This article sets out an approach to service improvement and development that depends on psychiatrists acquiring management skills, working with managers and selecting, understanding and using some structured business tools. These are essential elements in the development of clinical leadership and service vision and can add enormously to the improvement of patient care and treatment outcomes. It is important for psychiatrists to begin to acquire these skills during their training and to continue to develop them throughout their careers.

We try to demonstrate that using psychodynamic principles as part of case formulation is both possible and useful in everyday practice. We consider steps to developing a psychodynamically informed formulation, frameworks that can be used to structure this, and processes and resources needed to support good-quality formulation. We discuss the potential value of incorporating psychodynamic thinking and emphasise that this is complementary to other frameworks for understanding psychosis. Detailed case studies are provided.

Young people who cut themselves may do so for reasons that go beyond diagnosis. Relevant processes include responses to trauma, coping, emotion regulation and cultural identification. Some clinicians regard those who self-harm negatively or consider one therapeutic approach to be suitable for all. This article explores the possible mechanisms involved when young people cut themselves and discusses therapeutic approaches in the light of these. Clinicians and researchers are encouraged to refine, develop and research interventions for young people who self-harm by cutting.

Kevin Hines gives a high-impact and deeply poignant account of his suicidal crisis, which culminated in an attempt to end his life, and an inspirational account of his recovery and return to mental well-being.

The artist Arshile Gorky played a central role in the development of Abstract Expressionism during the 1940s. Born in Armenia, his early figurative works recall a childhood of persecution by Ottoman Turks, a period during which he suffered a number of significant losses. The painting The Artist and His Mother (c. 1926–1936) is based on a photograph showing the 7-year-old Gorky with his mother, 7 years before she starved to death during the Armenian Genocide. This article explores the early experiences that haunt this painting and the difficulties Gorky struggled with during his adult life as an immigrant to the USA – factors that contribute to an understanding of his suicide in 1948.

The case for better medical ‘leadership’ should be grounded in professional values and the need to deliver quality services for patients. But emerging ‘leadership language’ suggests that new ‘talent’ in management are in fact influenced by commercial imperatives. The profession needs to monitor such trends with care.

Crisis resolution and home treatment teams have been introduced throughout England as part of a transformation of the community mental healthcare system. They aim to assess all patients being considered for acute hospital admission, to offer intensive home treatment rather than hospital admission if feasible, and to facilitate early discharge from hospital. Key features include 24-hour availability and intensive contact in the community, with visits twice daily if needed. This article describes the main characteristics and core interventions of these teams, and reviews the impact of their nationwide introduction. The model has evolved as a pragmatic response to difficulties in the acute care system, and its adaptation continues. Key challenges include achieving close integration with the rest of the mental health system and delivering continuity of care and effective therapeutic relationships despite the involvement of multiple workers in each crisis.

Lithium is one of the most effective psychotropic drugs we have, but it is underused because of its low therapeutic index, the need for regular blood tests and perceptions about its adverse effects, including renal problems. The last include urinary concentration deficits and diabetes insipidus, chronic kidney disease (including renal failure), nephrotic syndrome, hypercalcaemia, hyperparathyroidism and distal tubular acidosis. This article reviews these adverse effects with special emphasis on their management.

Consultant psychiatrists are familiar with mental health tribunals, at which they appear as key witnesses giving both factual evidence and expert opinion. They also commonly act as the representative of the ‘responsible authority’. The implications of this in terms of roles and responsibilities, and in terms of training and continuing professional development, have received little attention. Psychiatrists should not accept a representative role unless they are sure that they have the necessary competencies and resources – competencies that are alien to most clinicians and resources that are not available in many services. This article outlines those requirements so that psychiatrists can make better-informed decisions about whether or not to undertake the role and provides practical guidance for those who choose to do so.

There has been a surge in interest in the boundaries of psychiatry, both as a specialty in its own right and as a branch of medicine separate from neurology. Our article expands on this, giving examples of how recent developments in neuroimmunology can be beneficial for psychiatry, using multiple sclerosis (MS) as an example. We also provide a summary of literature on novel research in the treatment of depression using anti-inflammatory agents. Finally, we suggest approaches to the identification and management of major depressive disorder in patients with MS or other physical illnesses, and how this translates to general psychiatric practice.

Delusional disorder, rare in clinical practice, remains one of the most enigmatic conditions in psychiatry. Linked to schizophrenia spectrum disorders since the mid-20th century, recent work has confirmed 19th-century notions of an aetiology based on attentional biases and personality dimensions. Unfortunately, the literature exists largely as case reports and series, often published as ‘curiosities’, and therefore lacks the rigour of formal diagnosis. This article reviews current thinking on aetiology and epidemiology, considers diagnosis, and reviews recent work on physical and psychological therapies. It concludes that delusional disorder is likely to respond well to treatment with standard antipsychotics, often at low doses, but that adherence and concordance remain particular problems. Cognitive therapy has been shown to be beneficial but is time-consuming and resource-intensive. Selective serotonin reuptake inhibitors may profit further investigation. There remains considerable scope for investigation of this fascinating condition.

This article outlines common psychodynamics in psychosis. We consider psychosis as a response to unbearable aspects of reality and illustrate how psychodynamic concepts of psychological defence can be used as a framework for understanding this. We also present a psychodynamic approach to understanding the development of psychosis, using the stress–vulnerability model, and discuss interpersonal dynamics in psychosis, particularly their relevance to therapeutic relationships and to interactions between patients and their families. The perspectives presented are intended to complement and enrich other frameworks rather than compete with them.

Making potentially critical clinical decisions in complex cases with the real risk of death by suicide is a most challenging job in psychiatry. Sadly, risk assessment and management of harm to self is a largely ignored area compared with risk of harm to others. The legal and ethical challenges are more nuanced, and contemporary training schemes and textbooks on psychiatry have not always done justice to this area, where front-line clinicians require probably most assistance. This article is an attempt to integrate the seemingly disparate threads from legal, ethical and clinical realms to assist decision-making, and it introduces a set of principles for managing these in clinical practice. It refers in particular to legislation in England and Wales, but the clinical and ethical issues discussed are universal.

Depressive disorder in those over the age of 60 has many clinical similarities to depression in younger adults, but biological changes related to ageing may necessitate a different approach to treatment. We present an evidence-based review of treatment for late-life depression, focusing on pharmacological approaches, including monotherapy, combination and augmentation strategies. Selective serotonin reuptake inhibitors such as sertraline and citalopram are well tolerated, have the advantage of a favourable side-effect profile, and are good options for first-line treatment. Second-line treatment options include combination therapy with a second antidepressant, or treatment augmentation with an antipsychotic or lithium. We also consider evidence for nonpharmacological treatment strategies, including psychological therapy and neurostimulation. Finally, we summarise evidence for treatment of depression in patients in dementia.

Sexual dysfunction is one of the most common psychiatric disorders, but it is often ignored in assessment. It can be primary or secondary (a result of psychiatric disorder or medication). Success rates in managing sexual dysfunction are relatively high, with good response to psychological and medical interventions. In ICD-10 and DSM-IV-TR, sexual dysfunctions are broadly classified on the basis of the stages of sexual activity, from arousal to orgasm. There are major similarities between ICD and DSM in diagnosis and classification of sexual dysfunction, but both systems raise challenges. These include definitions of what is ‘normal’ and how abnormality is defined. In this article, we describe the role of the two systems and possible amendments that might help researchers and clinicians. We also present key principles for the assessment and treatment of people who experience sexual dysfunction. We consider problems that need to be managed in engaging and in the therapeutic alliance.

This article examines the life and work of John Kennedy Toole, focusing on his 1981 Pulitzer Prize winning novel A Confederacy of Dunces. Toole finished the novel in 1966 and, after failing to rework his manuscript to his editor's satisfaction, he shelved the project. Following this, he displayed symptoms typical of paranoid schizophrenia and he took his own life at the age of 31. In his novel, Toole parodies both psychoanalysis and the practice of psychiatry at the time, with a strong overlap with the emerging perspectives critical of psychiatry popularised by figures such as Szasz, Laing and Foucault. Toole's life and work have relevance for psychiatrists interested in the relationship between creativity and mental illness, attitudes towards psychiatry in the 1960s, and the interplay between societal values and judgements of mental health.

The development of the concept of clinical leadership over the past 5 years, in conjunction with an ever-increasing emphasis on its importance in the medical world, has led to an explosion of reviews, resources, fellowships and other academic programmes in this area. Arguably, with the focus on clinicians as individual leaders, teamworking is a fundamental aspect of effective clinical leadership that has perhaps received less attention. This article explores aspects of leadership in the team setting and covers theories and concepts relating to team dynamics, team roles and functioning. This is with a view to providing clinicians with a sound knowledge base in this area, increased understanding of issues they may face in their own clinical teams, and ideas and tools to help increase team effectiveness.

The Quantity Theory of Insanity is a short story by the English novelist and journalist Will Self. It is one of six stories in a collection of the same name. Its central conceit is that there is ‘only a fixed proportion of sanity available to any given society at any given time’. The story is a broad satire of academia, social science and our treatment and understanding of mental disorder.