Despite Britain's high prevalence of problem gambling, its liberal gambling legislation, a rapidly expanding online gambling industry and the impending opening of casinos across the country, treatment provision is grossly inadequate. We discuss some of the present gaps and future opportunities in treating Britain's problem gamblers, and urge Britain's healthcare policy makers, gambling regulators, service commissioners and service providers to do more to help them.

Patients detained at high and medium security reveal significant gender differences in the presentation of psychopathology, mental disorder and social and offending profiles. However, secure mental health services in England, like prisons, generally fail to recognise the core importance of the differing biopsychosocial development in women and the impact of life experiences on women's subsequent biopsychosocial functioning. As a consequence, women are often inadequately provided for in services dictated by the identified needs, risks and responsiveness of men. The lack of clinically appropriate facilities for women may account for the increased frequency with which women are readmitted to medium security and for their longer admissions to both high and medium secure care. New tertiary services are developing as a result of the lessons learnt while providing gender-blind care. However, further development is required to ensure that women receive services of the same quality, range and nature of those received by men.

Delusions are a key symptom of psychosis and they are frequently distressing and disabling. Existing treatments, both pharmacological and psychological, are only partially effective. It is important to develop new treatment approaches based on theoretically derived and empirically tested processes. Delusions are associated with a reasoning bias: the jumping to conclusions (JTC) bias involves gathering limited information to reach decisions. It is proposed that this bias influences appraisals of psychotic experiences leading to the formation and persistence of delusions. Existing treatments do not influence JTC. A new intensive treatment approach – ‘reasoning training’ – is described. It aims to encourage participants to gather information, consider alternative explanations for events and review the evidence before reaching a decision. Preliminary data suggest that it is possible to change the JTC bias and that this improves belief flexibility and may reduce delusional conviction. The concepts and methods of this new approach have implications for clinical practice.

There is an increasing prevalence of hepatitis C, particularly among intravenous drug users. Estimates of infection with the hepatitis C virus (HCV) in patients with severe mental illness in the USA have ranged from 8.5% to 19.6%. Alcohol use and misuse is the single biggest contributory factor to the development of fatal liver disease in people with hepatitis C. Neuropsychiatric symptoms are present in HCV infection, independent of any treatment. Despite such alarming observations, the success rate of antiviral treatment in chronic hepatitis C has improved considerably in recent years. This article explores psychiatrists' involvement in advocating for treatment inclusion, assessing patients' capacity to make treatment-related decisions and supporting the medical team in managing the complex journey a patient undertakes from being at high risk to receiving treatment for neuropsychiatric symptoms.

The Defence Mental Health Services (DMHS) provide an occupationally focused service for the UK armed forces when deployed and when at home. Although much of the work is similar to that carried out by National Health Service community mental health teams, there are many unique aspects to working with the military. Although carrying out operational duties is a key function of the armed forces, the majority of cases managed by the DMHS are not related to traumatic exposures; instead, adjustment, mood and substance use disorders form the bulk of the case work. However, DMHS personnel carry out a considerable amount of psychological education and command liaison functions to support the concept that the psychological welfare of troops is primarily a chain of command responsibility. This article outlines the structure and function of the DMHS and its approach to risk management.

Mania in late life is a serious disorder that demands specialist assessment and management. However, it is greatly under-researched, with only a paucity of studies specifically analysing older populations. The mainstay of the old age psychiatry workload will inevitably be concerned with assessing and managing dementia and depression, but the steady rise in the aging population with longer survival means that there will be an increase in absolute numbers of older people presenting with mania. There are no specific treatment algorithms available for mania in late life. This article reviews mania and hypomania in late life and concentrates on diagnosis, assessment and treatment, as well as on the management considerations associated with this important age group.

Despite the guidance published in revised Codes of Practice and by the Royal College of Psychiatrists, implementation of Section 136 of the Mental Health Act 1983 is still variable. Government funding in England to establish places of safety in psychiatric facilities has been effective but custody suites are still used excessively, especially for those who are brought in intoxicated. Patients feel criminalised by this use of custody suites and by the use of police vehicles rather than ambulance transport for conveyance to the place of safety. There is often a delay in commencing the assessment and the first doctor does not always have Section 12 approval as recommended in the Codes of Practice. The importance of the local Section 136 group tasked with developing and overseeing the implementation of local policy and monitoring is highlighted. There is a need for monitoring locally, but ideally in a form that can be used nationally for benchmarking and research.

A recommendation of the UK's National Dementia Strategy is to develop the skills of the care workers who provide day-to-day care for people with dementia. On the basis of a systematic review of the literature, we suggest evidence-based areas in which the skills of care workers can be developed to reduce the incidence of difficult behaviour and the use of antipsychotic medication in dementia. We discuss core features of carer training, education and practice. Psychiatrists involved in the training of carers can teach new skills to carers. Psychiatrists in community mental health teams can, through leadership and clinical liaison, reinforce and enable these skills in care homes, domiciliary services and in-patient settings serving people with dementia.

Gender identity disorders are not common. The most frequent is dual-role transvestism, but it rarely needs medical attention. The least frequent is transsexualism. Transsexualism is not usually indicative of serious psychopathology. Diagnoses should be made by a gender identity clinic and never by the patient, and a clear change of gender role should precede any hormone treatment. Patients must have lived and thrived entirely in their new gender role for at least 2 years before any genital surgery is undertaken. However, bilateral mastectomy might be considered for females after a year of life in a male role. With these selection criteria, the outcomes of surgery are generally good. In the UK, individuals may legally change their recorded sex, usually after gender reassignment treatment.

Research that should change clinical practice is often ignored for years. Fifty-five new trials are reported in medicine every day. Psychiatrists need to have some way to sift, digest and act on new research to benefit their patients. This article outlines the key elements of evidence-based psychiatry in an attempt to address these needs. Initially, an evidence-based approach is about asking an answerable question, searching for the evidence and then critically appraising the available information for its validity and relevance. The fourth step involves integrating the evidence with clinical expertise and the patient's values. The whole idea is to improve real-life patient care. This article outlines a number of the tools needed to overcome some of the common problems that psychiatrists face when trying to find and use published research results to help solve patients' problems.