The Mental Capacity Act 2005 provides a new legal framework within which health and social care professionals (as well as informal carers) must act when providing care and treatment for the estimated 2 million people in England, Wales and Northern Ireland who lack the capacity to make certain decisions for themselves. Although the Mental Capacity Act 2005 Code of Practice provides comprehensive advice on good practice in assessing capacity, it does not identify a specific process to be used. Good clinical practice depends on the exercise of clinical judgement within a valid and contestable process. This article outlines a flow chart (Fig. 1) that can be used to guide the process of capacity assessments in more complex cases, in line with the Mental Capacity Act 2005 and the Code of Practice.

Community treatment orders (CTOs) were introduced into the UK despite unconvincing international evidence for their effectiveness. The Oxford Community Treatment Order Evaluation Trial (OCTET) is a multisite randomised controlled trial of 333 patients with psychosis conducted in the UK. It confirms an absence of any obvious benefit in reducing relapse despite significant curtailment of liberty. Community mental health teams need to seriously consider whether they should continue using CTOs or shift their clinical focus to strengthening the working alliance.

Complaints of delays at out-patient clinics are common; a Newham patient's complaint that she had not been kept waiting long enough was correspondingly puzzling but has subsequently proved very fruitful. Her explanation that discussions with other waiting patients and the OPD nurse were often more helpful than the interview with the doctor triggered the development of a clinic designed for fuller participation of patients and staff.

Deaths of patients under psychiatric care, especially if they are in-patients, have been the subject of a number of retrospective studies (Copas & Robin, 1982; Morgan & Priest, 1991; Modestin et al, 1992; Roy & Draper, 1995; Proulx et al, 1997). They have also been a particular focus of the National Confidential Inquiry (Appleby et al, 1999) as well as many individual inquiries. In contrast, little has been published on how individual psychiatric departments and trusts might best review and learn from local deaths or ‘near misses' of patients under their care. In particular, there is no well publicised or widely accepted model for routinely examining such occurrences.

For young people with emerging psychosis, early weight gain and its potential cardiac and metabolic consequences amplify worrying UK public health trends for young people in general. This paper will argue that if clinicians dismiss these changes as of secondary concern in psychiatric treatment for their young patients, they may be inadvertently condoning a first critical step on a path towards physical health inequalities. Greater recognition is needed for this patient population in their 20s and 30s, at ages not normally considered for active primary or secondary cardiovascular prevention, who are at high risk of dying prematurely. The early phase of psychosis presents an important treatment window for protecting cardiometabolic health.

Rigorous studies of community alternatives to hospitalisation show that they are feasible and effective but have spawned considerable debate about their methodology, replicability, and appropriateness for normal clinical practice. In Britain, many demonstration projects have been centrally funded and evaluated initially by the Personal Social Services Research Unit at the University of Kent and latterly by Good Practices in Mental Health (Renshaw et al, 1988). Such community-based projects have attempted to avoid the problems of community mental health centres in the United States which have, with some important exceptions, failed to offer a comprehensive service that would allow closure or a significant drop in bed numbers at state hospitals (Dowell & Ciarlo, 1983). In practice, the design of community services is very dependent on local circumstances, including the demography of the population, existing service provision and attitudes. For this reason, planners and practitioners need to be aware of many practical options for service delivery.

Although antidepressants are regarded as effective and specific treatments, they are barely superior to placebo in randomised trials, and differences are unlikely to be clinically relevant. The conventional disease-centred understanding of drug action regards antidepressants as targeting an underlying brain process, but an alternative ‘drug-centred’ view suggests they are psychoactive substances that modify normal mental states and behaviour. These alterations, such as numbing of emotions, may reduce feelings of depression, and also create amplified placebo effects in randomised trials. Patients should be informed that there is no evidence that antidepressants work by correcting a chemical imbalance, that antidepressants have mind-altering effects, and that evidence suggests they produce no noticeable benefit compared with placebo.

There is an inexorable drive in psychiatric services in the UK, including forensic services, towards organising and delivering care based on the principles of the recovery model. Hence recovery, and its subjective and objective measures, is the goal of these services and the standard by which the quality of the service is evaluated. At the same time, all psychiatric services are expected to practise evidence-based risk assessment and management practices and can be subject to severe criticism or sanctions if they do not do so. In this paper I set out the view that the values that underlie the recovery approach and the clinical risk assessment approach appear to be polar opposites. However, an understanding of human behaviour using a humanneeds model is an explanatory paradigm that underlies both the recovery model and the understanding of risk behaviour, and can thus unify these two approaches. Therefore a more explicit integration of this model into forensic care would be beneficial and there should be more research directed to the correlates of recovery-oriented measures and risk-related measures.

In the Oxford Community Treatment Order Evaluation Trial (OCTET), patients were randomised either to be made subject to a community treatment order (CTO) or to be managed with Section 17 leave and discharge. No differences in outcome between the two groups were observed. Here it is argued that the patients studied were not those who might have benefited from a CTO and that the psychiatrists involved were unlikely to have used the provisions of a CTO assertively. Consideration of the lengths of time for which both Section 17 leave and CTOs were used supports the notion that CTOs were not used appropriately for a group of patients who might have benefited from them. Hence the results of this study should not be taken to provide any evidence as to the effectiveness or otherwise of CTOs.

This paper argues for the inclusion of religion and spirituality in psychiatric care. After discussing the antagonism of psychiatrists and psychologists to religion, I present a critical overview of studies examining the relationships between spirituality, religion and diverse aspects of mental health: depression, suicide, anxiety, delinquency, drug abuse and schizophrenia. The need to assesses the impact of religion in different faith groups is discussed. Measures of religious coping, both positive and negative, may provide a more accurate portrayal as to how individuals deploy religion in their lives than global measures such as belief and attendance. I highlight the fact that there is a dearth of research on ritual, prayer and other aspects of religious experience. While many studies demonstrate positive effects of religion on mental health, others find detrimental effects. Finally I examine the clinical implications of these findings.