This article explores the philosophical concept of akrasia, also known as weakness of will, and demonstrates its relevance to clinical practice. In particular, it challenges an implicit notion of control over one's actions that might impede recovery from substance misuse. Reflecting on three fictional case vignettes, we show how philosophical work on akrasia helps avoid this potentially harmful notion of control by supporting a holistic engagement with people for whom substance misuse is a problem. We argue that such engagement enhances their prospects of recovery by focusing on agency over time, as opposed to individual lapses.

The language of psychiatry can be ambiguous and idiosyncratic, reflecting the elastic borders of mental illness and psychiatric disorder. This problem is not unique to psychiatry, but as the medical specialty moves closer towards a 'spectrum view’ of mental illness, psychiatric terminology increasingly risks misappropriation and conflation with lay concepts of normal suffering. Deciding what words mean and how psychiatric disorders are defined requires ongoing consideration of the pragmatic consequences, both intended and unintended. Refining the lexicon of psychiatry with an eye towards precision and the minimisation of stigma requires that terms be revised and updated from time to time, but often suitable word replacements remain elusive.

Misuse of drugs such as opium, cocaine and cannabis was common around the world before the First World War and it provided a valuable market for the colonial powers. There seems to have been a brief period of sobriety between the two World Wars, along with widespread criminalisation of drug dealing and use, followed by an explosion of the illicit drug market and the hugely expensive US-led ‘war on drugs'. The cost and impracticality of drug criminalisation, together with changes in Western public opinion, mean that cannabis legalisation has very recently been accepted in some countries and drug prohibition is being dismantled.

Autism and schizophrenia were placed in different diagnostic categories in DSM-III, having previously been considered as related diagnostic entities. New evidence suggests that these disorders show clinical and cognitive deficit overlaps and shared neurobiological characteristics. Furthermore, children presenting with both autism spectrum disorder (ASD) and psychotic experiences may represent a subgroup of ASD more closely linked to psychosis. The study of ASD and childhood schizophrenia, and their clinical boundaries and overlapping pathophysiological characteristics, may clarify their relationship and lead to more effective interventions. This article discusses the relationship through a critical review of current and historical dilemmas surrounding the phenomenology and pathophysiology of these disorders. It provides a framework for working with children and young people with mixed clinical presentations, illustrated by three brief fictional case vignettes.

This article describes how the M'Naghten Rules, which govern the law of insanity in England and Wales, came into existence. In relation to knowledge of the wrongfulness of the alleged act, the article reveals how the Court of Appeal has sought to limit the defence, whereas the courts of first instance, and a number of other jurisdictions, have adopted interpretations of the Rules that accord more closely with the law of insanity as it existed at the time of Daniel McNaughtan's trial and that the Rules were probably meant to formulate. Three cases are used to illustrate the difficulties resulting from the position adopted by the Court of Appeal. It is suggested that in cases where the insanity defence is raised, justice is likely to be better served by addressing specifically and separately the accused's understanding or appreciation of the moral wrongfulness of the alleged act and their knowledge as to whether the alleged act is contrary to the law of the land.

This article updates previous evidence on the role of primary care in the management of depression and related disorders, unexplained physical symptoms, and severe and enduring mental illness. Regarding depression and related disorders, there is now evidence for the benefits of non-medical interventions and collaborative care, providing alternatives to the simplistic over prescription of antidepressant medication. For severe and enduring illness, the emphasis in primary care is now on the effective management of comorbid physical health problems. The article also summarises best practice for the primary care assessment and management of dementia, including the need for holistic review of care quality and the potential benefits of collaborative care. Finally, it notes the growing emphasis on primary mental healthcare in low- and middle-income countries (LMIC).

The concept of an ‘at-risk mental state’ for psychosis arose from previous work attempting to identify a putative psychosis prodrome. In this article we summarise the current criteria used to identify ‘at-risk’ individuals, such as the ultra-high-risk (UHR) criteria, and the further identification of important clinical risk factors or biomarkers to improve prediction of who might develop a psychotic disorder. We also discuss important ethical issues in classifying and treating at-risk individuals, current treatment trials in this area and what treatment current services can offer.

Auditory hallucinations (voices) are the most common symptom in schizophrenia, occurring in 70% of those with the diagnosis. A proportion respond to antipsychotic medication, but despite adequate concordance with prescribed medication, voices may still remain. Voice hearers often inadvertently activate coping strategies that maintain the symptoms and linked distress. Assessment can identify ineffective strategies. Effective strategies can then be initiated, starting with distraction to reduce distress in the short term and leading to focusing approaches that give an improved understanding of voice maintenance. This article describes how to recognise voice hearers' ineffective coping strategies and how to teach effective approaches that are a crucial catalyst in the recovery process.

Working with people who are experiencing mental health difficulties brings many challenges about how best to progress towards shared goals. The cognitive-behavioural therapy (CBT) approach can provide a structure and framework for effective treatment. It aims to help people identify goals and work towards them. We describe a practical approach that provides a structure for step-by-step planning, engaging the patient and promoting planned change.

Miguel de Cervantes, the most influential writer in Spanish literature, created two of the most recognisable fictional characters, Don Quixote de la Mancha and Sancho Panza, in 1605. His novel The Ingenious Hidalgo Don Quixote de la Mancha is regarded as the first modern novel and first international best seller. This article, in the 400th anniversary year of Cervantes' death, introduces Cervantes' biography, discusses the enduring features of his classic novel and explores the value and importance of the novel for psychiatry.

Patients presenting to psychiatrists frequently have comorbid medical conditions for which they are receiving treatment. A range of medications used for treatment of these conditions can have adverse effects resembling psychiatric symptoms. This article presents the results of our review of the literature on psychiatric adverse effects of various non-psychotropic medications, and discusses the mechanisms of such effects, their assessment and management. Among the commonly prescribed drugs found to have psychiatric adverse effects are corticosteroids, anti-Parkinsonian drugs, anti-epileptics, antiretrovirals, antibiotics, anticancer drugs, analgesics, drugs targeting endocrine and cardiovascular disorders, immunosuppressants, skeletal muscle relaxants and bronchodilators. Some adverse effects are predictable and dose dependent, whereas others are rare and idiosyncratic, and psychiatrists need to be aware of them for accurate diagnosis and appropriate treatment.

We review how research over the past decade both supports existing knowledge about the risk factors that children in the UK affected by parental substance misuse face, and adds to our knowledge about the protective factors, protective processes and evidence of resilience which can reduce the likelihood that children will experience poor outcomes. Further research is needed to understand what areas of resilience are most important to target and how other variables, such as gender or age, may influence how protective factors affect the development of resilience. Longitudinal research is also needed to better understand how an individual's resilience may change over time. Finally, there remain many considerable challenges which practitioners, service providers, commissioners and policy makers face in better meeting the needs of this population of children.

The internet provides access to what is often a bewildering array of medical knowledge on mental health, some (but not all) of which is evidence based. As well as information for clinicians, there has been a dramatic increase in the variety and quality of information available for patients and carers. In this article we discuss the advantages and limitations of the types of information available, with suggested sites and strategies for assessing their relative merits.

This article is aimed primarily at psychiatry trainees, MRCPsych course organisers, College tutors, educational supervisors and clinical supervisors. It describes recent changes to the MRCPsych curriculum and examinations and discusses the different approaches that educators can utilise to best help their trainees. We describe how the content of MRCPsych courses can help prepare trainees for both the written papers and the clinical assessment of skills and competencies (CASC). We discuss ways of incorporating patients and carers into course development, innovative approaches using technology to enhance learning, the role of workplace-based assessments and how international graduates may maximise their pass rate.

Alcohol is the most commonly used recreational drug in the world and the third leading cause of preventable death. Alcohol consumption and alcohol problems have increased steadily over the past six decades. Methods likely to reduce alcohol problems (e.g. minimum pricing, restricting licensing hours and increasing the availability of alcohol treatment) tend not to be supported by the drinks industry. Methods favoured by the industry (e.g. public education, industry self-regulation and product warning labelling) are less effective or do not work. The recent history of alcohol policy clearly demonstrates how the financial power of industry can influence governments and undermine effective public health measures, for instance by lobbying, political donations, confusion marketing and creating fnancial vested interests by grants from industry-sponsored 'social aspect organisations'.

This article is a practical guide for psychiatrists who want to apply basic and straightforward statistics in their research. It describes ways of summarising data and provides an overview of statistical tests for comparing patients' characteristics. Measures of association such as correlation and regression are also explained, along with principal components analysis, a method for reducing the dimensionality of data. Explanations are clarified using data from the published studies.

The clinical and public mental health aspects of alcohol misuse in older people (both men and women) have increasing relevance for both old age and addiction psychiatrists. Clinical presentations are often complex and involve a number of different psychiatric, physical and psychosocial factors. The assessment, treatment and aftercare of alcohol-related and comorbid other mental disorders will also involve a broad range of interventions from a wide range of practitioners. Given its growing clinical relevance, there are particular areas, such as alcohol-related brain damage and drug interactions with alcohol, that deserve special attention.

The presentation of anxiety disorders in children and adolescents shares similarities and differences with that in adults, and may vary significantly, depending on the age of the individual. Assessment must differentiate anxiety disorders from developmentally appropriate fears as well as medical conditions and drugs that can mimic anxiety states. Aetiology of anxiety disorders in this group encompasses complex genetic and environmental influences. Additional insight into causation is provided by neuroimaging and research into temperament. Recommended interventions include both cognitive-behavioural therapy and pharmacology. Although childhood anxiety disorders generally remit, there remains an increased risk for anxiety and depressive disorders to emerge in adulthood, most likely through heterotypical continuity.