Over the course of a year, about three-quarters of patients prescribed psychotropic medication will discontinue, often coming to the decision themselves and without informing a health professional. Costs associated with unplanned discontinuation may be substantial if left uncorrected. Partial non-adherence (much more common than full discontinuation) can also be detrimental, although some patients rationally adjust their medication regimen without ill-effect. This article reviews the literature on non-adherence, whether intentional or not, and discusses patients' reasons for failure to concord with medical advice, and predictors of and solutions to the problem of non-adherence.

There has been significant anxiety among prescribers regarding the potential for cardiac adverse effects associated with acetylcholinesterase (AChE) inhibitors in Alzheimer's disease. There is no consensus on how to manage this cardiovascular risk, and memory clinics vary widely in their practice. Review of published evidence reveals that the incidence of cardiovascular side-effects is low, and that serious adverse events are rare. Intensive cardiovascular screening such as pre-treatment electrocardiograms or 24 h cardiac monitoring is not justified. Furthermore, there are no high-risk groups to target. This article suggests pragmatic guidelines for managing cardiovascular risk in patients receiving AChE inhibitors. The guidelines are intended to be easy to incorporate into routine clinical practice in a memory clinic.

Cognitive–behavioural therapy (CBT) is an effective treatment for a number of psychiatric disorders in adults of all ages. With the proportion of the population aged 65 or over increasing steadily, it is important to be aware of how the CBT needs of this age group can be best met. This article provides an overview of CBT and the historical context of using it with older people. Although an understanding of the individual, irrespective of age, is at the core of CBT, potential modifications to the procedure and content aimed at optimising its effectiveness for older people are discussed.

This article describes the literature specific to partnership working across the National Health Service, social services and voluntary and community sector in order to summarise the potential advantages and challenges of partnerships. We explore the meaning of partnership working and review the policy developments and investment initiatives underpinning the Government's emphasis on partnership working between statutory services and the voluntary and community sector. A number of barriers hinder effective partnership working and we examine some possible solutions to overcome these. We then address the key issues influencing the approach to increasing the voluntary sector's participation in partnership activities within mental health services and provide brief examples of good practice. Finally, we discuss practical issues relevant to planning partnerships and the role consultant psychiatrists can play in initiating and developing partnership working between the voluntary sector and statutory mental health services.

What cardiovascular screening is needed before prescribing cholinesterase inhibitors in the memory clinic has led to much debate and contradictory advice – especially concerning the need for electrocardiograms (ECGs). Having looked at the current evidence base Rowland et al have produced simple and pragmatic advice that should be adopted immediately across the many memory clinics currently in operation. It is rare to have simple protocols these days – it is a relief to have such a breath of pragmatism.

Enhancing a patient's adherence to psychotropic medication regimens is one of the challenges facing all mental health professionals. Medication is part of an overall care package that often depends on patients' engagement with the clinician or service. The therapeutic alliance might be improved by more active listening to patients. A reduced capacity may limit a patient's ability to make a treatment choice. This can be improved by provision of more time and information. If these techniques are insufficient, closer monitoring may be achieved by working with relatives and carers, or more frequent visiting. Strategies to avoid covert non-adherence could include checking for picked up prescriptions and the use of depot preparations. Finally, the use of compulsory powers may be appropriate, with attention to preserving or rebuilding the therapeutic alliance.

Partnership working with the voluntary sector is developing across mental health services. Such partnerships have the support of the Royal College of Psychiatrists and the Department of Health. Setting up a partnership requires enthusiastic psychiatrists who are willing to work in new ways. These psychiatrists will face issues of personal and clinical responsibility, confidentiality and fairness. They will also have to deal with continuing changes that could unsettle a new and developing collaboration. Early intervention services may use partnerships more than other adult psychiatry services, but partnerships could be established in any specialty. Psychiatrists should make sure that appropriate evaluation is built into any new partnership.

Post-traumatic stress disorder (PTSD) causes significant distress and is often associated with markedly reduced functioning. Recent reviews have consistently recommended trauma-focused psychological therapies as a first-line treatment for PTSD. Pharmacological treatments have also been recommended but not as consistently. This article reviews the available trials of the pharmacological treatment of PTSD and discusses their implications.

The role of psychotherapy for elderly people is the subject of much debate. Yet this has not resulted in a shift of resources towards increasing its availability within the UK's National Health Service. Over the past decade the pessimistic view of psychotherapy for elderly people has diminished owing to the growing evidence base and the commitment of champions in old age psychiatry and psychotherapy. However, there is still very little structured research into psychotherapy in dementia. Supportive psychotherapy is a poorly understood but very practical means of helping people with dementia to adjust to the effects of their illness. Its inherent flexibility enables individual sessions to be tailored to the patient's needs and deficits. An understanding of supportive psychotherapy and its benefits could enable clinicians to improve the quality of life of people with dementia and their carers within the ever-present constraints of limited time and resources. This article explores the use of supportive psychotherapy as a treatment option in dementia.

Patients miss about 20% of scheduled appointments for mental health treatment, almost twice the rate in other medical specialties. Up to 50% of patients who miss appointments drop out of scheduled care. Many who miss appointments because of slips and lapses later rearrange their appointments without adverse consequences. Those that do not are at risk of further deterioration, relapse and hospital readmission. Predictors of non-attendance are complex and linked with the predictors of missed medication. Service barriers and administrative errors are common but are often overlooked in the absence of feedback from patients. Of prime importance are the therapeutic alliance and degree of ‘helpfulness’ of the clinician but again these are rarely measured routinely. Useful markers of engagement include patient-rated trust, satisfaction and degree of perceived participation in treatment decisions. Much can be done to improve attendance in most services. Simple measures such as offering prompt, convenient appointments, offering reminders and augmenting with telephone contact have a reasonable evidence base. Scales to assess therapeutic alliance are now available. Complex interventions need to be evaluated carefully in order that the overall benefits outweigh costs. We suggest that clinicians consider accessibility, discharge policies and patient feedback when examining local rates of non-attendance.

I explore some of the ways in which intellectual disability (learning disability) is depicted in fiction. My premise is that literature both reflects and shapes societal attitudes to people in this vulnerable minority group. People with intellectual disabilities are seldom able to determine, confirm or counter narratives about themselves. This situation, in which the subject is fundamentally unable to participate in their representation, raises unique ethical considerations. I use examples from various English-language novels to discuss how subjective accounts, observable behaviours and physical attributes are all employed to characterise people with intellectual disabilities.

This article is aimed at psychotherapists and health practitioners who have not reflected on the role of race, culture and ethnicity in the provision of psychological treatments. We highlight the key issues of importance in engagement, assessment and ongoing therapy, supporting practitioners to reach a stage of pre-competency. Competency will be achieved with additional training, supervision and innovation.

The Royal College of Psychiatrists' requirements for psychotherapy training and the role of the local psychotherapy tutor are summarised. Practical issues concerning the provision of this training are discussed, taking into account the anxieties that trainees experience. Suggestions are made about conducting case discussion groups, providing case supervision in small groups, locating short cases and arranging group and systemic therapy experience.

In this issue of APT Mitchell & Selmes present an article detailing why patients miss appointments and how clinicians should respond. Many of the papers quoted relate to the psychiatric out-patient clinic. In this commentary as well as picking up on some of the themes that emerge from their article, I explore the attachment that psychiatrists seem to have to this particular model of patient contact.

There is evidence pointing to a bias in the application of the Mental Health Act 1983 (which is in force in England and Wales). One study found that Black people on in-patient units were four times more likely to have been compulsorily admitted than White people. Furthermore, it has been shown that compulsory admissions to secure units are 2.9–5.6 times higher for Black than for White patients. Any understanding of this bias necessitates an examination of the attitudes of mental health professionals towards Africans and African–Caribbeans. Here we discuss possible contributory factors and examine a number of initiatives that have been instituted in order to tackle this problem.

A significant minority of people who use the internet develop ‘internet addiction’ – a relatively new concept in psychiatry not yet recognised by ICD–10 or DSM–IV. Preliminary research offers interesting insight into predisposing factors and psychosocial treatment options. Mental health professionals need a basic understanding of internet addiction so that they can recognise it early and intervene appropriately. In this article, we present an overview of the aetiological frameworks, assessment and treatments of internet addiction.

The concept of computer addiction is examined and the importance of conceptual and nosological clarity emphasised. The risk of tautology in the construction of such conditions is raised, as is the issue of whether it would be better to classify many affected individuals in terms of the end behaviour rather than the mediating mechanism. Definitional difficulties and sociocultural contexts are explored.

In the UK, the National Institute for Health and Clinical Excellence's guidelines on obsessive–compulsive disorder (OCD) recommend cognitive–behavioural therapy, including exposure and response prevention, as an effective treatment for the disorder. This article introduces a cognitive–behavioural model of the maintenance of symptoms in OCD. It discusses the process of engagement and how to develop a formulation to guide the strategies for overcoming the disorder.

Patient suicide is a relatively common event: 50–70% of consultant psychiatrists and 40–50% of psychiatric trainees have experienced at least one patient suicide. Patient suicide can have significant personal and professional effects on psychiatrists, including increased stress, social withdrawal, disruption to relationships, symptoms of post-traumatic stress disorder and consideration of early retirement. Following patient suicide, psychiatrists derive most support from informal contacts with team members, family and friends; additional support may be available through formal support structures or local team initiatives. It is important to place appropriate emphasis on the effects of patient suicide in psychiatry training programmes; to maintain awareness of the importance of informal supports following patient suicide; to strengthen formal systems of support; to identify other potential forms of assistance (e.g. spiritual support); and to develop local team initiatives in this area.

One in four people with mental health problems in Britain report debt or arrears, which is nearly three times the rate among individuals without similar conditions. Although health professionals commonly encounter debt among patients, some report that they lack basic knowledge to effectively intervene and that patient debt is often not acted on until a crisis emerges. Our aim in this article is to improve psychiatrists' knowledge and confidence in dealing with patient debt. We provide basic definitions of debt and problem debt; outline the impact that debt can have on patients' health, social and financial well-being; identify the stages and signs that a patient may be accruing problem debt; describe how psychiatrists should respond; and review the instruments available to assess patients' mental capacity to make financial decisions. We do not expect psychiatrists to become ‘debt experts’, but provide working knowledge for engaging more effectively with this problem.