Depression has a large socioeconomic burden, affecting an estimated 280 million people worldwide. Up to 55% remain symptomatic following pharmacological and psychological treatment and may be classified as having treatment-resistant depression. This commentary assesses two treatment options for this group – electroconvulsive therapy (ECT) and a novel approach, magnetic seizure therapy (MST) – with reference to a Cochrane Review comparing the two. The Cochrane analysis showed no clear benefit for MST, but the evidence is currently insufficient to draw firm conclusions.

There are many pressures on elite footballers. They work in a meritocracy, where only the best are selected and play at the highest levels. From the moment they enter an academy to their retirement there is a fear of deselection and rejection. Elite players need to contend with criticisms from fans and via social media; team and management dynamics can be stressful. Fears of injury are major concerns. In addition, the players are likely to face everyday difficulties experienced by the rest of society, such as relationship, family and financial problems. There is a great deal of stigma associated with mental health problems in footballers, hence approaches are required that are destigmatising. This article presents two frameworks conceptualising stress in footballers: the Power Threat Meaning Framework, which describes stress in non-diagnostic terms; and the Yerkes–Dodson curve, which describes how stress can affect footballers’ mental and physical performances on the pitch. Both frameworks can combine to enable therapists to understand players’ distress and its impact and to guide towards appropriate treatments, as we show in a fictitious case study.

This month's Cochrane Corner meta-analysis evaluates the evidence for the use of aripiprazole in ‘autism spectrum disorders’ – although in fact, outcome measures mainly included subtypes of challenging behaviour and side-effects. Aripiprazole was found to be effective in reducing irritability and hyperactivity, while causing extrapyramidal side-effects and weight gain. Only three trials were included in the review, with two small trials eventually included in the meta-analysis. All trials were conducted in under-18s in the USA, with no requirement for a trial of behavioural management before psychotropic medication, and excluding under-18s with important comorbidities such as medicated attention-deficit hyperactivity disorder. All three studies were sponsored and funded by the manufacturer of aripiprazole. Further, a discontinuation trial showed no evidence of sustained benefit beyond 16 weeks of treatment.

The COVID-19 pandemic has rapidly accelerated the use of online and remote mental healthcare provision. The immediate need to transform services has not allowed for thorough examination of the literature supporting remote delivery of psychiatric care. In this article we review the history of telepsychiatry, the rationale for continuing to offer services remotely and the limitations of psychiatry without in-person care. Focusing on randomised controlled trials we find that evidence for the efficacy of remotely delivered psychiatric care compared with in-person treatment is of low quality and limited scope but does not demonstrate clear superiority of one care delivery method over the other.

Depression and anxiety are common in adolescents, but most affected will not get any formal help. Digital mental health technologies (i.e. resources and interventions to support and improve mental health) are a potential way to extend the reach and increase adolescents’ access to therapies, at a relatively low cost. Many young people can access the internet and mobile technologies, including in low- and middle-income countries. There has been increased interest in integrating technologies in a range of settings, especially because of the effect of the COVID-19 pandemic on adolescent mental health, at a time when services are under pressure. This clinical review gives an overview of digital technologies to support the prevention and management of depression and anxiety in adolescence. The technologies are presented in relation to their technological approaches, underlying psychological or other theories, setting, development, evaluations to date and how they might be accessed. There is also a discussion of the potential benefits, challenges and future developments in this field.

Although hypnosis has played a part in psychotherapy for a long time, it is not yet seen as an evidence-based therapy and is absent from many practice guidelines when it comes to the treatment of psychiatric disorders. At present, the applications and methods of hypnotherapy are poorly understood and other methods of psychotherapy tend to be favoured. This review article aims to introduce the role of hypnotherapy and its application for certain common psychiatric presentations, as well as examine its efficacy by summarising recent evidence from high-quality outcome studies and meta-analyses.

The strong, life-long association between epilepsy and intellectual disability means that psychiatric teams, and the services they exist in, have a need for significant competencies in the field of epilepsy. This article addresses these competencies through the pathway of care. It will focus on those areas most relevant to psychiatric care and, when possible, explore where technology has begun to influence practice. The pathway leads from diagnosis through, in some cases, to mortality and support of the bereaved in psychiatric care. We will approach the topic through showing how the intertwining themes of information, empowerment, access to care, assessment of risk and psychological support are important. Technological advances are supporting changes in most of these areas, and psychological support, a knowledge of the needs of people with epilepsy and intellectual disability and epilepsy skills remain the foundation in the application of these advances.

Lithium is a gold standard maintenance treatment in bipolar affective disorder. It has a narrow therapeutic range, and at higher serum lithium levels there is a risk of adverse effects and toxicity. There are three patterns of lithium intoxication: acute, acute-on-chronic and chronic. We describe risk factors for lithium intoxication, mechanisms of toxicity and clinical symptoms seen in lithium intoxication. We describe both the acute and chronic effects of lithium toxicity. Lithium intoxication may be life-threatening and associated with longer-term sequelae. The management of lithium intoxication involves determining the type of intoxication. We discuss treatment strategies aimed at reducing absorption and increasing elimination of lithium. We discuss clinical indications for extracorporeal methods such as dialysis, which are used to limit the time and degree of exposure of the central nervous system to toxic lithium concentrations. Haemodialysis is the most rapid method of eliminating lithium from the body, but careful monitoring is required. Preventive strategies to mitigate the risk for lithium intoxication are discussed.

Part 1 of this three-part series on integrated care discussed the drivers for change in healthcare delivery in England set out in the NHS Long Term Plan. This second part explores the evolution of mental health services within the wider National Health Service (NHS), and describes important relevant legislation and policy over the past decade, leading up to the 2019 Long Term Plan. We explain the implications of this, including the detail of emerging structures such as integrated care systems (ICSs) and primary care networks (PCNs), and conclude with challenges facing these novel systems. Part 3 will address the practical local implementation of integrated care.

In clinical psychiatry, it is common to see pregnant and postpartum patients who express excessive anxiety and concerns about pregnancy or childbearing. This implies the need to distinguish between symptoms that could be considered to be an expected reaction to the situation, the diagnosis of an anxiety disorder or the presence of pregnancy-related (pregnancy-specific) anxiety. The last presents as a specific clinical phenomenon, identified in the literature as concerns exclusively linked to the situation of pregnancy or childbirth. In this article I review key points in the differential diagnosis of perinatal anxiety and its impact on both the pregnancy and the baby, as well as aspects of detection and diagnosis. I also give a brief summary of possible management approaches and treatments.

The first two articles in this series have shown the direction of travel for health and social care in England, and how the status quo in already stressed systems is not viable. It is difficult to disagree with the principles of ‘integrated care’, yet we currently lack evidenced models on which we might build. There is a need for experiential learning and sharing of experiences. This third article describes in more granularity the experiences, positive and negative, of an early-adopting integrating service in south-east London that incorporated aspects of the local authority and secondary care physical and mental health services. It provides structured guidance on which types of integration one might aim for, managing internal and external relationships, and discussion on evaluating progress.

In recent years, mass violence associated with men who identify as involuntary celibates (incels) has been of increasing concern. Incels engage in an online community where misogyny and incitements to violence against women are prevalent, often owing to the belief that women are denying them a ‘right’ to sex. Indeed, inceldom can be considered a form of extremism. Information released about the prepetrators of incel-associated violence consistently suggests that mental disorder is a contributory factor and may increase vulnerability to engaging with the incel community. Depression, autism and personality disorder are particularly relevant. To date, there has been little research into the mental health of incels and how, in some, this contributes to violence. This article considers the associations between mental disorder and inceldom, including the risk factors for incel-related violence, and makes recommendations for best practice in risk assessment and clinical intervention.

This article examines notions of hedonism, altruism and conscience in relation to the activity of four neurotransmitter pathways: the dopamine reward, noradrenaline fight or flight, serotonin calming and glutamine learning pathways. Associated brain areas that modulate behaviour are highlighted: the prefrontal cortex (activity planning, risk mitigation), the hippocampus (memory retrieval) and the insular cortex (integration of information to decide on action). Putative epigenetic changes influencing adult behaviours after childhood privation are discussed. Pharmacological and psychological means of mitigating harmful behaviours are summarised, alongside the ethics of epigenetic screening to predict future addictive and violent tendencies.

The use of hypnotherapy in psychiatry has been controversial. However, evidence presented by Chan and colleagues shows that it is beneficial to the promotion of good mental health and well-being, specifically being applicable in the management of mental disorders. But what does this mean for practice? This commentary looks at what we agree and disagree with, what we opine is missing from the article and what now needs to happen. Patients should be able to access hypnotherapy or hypnosis routinely on the National Health Service. Since it works, who may it work for and how may we make this available to those who could benefit from it?

Clozapine dose assessment in treatment-refractory schizophrenia is complicated. There is a narrow margin between an effective and a potentially toxic dose and wide inter-individual variation in clozapine metabolic capacity. Moreover, factors such as changes in smoking habit, infection/inflammation, co-prescription of certain drugs, notably fluvoxamine, and age alter the dose requirement within individuals. Therapeutic drug monitoring (TDM) of plasma clozapine and N-desmethylclozapine (norclozapine) can help assess adherence, guide dosage and guard against toxicity. This article gives an overview of clozapine pharmacokinetics and factors affecting clozapine dose requirements. It then outlines the procedures and processes of clozapine TDM, from taking the blood sample for laboratory assay or point-of-contact (finger-prick) testing (POCT) to interpreting and acting on the results.

Almost a quarter of people with intellectual disabilities have epilepsy. This life-long condition adversely affects their health, safety and well-being and carries an increased risk of sudden unexpected death in epilepsy (SUDEP) in this population. This commentary considers what not only health and social services but also communities and people with intellectual disabilities themselves can do to improve outcomes.

Genetic testing in psychiatry is becoming more common, but psychiatrists often receive little training in it. Given the pace of change in genetics, understanding the current methods of testing and their associated merits and limitations can therefore be challenging for some. This narrative, written for psychiatrists in the clinic, aims to cut through the jargon and describe current genetic testing techniques and their evolution from previous methods. It discusses benefits and risks of testing, how geneticists decide whether genetic variants are pathogenic, terminology found in genetic test results and how best to support patients with genetic diagnoses. It also describes methods used to study the genetics of polygenic disorders. It is anticipated this will facilitate a greater understanding of genetic testing and promote confidence among psychiatrists to discuss its clinical utility and implications with patients.

We describe the importance of relational factors in prescribing practices and discuss how they may influence treatment outcomes. Although relational factors play a part in every clinician–patient interaction, they are particularly relevant when managing patients with complex emotional needs. We discuss how relational prescribing can add value when incorporated into standard practice. We introduce psychodynamic theory principles, and we suggest a framework to facilitate reflection and support decision-making when clinicians are faced with complex prescribing decisions.

Despite numerous UK government policies aimed at reducing the number of autistic people and people with an intellectual disability in mental health hospitals, little progress has been made, with many experiencing lengthy stays that offer little therapeutic benefit. Once admitted, people are at risk of restrictive interventions and significantly delayed discharge, resulting in trauma. This article draws on the cases of four people to illustrate the limitations of current mental health system approaches to the challenges experienced by autistic people and people with an intellectual disability. The importance of relational working and listening to people is explored, and we demonstrate how this can facilitate the provision of bespoke housing and care packages to enable a successful return to life in the community. Finally, we offer recommendations on the changes urgently needed to ensure that autistic people and people with an intellectual disability can live ordinary lives in their own homes, with timely and effective support from mental health services when needed, just like everyone else.

This commentary is a response to three articles on integrated care systems in this journal. It explores some aspects of the latest transformation of England's National Health Service (NHS) and raises some questions on the extent to which the proposed NHS Long Term Plan can deliver on the current challenges.