Human beings are social animals, and familial or social relationships can cause a variety of difficulties as well as providing support in our social functioning. The traditional way of looking at mental illness has focused on abnormal thoughts, actions and behaviours in response to internal causes (such as biological factors) as well as external ones such as social determinants and social stressors. We contend that psychiatry is social. Mental illness and interventions in psychiatry should be considered in the framework of social context where patients live and factors they face on a daily basis.

In 2008 it became policy that all those on the care programme approach were assessed for sexual violence/abuse. The implementation of this policy was assessed 8 years on. The findings of a survey and data request to Health and Social Care Information Centre are disappointing. We argue that this important initiative needs to be reinvigorated.

The performance culture of the health service means that the psychological well-being of staff is becoming paramount in maintaining the workforce and in sustaining psychological health and morale. A Charter for Psychological Staff Wellbeing and Resilience is introduced that puts the onus on us and on employers to make the necessary adjustments to their workplace cultures and encourage professionals – us – to break through the barrier of stigma.

As general medicine moves away from ‘paternalism’ and places an increasing emphasis on patient choice and autonomy, George Szmukler and Brendan D. Kelly debate whether conventional mental health legislation should be replaced with a model that focuses on the person's decision-making capabilities.

Over the past decade there have been significant efforts to scale-up mental health services in resource-poor countries. A number of cost-effective innovations have emerged as a result. At the same time, there is increasing concern in resource-rich countries about efficacy, efficiency and acceptability of mental health services. We consider two specific innovations used widely in low- and middle-income countries, task-sharing and a development model of mental healthcare, that we believe have the potential to address some of the current challenges facing mental health services in high-income countries.

Patients who recover from an acute episode of psychosis are frequently prescribed prophylactic antipsychotics for many years, especially if they are diagnosed as having schizophrenia. However, there is a dearth of evidence concerning the long-term effectiveness of this practice, and growing concern over the cumulative effects of antipsychotics on physical health and brain structure. Although controversy remains concerning some of the data, the wise psychiatrist should regularly review the benefit to each patient of continuing prophylactic antipsychotics against the risk of side-effects and loss of effectiveness through the development of supersensitivity of the dopamine D2 receptor. Psychiatrists should work with their patients to slowly reduce the antipsychotic to the lowest dose that prevents the return of distressing symptoms. Up to 40% of those whose psychosis remits after a first episode should be able to achieve a good outcome in the long term either with no antipsychotic medication or with a very low dose.

People with severe mental illness (SMI) experience a reduction in life expectancy of 15–20 years. Physical health and mortality experience may be even worse for ethnic minority groups with SMI, but evidence is limited. We suggest clinical, policy and research recommendations to address this inequality.

Significant efforts have been made to identify risk factors associated with suicide. However, the evidence suggests that risk categorisation may be of limited value, or worse, potentially harmful, confusing clinical thinking. We argue instead for a shift in focus towards real engagement with the individual patient, their specific problems and circumstances.

Two recent reports convincingly demonstrate that the risk of schizophrenia is influenced by common variation of C4, which codes for complement component 4, and by rare, disruptive mutations of SETD1A, which codes for a histone methylase. These important results open the way for major advances in our understanding of the fundamental biological processes leading to disease.

We explore whether we can reduce paternalism by increasing patient autonomy. We argue that autonomy should not have any automatic priority over other ethical values. Thus, balancing autonomy v. other ethical pillars and finding the optimal balance between the patient's wishes and those of other relevant stakeholders such as the patient's family has to be dynamic over time.

Not all interventions that show promise in exploratory trials will be supported in phase III studies. But the high failure rate in recent trials of complex mental health interventions is a concern. Proper consideration of trial processes and greater use of adaptive trial designs could ensure better use of available resources.