The past three decades in the UK have seen a prolonged experiment in community mental healthcare that has attempted to address the problem of the disgorgement of institutional psychiatry into a poorly prepared community service. The effectiveness of new ‘functionalised’ service models is considered, together with a reminder of the fundamental components of community mental healthcare and a statement of the principles that should inform future service models.

The term ‘schizoaffective disorder’ has meant different things to different people over the 80 years since Kasanin described a series of cases with an admixture of schizophrenia-like and mood-like symptoms. This article provides a brief overview of the history of the concept, and suggests a parsimonious approach for clinicians.

Working with people who are experiencing mental health difficulties brings many challenges about how best to progress towards shared goals. The cognitive-behavioural therapy (CBT) approach can provide a structure and framework for effective treatment. It aims to help people identify goals and work towards them. We describe a practical approach that provides a structure for step-by-step planning, engaging the patient and promoting planned change.

Attention-deficit hyperactivity disorder (ADHD) is a persistent, pervasive disorder characterised by symptoms of inattention, impulsivity and hyperactivity. Although traditionally considered a disorder of childhood, symptoms and associated impairments persist into adulthood for a significant proportion of individuals. Untreated ADHD can have a number of adverse effects for both the individual and wider society. Despite this, ADHD in adults is often misdiagnosed or its diagnosis is ‘missed’ in general psychiatric settings and this article highlights some reasons for this.

Genetic research into psychotic disorders is advancing rapidly. On the basis of general evidence for genetic influences from family, twin and adoption studies, molecular genetic studies, particularly genome-wide association studies (GWAS), are identifying a range of common genetic risk factors that each have a small effect on risk, while certain chromosomal copy number variants (CNVs) are rarer, but have a larger effect on risk. There is also evidence for partial overlap of genetic influences among psychotic disorders and with non-psychotic disorders. This brief article summarises the main themes, current findings and potential future directions.

There are well-established links between recurring copy number variants (CNVs) (ubiquitous structural variations within chromosomes) and many psychiatric diagnoses. This article considers potential advances that enhanced understanding of CNVs might offer psychiatry – a scientifically rigorous footing for the discipline and personalised prescribing based on genetic data that would benefit patients from pre-diagnosis to treatment.

From a very deprived baseline, mental health services in Hong Kong have undergone some growth over the past decade. The number of inpatient beds for psychiatric treatment dropped by one-third, but the community mental health service expanded significantly. A number of low-resource phase-specific and age-specific treatment programmes were introduced, with promising initial results. However, there remain many challenges, including a serious shortage of well-trained mental health professionals. Much more investment in mental health workforce development is required to meet the service needs not only of today, but also of tomorrow.

Mindfulness is increasingly being recommended to help patients with recurrent depression and anxiety stay well. However, current treatment recommendations ask a lot in terms of commitment, with around 100 hours of practice and learning over a 2-month period. There is therefore increased interest in approaches that deliver key mindfulness skills in a shorter time frame.

The mental state examination is unlike any other assessment in medicine. Karl Jaspers is largely attributed with describing the structure and method of its use. In the centenary year of Jaspers' seminal work General Psychopathology, psychiatry can celebrate the mental state examination as part of its rational and secular heritage.

Bipolar disorder is a common mental disorder that can be challenging to diagnose. This brief article outlines how bipolar disorder is diagnosed and how it can be distinguished from other disorders with similar phenotypes.

Sialorrhoea (hypersalivation) is a common adverse effect of clozapine. If severe, it can affect patients' quality of life and adherence to the treatment. Clinicians therefore need to proactively manage this effect. At present, no drugs are licensed to manage clozapine-induced sialorrhoea, although there are many off-label treatment options, with variable effectiveness. Anticholinergic medications are commonly prescribed for it, but they have limited effect and can worsen constipation. This article gives a brief overview of other practical and pharmacological management options.

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

The authors summarise the evolving understanding of the neuropsychophysiology of chronic pain, including the relevance of adverse childhood experiences in facilitating it and similarities between the central physiology of chronic pain and opioid addiction. Emerging understanding highlights the importance of dopamine-expressing GABAergic neurons in the nucleus accumbens and suggests that D1 expression is associated with a sense of pleasure and approach behaviour and D2 with a sense of punishment and behavioural inhibition. Regulation of D1 and D2 expression may be mediated by nigrostriatal and medial frontal striatal pathways within the increasingly understood brain as a ‘predictive’ organ. The distinction between the predictive brain and personal ‘expectations’ and the importance of the latter for clinical outcomes are emphasised. The relevance of findings for possible future psychopharmacological treatment avenues is also presented.

Psychiatry faces a number of external and internal challenges. At the heart of its difficulties is an identity crisis and attempts to resolve this have so far split the specialty. British psychiatry has in recent years taken an increasingly ‘neurophobic’ stance. This article argues that, despite the current situation, opportunities remain for a medicine of the mind to thrive. Neuroscientific advances in our understanding of psychiatric disorders need to be made more explicit in training and in the structure of mental health services.

The adjective ‘comorbid’, and its fellow noun ‘comorbidity’, are used repeatedly in psychiatric practice, but we frequently use them sloppily and ignore what they really mean. Here, I briefly define comorbidity of disorders, and suggest the alternative categories of consanguinity and co-occurrence.

The differentiation of pathological stress responses from responses that are appropriate and adaptive is a challenge with little to guide the clinician. This refreshment considers adjustment disorder and possible approaches to distinguishing those who have the disorder from those who are responding ‘normally’ to stressful events.

Obsessive–compulsive disorder (OCD) is a common psychiatric condition and many patients have childcare responsibilities. A small proportion have aggressive and sexual thoughts about their children. There is little risk that they will act on these thoughts, but primary healthcare and social care professionals are often unaware of this and instigate unnecessary and potentially harmful child safeguarding processes. Psychiatrists have an essential role in educating and liaising with other professionals to prevent these inappropriate interventions.

Clinicians trained in cognitive–behavioural therapy (CBT) are frequently not trained to work with dreams. Given the high prevalence and impact of nightmares and bad dreams, empowering CBT therapists to effectively work with these sleep phenomena is crucial to improve therapeutic outcomes. This article briefly outlines a cognitive–behavioural model of dreams and reviews some clinical guidelines for directly and indirectly addressing nightmares and bad dreams in CBT practice.

College tutors for psychiatry trainees are National Health Service (NHS) consultants who have responsibility for organisation and delivery of postgraduate education and learning opportunities for the core trainees in NHS trusts. College tutors are responsible for monitoring the progress of trainees through the core training schemes. Tutors have various roles and responsibilities in teaching and training. Being a tutor can be a rewarding experience and any consultant interested in postgraduate teaching should consider becoming one.

Eating disorders encompass physical, psychological and social pathologies that increase health risk. Anorexia nervosa has the highest mortality of any psychiatric disorder, but patients are not always managed by specialist eating disorders services and the duty of care sometimes falls to the general psychiatrist. This article is an aide-memoire for assessing and managing physical risk in patients with anorexia nervosa.