Patient risk factors for suicide are well known to psychiatrists, yet the availability of clinically useful, routine and systematic methods for risk recognition are limited. This article outlines the structured professional judgement approach to suicide risk assessment and management. This method combines psychiatric assessment and formulation with the evidence base for suicide risk factors. Structured professional judgement is contrasted with actuarial and clinical judgement approaches. A categorisation of risk factors is presented, with four groups described – static, stable, dynamic and future. Case histories illustrate long-term high risk contrasted with sudden and unpredictable onset of suicidality.

Depersonalisation disorder involves an unpleasant, chronic and disabling alteration in the experience of self and environment. In addition to these classic features of depersonalisation and derealisation, symptoms may also encompass alterations in bodily sensation and a loss of emotional reactivity. Primary depersonalisation disorder is probably more common than previously thought, and here we discuss the diagnosis, assessment and treatment of the condition, with particular reference to our experiences in a specialist depersonalisation clinic. We also consider psychological and biological aspects of the condition. Although there is as yet no recognised treatment for this disorder, various pharmacological interventions, particularly a combination of lamotrigine and a selective serotonin reuptake inhibitor, have shown promise. We discuss these drug treatments, together with psychological approaches, in particular a recent cognitive–behavioural conceptualisation and treatment approach.

The incidence of treatment resistance in schizophrenia (failure to respond to antipsychotic therapy) is about 20%. Factors that may contribute to it include non-adherence (non-compliance) to treatment, comorbid conditions and medication side-effects. The National Institute for Clinical Excellence recommends that clozapine be used for schizophrenia resistant to another atypical antipsychotic. Here we focus on patients who are also resistant to clozapine given in adequate dosage for sufficient duration. Switching from clozapine to a previously untried atypical (e.g. olanzapine, risperidone, quetiapine) might be of benefit in partial treatment resistance. In more difficult cases, augmentation of clozapine with benzamides (sulpiride, amisulpride) and anti-epileptics (lamotrigine) shows some success. In extreme treatment resistance, a strategy is recommended that combines the proven best drug for the particular patient and psychosocial treatments.

The first few years of a consultant's professional life can be difficult for all concerned. In this article we argue that the tasks facing the newly appointed consultant are in part instrumental, but that there are also important emotional and development challenges to be faced before the individual psychiatrist can truly fill out the consultant role. For the past 2 years we have been running a group, which we have called the transition group, for specialist registrars and newly appointed consultants working in the West of Scotland. The aim of this group is to provide peer support during this transitional process. Here we draw on our experience in this group to explore the development of professional identity, the exercise of personal authority and how this process can be supported by a group such as ours.

Case studies used in psychiatry for teaching and learning can include large amounts of personal information, and most medical journals refuse to publish case material without patient consent. However, not all patients are capable of consenting and maintaining anonymity is not always successful. Disclosure of personal information without consent can cause a sense of violation, but a principle of non-violation rigorously applied would prohibit the use of such material without consent, even if the patient is completely unidentifiable. A public interest argument can be made for using patient information for teaching purposes. Furthermore, a limited case can be made for using, and even publishing, some cases without consent, e.g. those requiring urgent public discussion or concerning people who are incapable of giving consent. Thus, an argument can be put forward for relaxing to this limited degree the demand for patient consent to publish case material.

Draper & Rogers (2005, this issue) have put an important subject under the ethical microscope. They have demonstrated that the current, fairly simple, rules applying to the publication of case studies and dissemination of patient information in teaching are inadequate and need revision. This is particularly important because such forms of communication are likely to increase in the future. Many journals, including the British Journal of Psychiatry, generally frown upon case studies as representing little value to science: case studies unnecessarily focus on the particular; their message is only valuable when it is general. However, they aren't going to go away because their educational value is obvious, as anyone who looks at the handling of almost any scientific subject in the mass media will testify. Experts can pontificate on hypotheses, proportions, means and significance to little effect and the real message comes home from a sufferer or successfully treated patient who adds human flesh to a dry factual skeleton. This need to particularise is necessary in all parts of teaching.

Draper & Rogers (2005, this issue) discuss the publication of case studies in psychiatry. They raise an issue in relation to consent that I would like to pursue in more detail: namely, what is it that we are asking patients to consent to when we ask them to participate in research?

People with schizophrenia die prematurely. Their illness, its treatment and their lifestyle all contribute to the excess morbidity and mortality. Lifestyle ‘choices' (e.g. poor diet, low rates of physical activity and increased likelihood to smoke cigarettes) predispose them to poor physical health and comorbid medical diseases. In addition, weight gain and obesity are a consequence of most antipsychotics, particularly the atypicals. Excessive body weight increases the risk of morbidity and mortality, and is the biggest risk factor for type II diabetes in schizophrenia. Much of the excess mortality of schizophrenia is preventable through lifestyle and risk factor modification and the treatment of common diseases, but the potential for improving outcomes in this area is only starting to be addressed.

Shared care in mental health is now a policy imperative in England and Wales, yet its meaning, form and function are still open to debate. In this article, I discuss the benefits of and barriers to a shared care approach, explain how policy is currently driving practice in this area, discuss recent shared care initiatives and highlight some of the tensions inherent in the approach, particularly from the viewpoint of patients. I also give some of the key factors that need to be in place within a ‘whole systems' approach to ensure that shared care moves from the rhetoric of the statute book to everyday practice.

‘Shared care in mental health is now a policy imperative in England and Wales, yet its meaning … [is] … still open to debate’. Dr Lester's opening line says it all (Lester, 2005, this issue). We're all in favour of it, but none of us is exactly sure what it is. Ambiguity is considered a failing in academic publications and, under pressure from editors, we usually excise the unnecessary and unclear. Politicians, however, often deliberately insert ambiguity, as it allows scope for interpretation. By a simple shift in emphasis, either shared care's achievement can be claimed as a manifesto success or slow progress towards it can be cited to justify further targets.

Physical disease is more prevalent in people with mental disorder than in the general population. It is important for psychiatrists to maintain skills in physical examination to ensure that physical illness is diagnosed and treated appropriately. A sound knowledge of medical illness ensures that examination is targeted at the relevant diseases. Mental health units should provide adequate facilities and equipment. All detailed examinations should be undertaken in the presence of a chaperone. Opportunities for psychiatrists to refresh their knowledge and skill are suggested.

This article is intended to update prescribers of electroconvulsive therapy (ECT) on the key points of the revised edition of the Royal College of Psychiatrist's ECT Handbook (due to be published in 2005). The two most important tenets that influenced the revision were that evidence from systematic reviews and appraisals was balanced with expert judgement based on clinical experience, and that both prescribers and practitioners should strive to reduce further the cognitive adverse effects of treatment. The article concentrates on revised guidance regarding the indications for ECT, important elements of the process of informed consent, and the prescription of treatment, i.e. choice of electrode placement and the frequency and total number of treatments.