There has been increasing interest in the culture of healthcare in the light of the two reports by Robert Francis into the care at Mid Staffordshire. This editorial encourages a comprehensive exploration of the conditions that promote a benign caring culture and make outbreaks of cruel neglect and abuse of patients less likely. Creating and sustaining such a culture is dependent on being honest and realistic about the forces that threaten to undermine it. The editorial argues that being able to confidently articulate the positive values that should define healthcare culture is particularly important at this time. The case is made for a conscious focus on the concept of intelligent kindness.

Dementia has been recognised as a major challenge to health, social care and economies. Research by Rubinsztein and colleagues, in this issue, has compared the services provided by memory clinics with those of traditional community mental health team services. They conclude that memory clinics offer a more comprehensive and multidisciplinary service at no extra cost. Here I will question some of their findings and highlight the importance of better continuity of care between primary and secondary services.

Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a form of encephalitis occurring primarily in women and associated with antibodies against NR1 or NR2 subunits of the NMDA receptor. As a potentially treatable differential for symptoms and signs seen in neurology and psychiatric clinics, clinicians practising across the lifespan should be aware of this form of encephalitis. Common clinical features include auditory and visual hallucinations, delusions, behavioural change (frequently with agitation), impaired consciousness, motor disturbance (ranging from dyskinesia to catatonia), seizures, and autonomic dysfunction. We present a review of the literature on the disorder, including its clinical presentation, differential diagnosis, epidemiology, treatment and prognosis.

The PACE trial was a four-arm trial of specialist medical care, compared with specialist medical care with a supplementary therapy: adaptive pacing therapy, cognitive–behavioural therapy or graded exercise therapy, for patients with chronic fatigue syndrome. The trial found that both cognitive–behavioural and graded exercise therapies were more effective than either of the other two treatments in reducing fatigue and improving physical disability. This paper describes the design, conduct and main results of the trial, along with a description of the challenges that had to be overcome in order to produce clear answers to the clinically important questions the trial posed.

Providing heroin to people with heroin addiction taking part in medical trials assessing the effectiveness of the drug as a treatment alternative breaches ethical research standards, some ethicists maintain. Heroin addicts, they say, are unable to consent voluntarily to taking part in these trials. Other ethicists disagree. In our view, both sides of the debate have an inadequate understanding of ‘voluntariness’. In this article we therefore offer a fuller definition of the concept, one which allows for a more flexible, case-to-case approach in which some heroin addicts are considered capable of consenting voluntarily, others not. An advantage of this approach, it is argued, is that it provides a safety net to minimise the risk of inflicting harm on trial participants.

We report anti-N-methyl-d-aspartate (NMDA) receptor encephalitis in two patients with autism and intellectual disability presenting with neuropsychiatric symptoms of catatonia and neuroleptic malignant syndrome. Case reports such as these help raise awareness of this clinical issue. By paving the way for earlier diagnoses they ultimately maximise the potential for curative treatments and prevention of long-term complications.

A personal bereavement from suicide prompts a critique of current mental healthcare. Fragmentation, lack of long-term attachment to a tenured professional, the dearth of family therapy, and professional ambivalence are identified as weaknesses in current provision. Implicit is the case for change in UK psychiatric services, both structural (need for long-term therapies) and cultural (need for a mentalising rather than protocol-driven, ‘choice’-led ethos).