Aripiprazole, brexpiprazole and cariprazine are partial dopamine (and serotonin) agonists developed as novel antipsychotics. This article discusses their pharmacology, evidence on their licensed and off-licence uses (including psychosis, mania, bipolar depression, Tourette syndrome and autism spectrum disorder) and side-effects. In schizophrenia, they have a low risk of Parkinsonism or hyperprolactinaemia, cause modest increases in body weight and are of moderate efficacy.

Perceptions of self-injurious behaviour as refractory to treatment, and of treatment outcomes as unpredictable, in children and adults with intellectual disabilities and/or autism may lead to treatment inertia or nihilism, restrictive practices and overuse of psychotropic medication in its management. Recent research suggests, however, that from infancy to young adulthood prospects for a positive outcome are fair, and markers predictive of treatment outcome have begun to be identified. In this clinical reflection we briefly describe this work, consider how it may contribute to case stratification, and outline current thinking on further functional differentiation of cases of SIB, promoting non-restrictive practices.

There are well-established links between recurring copy number variants (CNVs) (ubiquitous structural variations within chromosomes) and many psychiatric diagnoses. This article considers potential advances that enhanced understanding of CNVs might offer psychiatry – a scientifically rigorous footing for the discipline and personalised prescribing based on genetic data that would benefit patients from pre-diagnosis to treatment.

Neurosurgery for mental disorder is performed in the UK for treatment-refractory obsessive–compulsive disorder and depression. In this commentary, the procedures used are considered alongside other surgical interventions for psychiatric conditions. Given the evidence for efficacy, this commentary agrees with Whitehead & Barrera's assessment that such procedures be considered more widely in treatment-refractory illness and concurs that the advent of minimally invasive radiosurgery is an exciting prospect for patients who have not responded to other treatments.

Traditionally, service provision for neurodevelopmental disorders such as attention-deficit hyperactivity disorder, intellectual disability and autism – where this has been available – has focused on the needs of children, but there is now increased understanding of neurodevelopmental disorders as lifelong conditions, often with an ongoing need for health and social care provision. Medical and allied professionals frequently report limited education in neurodevelopmental disorders both during their training and post-qualification. This article gives an overview of theoretical and practical considerations for training of psychiatrists and allied healthcare professionals in relation to neurodevelopmental disorders. Key UK policy drivers and capability frameworks pertaining to this training are discussed. The Royal College of Psychiatrists’ 2022 revised curricula for medical trainees in psychiatry are examined in relation to neurodevelopmental disorders and ongoing CPD requirements in this area for career psychiatrists are considered. A brief overview of multidisciplinary training in neurodevelopmental disorders and the role of the psychiatrist in this is discussed. An international perspective on training in this area is touched on and current challenges in low- and middle-income countries are outlined. Last, the future direction of training in neurodevelopmental disorders is considered.

Partial agonists such as aripiprazole are often used in addition to a full antagonist such as amisulpride, risperidone or olanzapine in an attempt to mitigate side-effects such as sedation, hyperprolactinaemia and weight gain. However, there can be unintended consequences, including worsening of psychosis. Moreover, previous exposure to a partial agonist may impair the subsequent response to a potent antipsychotic such as haloperidol used to control symptoms of relapse. To understand the mechanisms involved, a method is needed to compare potency in the pharmacological effects of different drugs used in combinations. This article is intended to explore and explain the theoretical principles based on the dopamine hypothesis of schizophrenia. We apply the method to analyse a recently described trial in which two full antagonists (olanzapine and amisulpride) are compared individually and in combination.

Mental disorders are overrepresented in the criminal justice system, and this applies equally to police custody. These environments are complex and often pressured, and the acuity of the situation, combined with underlying mental disorders, comorbid medical problems and substance misuse, can lead to behavioural disturbance and increased psychiatric risk. Police custody may also present an opportunity to identify and signpost people with mental disorders and vulnerabilities who are ordinarily hard to reach by standard health services. This article considers the purposes of mental health screening of detainees in police custody. It gives an overview of research into screening for a range of psychiatric disorders and vulnerabilities (including substance misuse and traumatic brain injury) and summarises data on deaths in and immediately following release from custody. Given the inadequacy of statutory screening procedures in some jurisdictions, the authors offer a pragmatic evidence-based protocol to guide screening for mental disorders in custody detainees.

Clinicians should be aware of the inherent jurisdiction of the High Court in providing a ‘safety net’ to protect ‘vulnerable’ adults who are not within the scope of the Mental Capacity Act 2005 (MCA) or the Mental Health Act (MHA) 1983. Many situations in which the inherent jurisdiction has been deployed have been to safeguard vulnerable adults where there is abuse, coercion or undue influence, but the person does not lack decision-making capacity under the MCA. We explain the nature of the inherent jurisdiction, including descriptions of concepts surrounding ‘vulnerability’; as an intervention of last resort, we consider what statutory alternatives may exist, including safeguarding law under the Care Act 2014; we discuss decision-making capacity in relation to contact with others and, using real cases, the types of order that may be made under the court's inherent jurisdiction. It is important to be mindful that although there may be a legal remedy to safeguard this ‘vulnerable but capacitous’ group, there is a delicate and challenging balance between protecting those at risk and respecting their autonomy.

Partial agonists of dopamine receptors are used in combination with full antagonists in treating psychosis, either to mitigate side-effects or in the hope of increasing effectiveness. We examine how combinations may affect the occupancy of D2/D3 dopamine receptors and explore how these can explain the outcomes in the light of the dopamine hypothesis of psychosis. The combinations considered here are from published studies combining aripiprazole with amisulpride, with risperidone in people with hyperprolactinaemia and with olanzapine to mitigate weight gain. We discuss possible worsening of symptoms by the addition of a partial agonist or switching. We also examine the potentially adverse interaction with a full antagonist such as haloperidol given during a subsequent relapse to control severe agitation.

Autism is a neurodevelopmental condition associated with differences in social communication and interaction, as well as a restricted, repetitive repertoire of behaviours and interests. Autistic people will have areas of interest and can possess abilities that are of potential benefit to both themselves and wider society. However, many find that their opportunities are limited. Here, we will discuss how a social model of care can help meet the needs of autistic people.

Psychiatry in Dissent: Controversial Issues in Thought and Practice was published in 1976. In the book, Irish psychiatrist Anthony Clare (1942–2007) both defended and critiqued contemporary psychiatry. He demystified the field, analysed its problems and argued that psychiatry, for all its flaws, offered a reasoned and reasonable path forward. His arguments remain fiercely relevant today, sometimes eerily so.

Children with intellectual disability are often prescribed psychotropic medication to manage behaviours that challenge. Unfortunately, many receive medication with potentially serious long-term side-effects that has been prescribed inappropriately or for longer than is necessary. NHS England launched STOMP (stopping the over-medication of people with intellectual disability, autism or both with psychotropic medicines) in 2016 to reduce the inappropriate prescribing in adults. This was broadened to include children in 2018 by the addition of STAMP (supporting treatment and appropriate medication in paediatrics). In this article we review the rationale for STOMP–STAMP, highlight the Royal College of Psychiatrists’ position statement on STOMP–STAMP and give clinical advice for psychiatrists who treat children with intellectual disability, autism and/or attention-deficit hyperactivity disorder (ADHD). Importantly, it is essential to consider that ADHD may have been missed and that by diagnosing and treating it, the need for inappropriate antipsychotic medication may be reduced.

Advances in data science and machine learning have allowed for the analysis of increasingly complex and large data-sets. Digital devices are a source of such data, given their ability to collect information on users continuously and irrespective of location. Digital phenotyping aims to use these data to build a comprehensive picture of an individual's behaviour. Psychiatry is well-positioned to make use of this, since digital behaviour may be reflective of mental state. This article provides an overview of the field of digital phenotyping as it stands currently, on the verge of large-scale studies which may pave the way for clinical implementation in psychiatry.