The author reflects on discoveries over the course of a century concerning histamine as a potent chemical signal and neurotransmitter, the development of antihistamines, including promethazine, and chlorpromazine from a common precursor, and the recognition of a major brain pathway involving histamine. Although chlorpromazine has been succeeded by numerous other antipsychotics, promethazine remains the antihistamine recommended for sedation in acutely disturbed patients, largely because it is potently anticholinergic at atropinic muscarinic receptors and therefore anti-Parkinsonian: this means it is also useful in combination with older antipsychotics such as haloperidol.

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

Rapid retitration of clozapine may be necessary to reduce the known high risk of mental state destabilisation in patients who have had a 48 h treatment break. It may carry a high risk of complications, including seizures and myocarditis. We reflect on the literature on standard and rapid retitration and present a case of rapid retitration in the community. In this case, of a 54-year-old homeless man with treatment-resistant schizophrenia and polysubstance misuse, we safely retitrated clozapine in a community setting four times during a 6-month period; each retitration was completed over 4 days. We used a specific protocol based on his psychiatric history. We are now more confident in delivering clozapine retitration to other patients, thus preventing unnecessary admissions.

The development of effective preventions for psychosis is hindered by conceptual challenges underlying diagnosis and the fact that few of the many biological risk factors identified to date are sufficiently well understood to form the basis of a targeted intervention. On the other hand, a great deal is known of the psychosocial conditions that increase the lifetime risk of most mental illnesses: surely enough to justify better resourcing of interventions focused on antenatal care and the emotional well-being of children from the early years through adolescence, where as much as a half of all mental ill health has its roots.

Leadership is a key role for psychiatrists, with many models that can be adopted depending in part on the nature of the individual and their training, the primary task of the team and the nature of the organisation. In this article we suggest a new concept and model of leadership, ‘psychotherapeutic leadership’. We discuss the theoretical background to this model, its benefits and the implications for training and professional development.