Two large, non-commercial clinical trials comparing first- and second-generation antipsychotic drugs for people with chronic schizophrenia in the US and UK have shown unexpected results. In general, the newer drugs were no more effective or better tolerated than the older drugs. Clozapine outperformed other second-generation drugs. The implications are considered.

Psychotropic drugs reduce morbidity and mortality related to maternal mental illness but may also cause harm to the foetus, the nature and magnitude of which is not completely understood. Up-to-date information should be shared as fully as possible with the pregnant woman and a treatment plan agreed jointly.

Recent developments in the classification of major depressive disorder are reviewed in light of the predictions made by Kendell in the 1970s. Particularly, the institution of operational diagnoses along with the contentious issues of subdividing major depressive disorder and its characterisation on a dimensional as opposed to a categorical scale.

A rationale for maintaining the existence of learned journals is put forward on the 343rd anniversary of the first such journal, the Philosophical Transactions of the Royal Society, and it is argued that the main aim of such journals has hardly changed since this time. The new-look British Journal of Psychiatry is intended to educate and instruct, and even entice readers from the functional and far less romantic online version.

Like recent medication studies, it appears that when cognitive-behaviouraltherapy is tested in pragmatic effectiveness trials involving routineclinical populations it does not fare as well as in efficacy trials. Giventhe multitude of factors that can ‘muddy the waters’ in clinical trials, howdo we best make sense of the findings?

Significant issues challenge the diagnosis of post-traumatic stress disorder (PTSD). Yet, applications of the PTSD ‘model’ have been extended to an increasing array of events and human reactions across diverse cultures. These issues have implications for clinical practice and for those who revise criteria in the DSM-V.

A drug acting at metabotropic glutamate receptors has recently been reported to be an effective antipsychotic, breaking the rule that only dopamine receptor-blocking drugs have this property. The finding complements accumulating evidence that glutamatergic abnormalities are important in the pathophysiology of schizophrenia.

We discuss the nature of intervention in developmental psychiatry and the implication of this for clinical trials. New ideas in the design of randomised trials for complex interventions, along with recent statistical advances in causal analysis, give such trials additional potential as a means by which to study the basic science of complex developmental disorders. The challenge for designers of trials is to model designs effectively to make best use of these new opportunities. We give examples of how this might be done and discuss implications for future trials designs in the area.

The politics of shortening hospital stays for people with psychosis has been questioned by a number of studies. Hospital practice in the meantime remains highly variable and the research evidence increasingly difficult to interpret given different conceptualisations of what constitutes effective treatment. In the absence of clearer guidelines from researchers in this area, decisions about duration of hospitalisation risk being driven by economic rather than clinical considerations.

Communication between clinicians and patients is at the heart of psychiatricpractice and particularly challenging with psychotic patients. It mayinfluence patient outcome indirectly or be therapeutic in its own right.Appropriate conceptual models, evidence on effective interventions andspecific training are required to optimise communication in everyday routinepractice.

Is alcoholism an illness or merely a self-inflicted indulgence? Can we afford specialist alcohol treatment services? Do they even work? Should the tax payer foot the bill? Is the lack of such services ‘perverse’? In this lively debate Drs Carnwath and Luty weigh up the pros and cons of controlling the effects of ‘our favourite drug’.