The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more attractive.

Staging models are used routinely in general medicine for potentially serious or chronic physical disorders such as diabetes, arthritis and cancers, describing the links between biomarkers, clinical phenotypes and disease extension, and promoting a personalised or stratified medicine approach to treatment planning. Clinical staging involves a detailed description of where an individual exists on a continuum of disorder progression from stage 0 (an at-risk or latency stage) through to stage IV (late or end-stage disease). The approach is popular owing to its clinical utility and is increasingly being applied in psychiatry. The concept offers an informed approach to research and the active promotion of indicated prevention and early intervention strategies. We suggest that for young persons with emerging bipolar disorder, such transdiagnostic staging models could provide a framework that better reflects the developmental psychopathology and matches the complex longitudinal inter-relationships between subsyndromal and syndromal mood, psychotic and other disorders.

Original ideas are needed in developing new interventions for psychosis, and computer-assisted therapy for auditory hallucinations is one such novel approach. As with any early-phase development, it will require further refinement and evaluation. There are now a range of ongoing studies into different intervention strategies and these promise to enhance the therapeutic potency of clinical psychiatrists and mental health teams. If the relative lack of research funding, focus and support from academic sources on this area were to change, even more could be delivered.

A new approach to understanding severe mental illnesses such as schizophrenia and affective disorders is to adopt a clinical staging model. Such a model defines the extent of the illness such that earlier and milder phenomena are distinguished from later, more impairing features. Part of the appeal of such a model is that it should have cross-diagnostic applications, but to date there has been no attempt to examine imaging or neurocognrtive evidence for staging in this way. We review these two domains of study with particular focus on major depression and bipolar affective disorder. Although there is some support for the staging model in affective disorders, conclusions are limited by the large variability in the clinical samples studied, especially with regard to the presence of psychotic symptoms. We suggest that future research needs to take a transdiagnostic and longitudinal approach.

The balanced care model proposes that a comprehensive mental health system needs to include both community-and hospital-based care. The model is based on a structured review of scientific evidence, and is also informed by the experience of experts active in mental health system change in many countries worldwide.

Pregnant women and their fetuses are increasingly likely to be exposed to antipsychotics. However, safety data remain limited. This editorial suggests that, in future, well-designed observational pharmaco-epidemiology is our best chance of illuminating risk for exposed populations and of informing decision-making for women and clinicians.

Copy number variants are small chromosomal deletions and duplications. When they alter the dose of genes critical for normal brain development and adult brain functioning they may cause severe disorders such as autism and schizophrenia. Numerous such loci have recently been identified. They are offering amazing leads for neuropsychiatric research.

Pathways into care have not changed significantly since the introduction of early intervention services for psychosis in London. Some groups have different pathways into care and those whose pathway originates in primary care have a longer route to services. This editorial explores the nature of these challenges, for both early intervention services and referring agencies.

Depressive symptoms and depressive illness are associated with impairments in sexual function and satisfaction but the findings of randomised placebo-controlled trials demonstrate that antidepressant drugs can be associated with the development or worsening of sexual dysfunction. Sexual difficulties during antidepressant treatment often resolve as depression lifts but may persist over long periods, and can reduce self-esteem and affect mood and relationships adversely. Sexual dysfunction during antidepressant treatment is typically associated with many possible causes, but the risk of dysfunction varies with differing antidepressants, and should be considered when selecting an antidepressant.

Biological psychiatry has not yet produced clinically viable biomarkers for any of the major psychiatric diseases, and the past 25 years have not brought any fundamentally new biological treatment principles. I discuss reasons for this slow progress and suggest avenues for the development of biomarkers and the discovery of new treatment targets.

Parental depression is a risk factor for psychiatric problems in children and adolescents. Exciting scientific developments have elucidated potential early mechanisms of intergenerational risk transmission and new models of intervention may help to prevent some childhood problems. However, caution is needed in interpreting such associations as causal and in targeting interventions appropriately.

The relationship between hypochondriasis and health anxiety is examined by considering a DSM-5 proposal to replace the current heterogeneous concept of hypochondriasis with two disorders. The key issues are to ascertain whether these conditions are relatively distinct and whether they adequately represent the full range of clinical manifestations encompassed by hypochondriasis.