Significant evidence has accrued suggesting that the hypothalamic–pituitary–adrenal (HPA) axis plays a role in some psychiatric disorders. This article reviews the physiology of the HPA axis, evidence of dysfunction in this axis in psychiatric illnesses and the role that this dysfunction might play in pharmacological treatment resistance. Future therapeutic strategies that may potentially arise from these researches are briefly outlined.

The impending regulatory changes for all medical professionals in the UK will make it necessary for doctors to be relicensed and, in the case of specialists, to be recertified. This editorial argues strongly in favour of recertification and proposes that continuing professional development is one of the main planks on which recertification of psychiatrists should be based. We present cogent reasons for this, as well as evidence that improved learning contributes positively to healthcare. We also recommend that psychiatrists should make learning objectives more clinically focused as well as properly resourced.

The central role of medication in the treatment of attention-deficit hyperactivity disorder (ADHD) in children and adolescents is the focus of controversy once more. Questions about the safety and appropriateness of medication have arisen both within and without the medical community. This coincides with the disappointing results for long-term ADHD treatment, illustrated recently by the first major outcome study to be published. Clinicians have had to contend with a number of public health scares following on from the actions of drug regulatory bodies, in addition to misinformation and misunderstanding from the media. Ironically, this comes at a time when we have an ever-widening range of medications and formulations available to us, and better-quality studies to inform treatment decisions. The recently published National Institute for Health and Clinical Excellence guidelines address some of these issues and provide a welcome summary and reference point for beleaguered clinicians.

The number of in-patient beds for psychiatric treatment in America has declined dramatically over the past 40 years. Public and private policies have encouraged an extremely short-term, crisis-stabilisation model of treatment. This is true on both general and subspecialty units. As a result, readmissions have increased, emergency rooms are crowded, and many patients end up homeless or incarcerated in the criminal justice system. These changes have created a public health crisis in America, and are the greatest challenges that American psychiatry faces today.

A judgement may be defined as an assertion made with evidence or good reason in a context of uncertainty. In psychiatry the uncertainty is inherent in the professional context and the evidence derives from academic literature and scientific studies as they are applied to a specific patient. The nature of the uncertainty and the factors that should inform professional judgement are explored in this article. Professional judgement currently faces two serious challenges: an obsession with numbers, which comes from within medicine, and the ‘patient choice’ agenda, which is politically inspired and comes from outside medicine. In this article we strive to defend professional judgement in the clinic against both challenges.

Although recent cases of egregious boundary violations in professional relationships in the UK have led to a concerted and robust government response, the issue of doctors having relationships with former patients is relatively sparsely talked about. Publications by the General Medical Council and the Department of Health deal with this tricky and often contentious matter in some depth. This article discusses the abuse of professional relationships and examines the ethics, law and advances in understanding in the area of doctors' relationships with former patients.

This article asks whether it is ever acceptable for a psychiatrist to form an intimate relationship with a former patient. It explores the tensions that arise between the freedom of autonomous adults, the need to protect vulnerable individuals, and the public interest in maintaining trust in the doctor–patient relationship. It argues that although a complete ban on all sexual relationships between doctors and former patients would be excessively restrictive, a special case can be made for relationships with former psychiatric patients. The particular vulnerability of psychiatric patients, and the resulting need to ensure the highest standards of trust in the profession, strengthen the case for a complete ban.

In the search for antidepressant drugs with enhanced efficacy, targeting the hypothalamic–pituitary–adrenal (HPA) axis is a valid strategy. This commentary critically summarises the evidence for the efficacy of antidepressant drugs targeting the HPA axis, and concludes that the available clinical trials do not support claims that this class of drugs is superior to existing treatments.

Although in agreement with their conclusions about the importance of clinical judgement, this commentary criticises the way that Downie & Macnaughton defend it in their article. I argue that their defence is both overly limited in its account of the role of judgement and that it employs unnecessarily contentious arguments. I outline the ineliminable role that judgement plays in determining which general diagnostic concepts fit individual patients given their individuality and specificity.

This article discusses the aetiology of both simple and complex post-traumatic stress disorders (PTSDs) in terms of attachment theory, and points out the similarities between the diagnosis of complex PTSD and of borderline personality disorder. Case vignettes illustrate an outline of the assessment and treatment of the psychobiological symptoms of PTSD informed by attachment research.

During the period 2000–2004 the average annual suicide rate in England and Wales was 10.2 deaths per 100 000 population over 10 years of age. About a quarter of those who take their own lives are in contact with mental health services in the year before their death. This means that an average in-patient, sector or community psychiatrist is likely to experience the death of at least one patient by suicide in most years. Suicides by patients cause considerable distress for the psychiatrist that is unlikely to resolve until after the coroner's hearing. This article discusses suicide prevention and provides guidance for psychiatrists on preparing for a coroner's inquest following a patient's death that may have been by suicide.

This article sets out the history of medical directorship, outlines the authors' view of the current contribution that medical directors can and should be making to the mental health arena and looks forward to the possibilities of this evolving role. The focus of the article is mainly on English policy and healthcare structures, recognising that these vary in the other jurisdictions of the UK. However, certain principles should be of wider interest and application.

Presence of fever in psychiatric patients may signify a number of potentially fatal conditions. Several of these are related to treatments (e.g. neuroleptic malignant syndrome with antipsychotics, serotonin syndrome with serotonergic antidepressants, and malignant hyperpyrexia with anaesthesia used for administration of electroconvulsive therapy) or exacerbated by them (e.g. malignant catatonia with antipsychotics). New classes of drug treatment may be changing the epidemiology of these disorders. We suggest that an initial diagnosis of hyperthermia syndrome is clinically useful as there are some important commonalities in treatment. We outline a systematic approach to identify a particular subtype of hyperthermia syndrome and the indications for more specific treatments where available.

Some people with obsessive–compulsive disorder (OCD) experience recurrent intrusive sexual, aggressive or death-related thoughts and as a result may be subjected to lengthy or inappropriate risk assessments. These apparent ‘primary’ risks can be dealt with relatively easily through a careful understanding of the disorder's phenomenology. However, there are other, less obvious ‘secondary’ risks, which require more careful consideration. This article discusses the differentiation of intrusive thoughts and urges in people with OCD from those experienced by sexual or violent offenders; assessing the risk of self-harm and suicide; discussing the nature of repugnant obsessions with a patient; assessing risk of harm and violence to the dependents and family living with someone with the disorder; and assessing the lack of insight and the use of the Mental Health Act. Issues specifically related to children and young people with OCD are also highlighted.