Psychotropic literature in recent years has become very concerned with the cardiac safety of certain psychotropic medication. This paper reviews some of the cardiac factors to be considered in the safer selection of psychotropic drugs for the vulnerable patient in everyday clinical practice.

Sensory impairment is often regarded from a medical/disability point of view and its effects on mental health can be poorly recognised. Communication is a key issue for deaf and deaf–blind people and difficulties here underlie developmental, psychological and emotional problems and delay or prevent appropriate assessment and treatment. Children may have additional problems associated with the cause of their sensory impairment and need early multi-disciplinary intervention. Emotional and practical support is needed for families to make fully informed choices. Those with and without sensory impairment need the same access to mental health services and this is particularly difficult to achieve for deaf and deaf–blind people. Local and specialist teams need to work together to implement the National Service Framework for this vulnerable patient group.

This article reviews what we should tell patients and carers about dementia. The attitudes and views of patients, carers and peer groups are examined, as is the practice of doctors and other professionals working in dementia care. Factors influencing the decision to disclose the diagnosis of dementia, including the degree of certainty of the diagnosis, the degree of insight of the patient and the severity of the dementia are considered. Advantages, disadvantages and ethical issues of disclosure are discussed, as well as when or whether and how to disclose the diagnosis. Flexible guidelines regarding the process of disclosure are introduced.

Language is the essential psychiatric tool for eliciting both history and mental state. Both diagnosis and treatment are handicapped if there is no common language between doctor and patient and understanding is facilitated through a third party, who usually has no psychiatric training. Many factors can affect this process resulting in a convoluted interview and greater potential for misunderstandings and diagnostic errors. Linguistics and the use of interpreters are rarely mentioned in standard psychiatric texts. The different processes of translation and interpretation and their use in psychiatry are explored here. The variety of errors and pitfalls described in the literature are considered. The authors offer advice on the use of trained and untrained interpreters in order to minimise errors and make the most of the information available.

Since the Woolf reforms were incorporated into legal practice in civil cases in England and Scotland, there has been a distinction between expert and professional witnesses. A common feature is the appointment of an agreed expert to give evidence on aspects of a case that require expert testimony. These changes do not apply in criminal cases nor in other jurisdictions such as the Republic of Ireland. However, all witnesses, whether professional or expert, must be objective, since their role is to assist the court. There is little or no training of clinicians in how to become an expert and suggestions for improving this are discussed. Practical aspects of accepting a brief from a solicitor are considered.

Expressed emotion has been used as a construct in understanding the interaction between patients and their carers and families. A considerable amount of data from Western cultures suggests that high expressed emotion can lead to relapse in vulnerable individuals, even when they are on medication. However, the data from other cultures are less solid. This paper reviews some of the existing findings and recommends that various components of expressed emotion must be seen in the cultural context and embedded in the normative data of the population before the concept can be considered in association with the pathogenesis of relapse.

Social phobia (or social anxiety disorder) manifests as a marked and persistent fear of negative evaluation in social or performance situations. The epidemiology, diagnosis and psychopathology are reviewed, including clinical presentation, cultural aspects and the differences between agoraphobia and social phobia. Behavioural treatments, including graded self-exposure and cognitive restructuring, are considered. A cognitive model of the maintenance of social phobia is discussed. It is hypothesised that attentional shifting towards imagery, safety behaviours and ‘post-mortem’ analyses play a key role in symptom maintenance. The implications of this for treatment are described, and guidelines for pharmacological treatment are summarised.

Home treatment as an alternative to acute adult in-patient care is part of the National Health Service Plan for mental health services in the UK. As a form of crisis intervention, it benefits from an understanding of, and ways of working with, the social systems relevant to the patient in crisis. This article reviews relevant terminology and background theory, and considers the social factors associated with psychiatric admission.

The evidence base for cognitive–behavioural therapy (CBT) for depression is discussed with reference to the review document Treatment Choice in Psychological Therapies and Counselling (Department of Health). This identifies the need to deliver evidence-based psychosocial interventions and identifies CBT as having the strongest research base for effectiveness, but does not cover how to deliver CBT within National Health Service settings. The traditional CBT model of weekly face-to-face appointments is widely offered, yet there is little evidence to support these traditions in the outcome literature. Reducing face-to-face contact by introducing self-help into treatment may be one method of improving access. The SPIRIT course is discussed which teaches how to offer core cognitive–behavioural skills using structured self-help materials.

Although mood stabilisers have substantially improved the treatment of bipolar disorder, recent studies suggest that treatment with lithium is not as effective as originally claimed. Furthermore, patients still have high rates of relapse even when prescribed medication. Recent research has shown that poor coping strategies in response to bipolar prodromes and disruptions of sleep and social routines increase the risk of relapse. Combining a psychosocial approach with medication may improve the rate of relapse prevention. Cognitive therapy teaches patients better self-monitoring and coping skills and is therefore an appropriate means of minimising psychosocial risk factors for relapse. Recent randomised controlled trials suggest that combined medication and cognitive therapy significantly reduce bipolar relapse compared with medication alone.

Thorough preparation is essential before going into the witness box as an expert witness. This involves, among other things, rereading all the case notes and other relevant documentation and being familiar with recent research in areas related to the case. Areas of probable disagreement between experts should be discussed during consultation with counsel, since cross-examination is likely to focus on these. A specific protocol applies in the courtroom, especially when in the witness box. The approach to examination-in-chief is outlined and the tactics used during cross-examination are described, as these can be used to undermine the evidence of the witness.

This paper addresses how mental illness and psychiatry are presented in autobiographical narratives. The richness of clinical psychopathology unmediated by the expectations of psychiatry is described. The rituals of psychiatry, the importance of the personal relationships between patients and clinicians, and the subjective beliefs of people about mental illness are explored.

Home treatment as an alternative to acute adult in-patient care is part of the National Health Service's Plan for mental health services in the UK. As a form of crisis intervention, it benefits from an understanding of, and ways of working with, the social systems relevant to the patient in crisis. This article describes the social systems intervention process as an alternative to admission and also considers its application in achieving early in-patient discharge.

About 6% of older people in the UK are immigrants. Concentrated in deprived inner-city areas, their numbers are rising rapidly, with the ageing of those arriving after the Second World War. Cultural, language and educational differences cause problems in studying this group's mental health. Idioms of distress may affect presentation, help-seeking behaviour and acceptability of treatment. Ethnic elders may be considered vulnerable to depression because of socio-economic deprivation, immigrant status and old age but studies are contradictory and may use inappropriate screening instruments. Relatively few consider immigrant status and dementia. Uncontrolled hypertension could relate to higher dementia rates in Black immigrants which are not reflected in the country of origin. No genetic risk has been found. There is potential for prevention in this population.

The Draft Mental Health Bill was published in June 2002 and was widely criticised. There were particular concerns regarding the possible detention of those with personality disorders solely for the protection of the general public. Subsequently the Draft Bill was omitted from the Queen's speech in November 2002. The Department of Health has stated that it intends to push for the Bill's inclusion in the next Parliamentary year. This review attempts to summarise the present situation so as to inform the debate. It considers the relationship between personality disorder and risk, with examination of treatment models and the existing and proposed mental health legislation.

This article outlines the current provision and describes the role of forensic psychotherapy in the management of forensic patients. The authors maintain that the contribution of forensic psychotherapy is not limited solely to treatment provision. The forensic psychotherapist has a supervisory role, which can help staff and institutions to understand the dynamic processes that arise from the effects of managing forensic patients. The article outlines how forensic psychotherapy can contribute towards risk assessment and highlights some particular areas of concern for the forensic psychotherapist.

Patricia Casey's papers (2003a, b, this issue) cover the situation regarding expert witnesses in England and Wales and in Ireland. The situation in Scotland is outlined below.

Success in preventing and responding to criminal behaviours on psychiatric wards may sometimes require cooperation between mental health services and local police services. This is especially so when seeking legal remedies through the criminal justice system. This article describes police perceptions of psychiatric services and psychiatric patients. It also reviews police procedures and factors that influence their response when the police are requested to intervene following an alleged criminal act by an in-patient. A case vignette is used to highlight the causes of tensions and guide the reader through the steps that might be considered when the issue of prosecution arises.