The royal charter of the Royal College of Psychiatrists is generally taken to enhance its status. However, the concept of a hereditary monarchy is intellectually indefensible and the realities of the British monarchy exacerbate inequalities in the UK. The connection is particularly problematic for psychiatrists because of their role in the compulsory detention and treatment of patients. The Royal affiliation can only serve to emphasise the power inequalities in society associated with these activities. College members should feel free to discuss whether this situation should continue or whether we should be British rather than Royal.

We challenge a prevalent belief that depression causes suicide and propose that certain symptoms of depression and other psychopathologies may function to prevent lethal self-injury. Theoretical and empirical evidence supports this position. As suicide posed an extreme fitness hazard throughout human evolution, our species evolved special-purpose psychological defences that continuously monitor and manage this danger. Last-ditch protections may present as diverse psychiatric phenomena. Mobilising in adolescence and adulthood in response to chronic distress, these usually stop suicidal thoughts from escalating into deadly actions. The theory is testable. We point to important implications for the clinical management of suicide and psychopathology.

Robust regulatory scrutiny is an unavoidable and necessary part of professional life for public sector professionals. Inspection and investigation can lead to poor mental health for individuals already working under pressure owing to increased workload and anticipation of poor outcomes. Although good regulation maintains standards and provides accountability to government and the public, regulators must face their obligation to understand the wider impact of their practices on the mental health of those they evaluate. This article discusses how regulation affects public sector culture and the potential risks and negative impact of regulatory practices and highlights how clinicians, working in occupational practice, are well placed to recognise ‘regulatory stress’ among public sector workers and offer vital support, guidance and advocacy.

Social prescribing is poorly defined and there is little evidence for its effectiveness. It cannot address the social determinants of mental health and it is unlikely to produce enduring change for that part of the population that suffers the worst physical and mental health, namely the most deprived and marginalised. It has emerged at a time of growing health inequity. This has occurred alongside the neglect of social care and of the social aspects of mental health intervention. Social prescribing gives a false impression of addressing social factors, and as such is counterproductive. We can do better than this.

Although antidepressants are regarded as effective and specific treatments, they are barely superior to placebo in randomised trials, and differences are unlikely to be clinically relevant. The conventional disease-centred understanding of drug action regards antidepressants as targeting an underlying brain process, but an alternative ‘drug-centred’ view suggests they are psychoactive substances that modify normal mental states and behaviour. These alterations, such as numbing of emotions, may reduce feelings of depression, and also create amplified placebo effects in randomised trials. Patients should be informed that there is no evidence that antidepressants work by correcting a chemical imbalance, that antidepressants have mind-altering effects, and that evidence suggests they produce no noticeable benefit compared with placebo.

The diagnosis of generalised anxiety disorder is a distraction of no value. It is highly unreliable, co-occurring with many other disorders of firmer diagnostic status, and has intrinsic connections to personality dysfunction. It is argued that classification would be heartily relieved to rid itself of this unnecessary appendage and for the symptom of anxiety to remain as a descriptive term only.

Humans have always used mind-altering drugs. However, in 1961 the United Nations approved the Single Convention, under which the production, sale or possession of a number of drugs, including heroin, cocaine, ecstasy and cannabis, became illegal. The prohibitionist regime was then introduced by most countries around the world and has substantially remained in place ever since. Some countries, particularly those in Latin America, have never criminalised the use of cannabis. A small number of countries have introduced more liberal policies. This article examines the evidence of the consequences of policy liberalisation and argues that there is now a clear case for every country to examine its drug policies and to introduce evidence-based policies with a public health focus.

Principlism is the dominant ethical theory in modern medicine. Autonomy is ‘king’ of the principles espoused and operationalised in consent. Consent is the mechanism by which all medical interactions occur. In borderline personality disorder (BPD) there is often a diffuse sense of self, emotional instability and impulsivity that can lead to medically dangerous non-suicidal self-injury, acute medical intervention and then a withdrawal of consent while the potential threat to the person's well-being remains high. Claims of lack of capacity lack veracity, and simply acting against the patient's will may be illegal. Understanding the will and preferences of patients is a step forward, but it is not always possible in time-sensitive situations. A cautious paternalism is therefore warranted both to ensure the patient's well-being while being honest as to the reasons for this, and to possibly build epistemic trust between the medical system and the patient with BPD.

This paper presents and responds to On the Heels of Ignorance, a sociological study which identifies five fundamental epistemological paradigm changes in American psychiatry in the service of its survival and details several tactics that have been employed to facilitate these professional reinventions. Issues raised in this presentation include the relationship between psychiatry, society and the state, and the nature and significance of psychiatric expertise. The dynamic of these relationships and the complexities of the required expertise create their own challenges for the advancement and professional accountability of the specialty. The conclusion suggests some future imperatives.

It is now becoming standard practice in most advanced economies to provide specialist services for those with personality disorder. Such services, almost exclusively, provide complex well-structured psychological interventions lasting many months for a small number of those with borderline personality disorder pathology. The evidence suggests that these treatments are effective but they can only be provided for a small number of people. However, in every area the numbers of patients with significant personality disorder far exceeds those that are treated, and most of these have other personality disorders. It is argued that the current service system is not working efficiently and should be replaced by one that provides resources and expertise within community teams with some external advice from specialists but no transfer of responsibility to a designated team.

Biological research has produced major advances in our understanding of our bodies and, where systems go wrong, is producing remedies to address these, but it has yet to do the same for the mind. This is because no causative biological evidence has been found for the major mental disorders in contrast to the wealth of psychosocial findings. This disparity in regard and resource needs to be addressed.

The Prime Minister's challenge on dementia called for improved dementia diagnosis rates, based on assumptions of benefit to individuals and those who care for them. Subsequent policies have led to increased target drives for clinical practice to achieve early diagnosis of dementia through intense case identification. However, the current evidence base and treatment options do not support screening for dementia, and there is little empirical evidence that such intensive case identification and early diagnosis for dementia is justified without a better understanding of the benefits, costs and potential harms to individuals and services.

This paper argues for the inclusion of religion and spirituality in psychiatric care. After discussing the antagonism of psychiatrists and psychologists to religion, I present a critical overview of studies examining the relationships between spirituality, religion and diverse aspects of mental health: depression, suicide, anxiety, delinquency, drug abuse and schizophrenia. The need to assesses the impact of religion in different faith groups is discussed. Measures of religious coping, both positive and negative, may provide a more accurate portrayal as to how individuals deploy religion in their lives than global measures such as belief and attendance. I highlight the fact that there is a dearth of research on ritual, prayer and other aspects of religious experience. While many studies demonstrate positive effects of religion on mental health, others find detrimental effects. Finally I examine the clinical implications of these findings.

Small financial incentives have been proven effective at promoting healthy behaviours across medicine, including in psychiatry. There are a range of philosophical and practical objections to financial incentives. Drawing on the existing literature, specifically attempts to use financial incentives to promote antipsychotic adherence, we propose a ‘patient-centred’ view of evaluating financial incentive regimes. We argue that there is evidence that mental health patients like financial incentives, considering them fair and respectful. The enthusiasm of mental health patients for financial incentives lends support to their use, although it does not invalidate all objections against them.

Psychiatrists often order investigations such as blood tests, neuroimaging and electroencephalograms for their patients. Rationales include ruling out ‘organic’ causes of psychiatric presentations, providing baseline parameters before starting psychotropic medications, and screening for general cardiometabolic health. Hospital protocols often recommend an extensive panel of blood tests on admission to a psychiatric ward. In this Against the Stream article, we argue that many of these investigations are at best useless and at worst harmful: the yield of positive findings that change clinical management is extremely low; special investigations are a poor substitute for a targeted history and examination; and incidental findings may cause anxiety and further unwarranted investigation. Cognitive and cultural reasons why over-investigation continues are discussed. We conclude by encouraging a more targeted approach guided by a thorough bedside clinical assessment.

Lowering the legal age of sexual consent would decriminalise a large number of ‘underage’ young people engaging in sexual intercourse. The arguments against such a change in the law are summarised and shown to lack validity.

This paper argues that intermittent nursing observations of in-patients at night do not reduce the risk of suicide or severe self-harm. Suicides between 23.00 h and 07.00 h are rare, and these overwhelmingly occur under intermittent observations. Such observation is purely a defensive intervention to document that a patient is safe at a particular time, as there is no engagement. For the large majority of in-patients, it has the unintended consequence of causing sleep deprivation. The intervention may cause harm to in-patients by making their disorder worse and increase their risk during the day. If patients are judged to be at immediate risk, then they should be placed on constant observation. If they are not, then optimising sleep is important for treating a psychiatric disorder and they should be placed on general observations.

In recent years, there have been extensive efforts in secondary schools to prevent, treat and raise awareness of adolescent mental health problems. For some adolescents, these efforts are essential and will lead to a reduction in clinical symptoms. However, it is also vital to assess whether, for others, the current approach might be causing iatrogenic harm. A growing body of quantitative research indicates that some aspects of school-based mental health interventions increase distress or clinical symptoms, relative to control activities, and qualitative work indicates that this may be partly due to the interventions themselves.

Within paediatrics, young children experiencing physical and emotional distress are admitted to hospital with their parents as a matter of course, recognising the trauma associated with parting children from their carers. Much of this practice is underpinned by our understanding of attachment theory, which also sits as a fundamental tenet of child psychiatry. Yet the culture in psychiatric in-patient hospitals remains to admit young children without their parents, often to units that are geographically distant from the family home. We argue that the practice of admitting lone children to psychiatric in-patient units is likely to be traumatising as well as less effective. We believe this culture requires challenge and change.