This chapter gives an introduction to key concepts in epidemiology for the clinician, student, trainee or early career researcher interested in psychiatry and mental health. Following a brief introduction to the history of epidemiology, we provide a comprehensive, yet accessible introduction to key epidemiological concepts and how these apply to psychiatry and mental health. We introduce the major observational (cohort, case-control, cross-sectional, ecological) and experimental (randomised controlled trial) designs used in epidemiology, their strengths and limitations and specific issues for their use in psychiatry. We also cover measures of disease frequency (incidence, prevalence), measures of effect (risk, rate and odds ratios) and measures of impact (population attributable risk). Our chapter then provides a comprehensive introduction to traditional and contemporary approaches to understanding the critical issue of causation, illustrated via the use of causal diagrams known as Directed Acyclic Graphs. Throughout, we use accessible examples from published research and hypothetical worked examples to consolidate the reader’s knowledge about key methods in psychiatric epidemiology.

This introductory chapter sets out the need for a handbook of university mental health. It considers the health of staff alongside that of students, and that does not presume American systems of education and healthcare. Far more of the UK population expects to attend university, with a consequent expansion in the size and numbers of institutions. Financial constraints mean that universities can no longer run as elite communities of self-governing scholars, but are now governed according to business models, with implications for the wellbeing of all involved. In the context of population-wide increases in mental disorder and demand for treatment, more students than ever now disclose a psychiatric diagnosis. The recent COVID pandemic and lockdown disproportionately threatened the well-being of students and may have changed for good some of the ways in which education and healthcare are delivered. The author summarises her own personal and professional of UK university life and describes the motivation for embarking on the production of a single author handbook on this topic. A wide readership is welcomed to the book, which will provide a series of interlinked but standalone chapters to be consulted piecemeal as well as read as a whole.

Any discussion of the classification of psychiatric disorders should begin with the frank admission that any definitive classification of disease must be based on aetiology. Until we know the causes of the various mental illnesses, we must adopt a pragmatic approach to classification that will best enable us to care for our patients, to communicate with other health professionals and to carry out high-quality research.

In physical medicine, syndromes existed long before the aetiology of these illnesses were known. Some of these syndromes have subsequently been shown to be true disease entities because they have one essential cause. Thus, smallpox and measles were carefully described and differentiated by the Arabian physician Rhazes in the tenth century. With each new step in the progress of medicine, such as auscultation, microscopy, immunology, electrophysiology and so on, some syndromes have been found to be true disease entities, while others have been split into discrete entities, and others still jettisoned.

This book is about some of the psychosocial aspects of emergencies, incidents, disasters, and disease outbreaks.

My clinical and academic engagement with the mental health consequences of, and responding to emergencies and disasters began when the Herald of Free Enterprise capsized in Zeebrugge Harbour on 6 March 1987, causing the deaths of 193 passengers and crew. Many more people survived; some were injured, and the impacts on the mental health of the survivors became a major long-term issue. I learned a huge amount from patients who were referred to me. This incident occurred relatively soon after the American Psychiatric Association had first included post-traumatic stress disorder (PTSD) in its Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. There have been huge developments in science and practice relating to the mental health aspects of disasters in the 37 years that have elapsed since the Zeebrugge ferry tragedy.

It is well established that people suffering from a mental disorder have poorer physical health outcomes, including increased mortality, than those without such a disorder (1). In addition, people with severe mental illness are more likely to be admitted to non-psychiatric medical services, have longer admissions and present with more emergencies (2). The mental health consultation-liaison (CL) team is perfectly placed to ensure holistic assessment and integrated care of this population, with the opportunity to improve both physical and mental health outcomes.

Self-awareness is a central characteristic of all complex systems including biological and organisational. The successful introduction of novel and complex IT systems to an organisation such as the NHS both enables, and requires, this self-awareness. IT systems promise great improvements in terms of process control, audit, governance as well as the direct delivery of clinical care. They require however that the organisation appreciates this kind of change is ‘adaptive’ as well as technical. Successful adoption requires strong, informed leadership, an honest appraisal of the degree of digital maturity, awareness of weaknesses and realism about timescales and scope. In this chapter, we will briefly survey the development of health informatics in the UK, examine some conspicuous examples of failed IT introductions and attempt to extract some lessons of use to clinicians asked to take part in such introductions. We will also survey some of the main current issues in mental health informatics from a UK perspective and make some tentative predictions for future developments.

Cells are the fundamental units of tissues in multicellular organisms. Animal cells are sealed sacs constructed of extremely thin (≈5 nm) lipid bilayer plasma membranes, spanning across which are various membrane proteins. Crucially, the membrane separates an intracellular biochemical compartment, the cytoplasm, from the extracellular environment. This separation enables gradients, or differences in concentration, of ions and small molecules to be maintained across the membrane, and acts to contain the cytoplasmic proteins and enzymes involved in metabolism, as well as organelles, or intracellular membrane compartments. Particularly importantly for the nervous system, the membrane is also an excellent electrical insulator: it is energetically very unfavourable for charged entities like free ions and electrons to jettison their interactions with polar water molecules in order to cross through the uncharged, non-polar hydrocarbon interior of the lipid bilayer membrane, and so transporting them across the membrane is normally very difficult. This high resistance allows an electrical potential difference to be maintained across the membrane – the membrane potential. An electrical potential difference is equivalent to a difference in the ‘concentration’ of unbalanced charges between the two sides of the membrane.

A purposeful, conscientious and well-intentioned mental health volunteer needs to be informed about the background, principles and ethics of global mental health in order to be impactful. This chapter provides background to aid such efforts and introduces global mental health within the wider voluntary context.

This chapter describes the context of the 11th Revision of the International Classification of Diseases (ICD-11) related to mental health. It contains an explanation of the procedure adopted in making this revision, some background to the field trials and their results, and a brief account of the main changes; many of which are amplified in the later chapters. A detailed account of the changes in the ICD-11 as compared with the ICD-10 has been published elsewhere,1 as has a detailed comparison of the ICD-11 and the DSM-5.2

There are many high-profile reports about the link between social media and mental health, and these sit within a broader social climate where people are asking pressing questions about the extent to which social media can ’affect’ or ’impact’ individuals. It is natural to fear new and fast-growing technologies, but regressing to the media ’effects’ models that have for so long been discredited may not be helpful, or indeed accurate. One of the aims of this chapter is therefore to argue that social media are not one thing and to instead introduce several aspects of the phenomenon to readers, briefly tracing standout phases in their evolution, the characteristics that differentiate them from older media technologies, their (increasingly controversial) business and governance models, and finally their use and non-use among particular social groups.

The basic principle of nutrition is the provision of adequate nutrients for populations or groups within populations. Adequate nutrition requires that all nutrients are consumed in adequate amounts and in the correct proportions. Energy is one of the most important things we obtain from food. In the body, energy consumed is used to support metabolic processes. Energy expenditure is made up of three components: basal metabolic rate, thermic effect of food and physical activity. Within the diet, the role of carbohydrates is to be a source of fuel, but overall carbohydrates are also part of energy stores, structural components of cell walls, part of nucleic acids (RNA and DNA) and part of many proteins and lipids. Protein is the most abundant nitrogen-containing compound in the diet. It is a major functional and structural component of all body cells. Fats, also known as lipids, are composed of a carbon skeleton with hydrogen and oxygen substitutions. Understanding the pathway for each nutrient allows for the development of dietary reference values, which aim for optimal levels of a nutrient for each population group. The types of foods eaten in different countries are influenced by factors such as ethnicity, culture, dietary habits, food preferences, intake patterns and food availability, and so the classification and types of foods contained in the major ‘food groups’ can vary somewhat from country to country.

A doctor can apply for a CESR in psychiatry if they can demonstrate to the GMC that they have six months of training in the specialty being applied for and/or a postgraduate qualification in the specialty attained anywhere in the world. Once successful in their application, the doctor is entered onto the Specialist Register for a psychiatry specialty, that is, given ‘specialist registration’ by the GMC. If they are overseas doctors who at the point of application do not have GMC registration at all, they are given both full GMC registration and specialist registration at the same time.

The chapter provides an introduction to neurodevelopmental disorders and summarises recent advances in published research, focusing on the very early development and function of the human brain. The main influences on the current delivery and development of forensic healthcare services is set within the context of available policy and guidance, which is limited in part by the available research evidence to inform it. The book is divided into three sections. The first provides an overview with an introduction to individual disorders and covers aetiology, prevalence, comorbid mental disorder and relevant policy to date. The second section focuses on the clinical aspects of the range of disorders including screening, assessment, diagnosis, risk assessments and therapeutic approaches. The final section examines the pathways through the criminal justice system from police to court to disposal and addresses the specific aspect of fitness to plead or stand trial for those with neurodevelopmental disorders. This section also describes current relevant legislation within the UK as well as forensic services for those with such disorders from a national and international perspective.

Violence and aggression never present themselves in a vacuum, yet this is typically the way policymakers approach the subject, its prevention and its management. Although guidelines exist in different sectors, too often little or no consideration is given to many of the wider issues in play, particularly the use of restraint when it becomes necessary. Despite the long-standing call for a common set of guidelines, we are only now looking at the introduction of the Restraint Reduction Network training standards, and it seems that anything approaching a set of common guidelines that all settings can embrace is a long way off. The aim of any good guidance seeking to influence practices in the prevention and management of violence and aggression should be to minimise the need for any restrictive intervention but where necessary to apply techniques as safely as possible within the relevant legislative framework. Certain staff in healthcare settings need to receive training to increase the organisation’s capacity and capability to deal with potentially violent situations without recourse to external agencies, such as police, who operate to a different set of standards to those within healthcare settings and who use techniques that healthcare staff would not wish to see used in their settings.

The potential negative effects of exercise addiction (EA) were first reported over 50 years ago, but it has only recently been formally recognized as a disorder in the leading clinical manuals. The inclusion of exercise behaviour as a potentially addictive behaviour will require greater consensus on how to define this disorder, with diagnostic criteria and course descriptions clearly supported by scientific evidence, and on how to categorize it in relation to other mental disorders. This chapter presents an overview of attempts to identify the defining features of EA, the development of instruments to measure it, estimates of its prevalence, and the main strategies for treating it. The diverse terminology used to describe this disorder reflects both the range of perspectives from which it has been examined, and the different manifestations of EA. The chapter concludes by recognizing that the development and validation of specific diagnostic criteria for EA pose many challenges.

This chapter defines fads and fallacies, and relates them to cognitive errors. It discusses broader problems with determining causality in science, and the reasons for the replication crisis in research. Examples of medical and surgical fads, namely chronic fatigue syndrome, chronic pain, and non-evidence-based surgical procedures, are examined. The chapter also discusses the role of the pharmaceutical industry in medical fallacies. It concludes by explaining how fads can be understood in the context of the challenges of chronicity in medicine.

Medicine is a rapidly developing field. Much of what many of us learned in medical school is now obsolete, and an expanding knowledge base has led to increasingly specialized services. If you add to this the fact that many doctors – by choice or as the result of service changes – change their areas of clinical practice, the need to continue learning and developing after completion of formal training is undeniable.

We learn on a day-to-day basis in our clinical practice. As well as taking the relatively obvious forms of reading a literature review or asking the advice of a colleague, learning will also be through continuous feedback, for example from patients about a particular approach we take or a good clinical outcome. Being open to everyday feedback and thoughtfully working in teams is therefore an important part of remaining a safe and effective practitioner.

Chapter 1 examines a range of biological processes which affect mental health, including attachment, genes and inheritance, the developing brain and puberty.

As this book is primarily about the general neurotic syndrome, I need to be convincing in creating the groundwork to persuade the reader to continue to read. Some may feel this syndrome is a fictitious creation and so I will have to work even harder to persuade these sceptics; all I would ask at this point is for people to have an open mind. The general neurotic syndrome is not (yet) a familiar term, even though it should be. As it has been a subject I have had in my head for over 45 years – I hope not as an obsession but as a guiding light – I need to put my thinking about it into context.

This document provides a new edition and an update to the 2015 NEPTUNE guidance on the clinical management of harms resulting from acute intoxication and from the harmful and dependent use of ‘club drugs’ and ‘novel psychoactive substances’ (NPS).