in public mental health settings. It has recently been included in national guidelines for the treatment of personality disorder in the National Health Service. CAT provides a coherent model of development and psychopathology, which centrally views the self as both socially formed and embedded. Owing to its core relational grounding, CAT is being increasingly applied to team contexts/systems, enabling a ‘common language’ for team formulation/practice. It is also being successfully delivered as a group therapy. This article describes the development and unique features of the CAT model, analyses the current evidence base and identifies potential future directions for the model.

In the UK, the National Institute for Health and Clinical Excellence's guidelines on obsessive–compulsive disorder (OCD) recommend cognitive–behavioural therapy, including exposure and response prevention, as an effective treatment for the disorder. This article introduces a cognitive–behavioural model of the maintenance of symptoms in OCD. It discusses the process of engagement and how to develop a formulation to guide the strategies for overcoming the disorder.

The incidence of treatment resistance in schizophrenia (failure to respond to antipsychotic therapy) is about 20%. Factors that may contribute to it include non-adherence (non-compliance) to treatment, comorbid conditions and medication side-effects. The National Institute for Clinical Excellence recommends that clozapine be used for schizophrenia resistant to another atypical antipsychotic. Here we focus on patients who are also resistant to clozapine given in adequate dosage for sufficient duration. Switching from clozapine to a previously untried atypical (e.g. olanzapine, risperidone, quetiapine) might be of benefit in partial treatment resistance. In more difficult cases, augmentation of clozapine with benzamides (sulpiride, amisulpride) and anti-epileptics (lamotrigine) shows some success. In extreme treatment resistance, a strategy is recommended that combines the proven best drug for the particular patient and psychosocial treatments.

Clinicians working with women patients in secure units will already know that they are the centre of a debate not of their own making, which is about the appropriate specification of services for women patients with security needs. This paper attempts to outline the relevant issues and proposed solutions.