Generative artificial intelligence (GenAI) shows promise for mental healthcare by increasing access to treatment. In this article, we analyse recent evidence on the use of GenAI chatbots as a treatment for common mental disorders. We examine key ethical and methodological considerations and discuss the specific risks for delusions. Adopting a precision psychiatry perspective, we propose that the therapeutic alliance can be improved by tailoring GenAI to mimic a user’s psychological traits, a version of socioaffective alignment.

This article explores the intersection of neurology and psychiatry in the assessment of psychosis. It provides a practical overview of neurological disorders associated with psychosis, including epilepsy, autoimmune encephalitis, neurodegenerative dementias, Parkinson’s disease, Huntington’s disease, Creutzfeldt–Jakob disease, cerebrovascular disease, traumatic brain injury, brain neoplasms, multiple sclerosis and genetic neurodevelopmental syndromes. Accurate diagnosis requires recognising clinical red flags and adopting a multidisciplinary approach that integrates psychopathology, neuropsychology, neuroimaging, electrophysiology and biomarker analysis. Treatment strategies vary according to aetiology and may include antipsychotics and others pharmacological resources, immunotherapy, neuromodulation and behavioural interventions.

Treatment-resistant schizophrenia (TRS) is a clinically challenging subtype of schizophrenia affecting up to 30% of patients, defined by persistent symptoms despite adequate trials of at least two antipsychotics. This review explores the complex neurobiology of TRS, highlighting the limitations of the dopamine hypothesis and emphasising the roles of glutamatergic, cholinergic and neurodevelopmental mechanisms. It outlines neuroimaging techniques (e.g. positron emission tomography, functional and structural magnetic resonance imaging, and proton magnetic resonance spectroscopy) used to explore neurotransmitter activity and structural brain changes in psychosis, and in TRS in particular, and gives an overview of their findings and utility. It also discusses frameworks like TRRIP and the INTEGRATE algorithm, which aim to facilitate earlier diagnosis and treatment. Integrating neuroimaging into practice may improve diagnosis and clinical outcomes and advance precision medicine approaches; emerging non-dopaminergic treatment options, such as xanomeline–trospium, may offer promising alternatives to standard clozapine treatment for TRS. Future research should prioritise biomarker discovery and the development of novel therapies beyond dopaminergic targets.

Clinical work with people who are seriously unwell and overwhelmed by psychotic functioning can be profoundly rewarding yet uniquely demanding. Beyond visible symptoms lie powerful unconscious forces that affect all involved. Drawing on psychoanalytic theory from Bion, Money-Kyrle, Menzies Lyth and Lucas, this article explores how psychotic processes such as splitting, projection, denial and rationalisation are transmitted to those providing care. Recognising and working with these dynamics not only deepens clinical understanding, enabling meaning to be found in apparently chaotic presentations, but also enhances the capacity to engage therapeutically with distress. Reflective practice, supervision and organisational containment are identified as essential clinical interventions to help clinicians understand the unconscious impact of psychotic processes and to preserve their capacity for thought and compassion.

Avoidant/restrictive food intake disorder (ARFID) is a condition characterised by an avoidance or restriction of food intake that has a detrimental impact on physical health, psychosocial functioning or both. ARFID has now been classified in ICD-11, alongside DSM-5; however, challenges remain for healthcare professionals in recognising ARFID in young people and identifying best practice for managing their care. This educational article aims to provide an update on the epidemiology and clinical presentation of ARFID in children and young people, with a particular focus on co-occurring neurodevelopmental conditions and psychiatric disorders. A multidisciplinary approach to assessment and management is key, working closely with the young person and the system around them. Physical and psychosocial risk assessment has been aided by the publication of the medical emergencies in eating disorders (MEED) guidelines. Crucially, there is a need for further research into ARFID in order to develop evidence-based standardised guidelines for assessment, management and transition to adult services if required.

Lewin and colleagues’ article in this journal gives a good overview of how artificial intelligence (AI) is contributing to the reshaping of mental healthcare. However, a deeper focus on the synergies between different approaches to AI and its goals is needed. This commentary aims to further consider the unique implications of digital mental health approaches, including predictive, explainable and generative AI, for both research and clinical objectives.

Most psychiatric disorders in adulthood originate in childhood or adolescence. Hence, managing mental health in children and adolescents is crucial. This clinical reflection aims to capture some of the contemporary and emerging trends in teaching and training in child and adolescent psychiatry worldwide. Future directions for child and adolescent psychiatry training programmes are also highlighted.

Despite the recent advances in its diagnosis (heralded by the revisions in ICD-11 and DSM-5) and the introduction of new approaches to treatment, managing personality disorder remains challenging to the psychiatric practitioner. I believe that one of the main reasons for this is that the condition lacks an overall theory that might guide practitioners in their assessment of it and what they might do to intervene. In this article, I suggest that interpersonal theory might be such a candidate, enabling practitioners to manage this condition more effectively. My aim is to provide a brief introduction to this theory in the hope that practitioners might be encouraged to explore its implications more fully.

There is growing concern regarding the increasing prevalence of synthetic opioids and their association with mortality and a range of health and social harms. Recognition, assessment and management of synthetic opioid use is a key challenge for practitioners working in hospitals, prisons and community services. This article gives an overview of the range and characteristics of synthetic opioids, key risks, the prevalence of synthetic opioid-related deaths in England, and prevention and management approaches. It highlights five areas critical to addressing the synthetic opioid crisis: improved access to medication for synthetic opioid addiction; increased naloxone availability and referral to addictions services following opioid overdose; strengthening prevention efforts targeting risk factors such as illicit drug markets and emerging trends in drug use; optimising pain management to reduce the use of prescription opioids and minimise the risk of associated synthetic opioid addiction; raising awareness among healthcare providers, patients and the general public about the dangers of synthetic opioids, including their potency, addictive nature and potential for overdose.

This brief article outlines a training programme, implemented during day-to-day practice, to teach psychodynamic skills to resident doctors in a variety of specialties and at all levels of training. By identifying and exploring the interpersonal dynamics between individual patients and staff, psychiatry residents learn skills such as psychodynamic assessment and formulation, intervention planning and risk reduction.

Obsessive–compulsive symptoms (OCS) and obsessive–compulsive disorder (OCD) are commonly observed to be associated with clozapine, but are often underdiagnosed in clinical practice. This can have a negative impact on a patient’s quality of life and prognosis. This article provides a brief guide for clinicians on managing clozapine-associated OCD/OCS to optimise patient care.

Functional neurological disorder (FND) presents with a range of neurological symptoms. Therefore, these patients are usually referred to the neurology team, although mental health liaison teams are also commonly involved in their care as in-patients. This article gives an overview of FND in adults, its diagnosis and management strategies, in the acute hospital. It discusses the common diagnoses it can be mistaken for, some techniques for psychoeducation and the value of the patient perspective. It emphasises the significance of clear communication, appropriate use of resources and considerate discharge planning. The role of liaison psychiatry is key, as an advocate for an improved multidisciplinary approach, establishment of local integrated multidisciplinary pathways, enhanced education for all clinicians and ongoing research to optimise treatment. FND needs an individualised, patient-centred approach to address the complex needs of this patient cohort.

Perceptual disturbances are common in psychiatric and neurological conditions, yet some rare, non-psychotic disorders remain poorly recognised. This review examines two such syndromes: visual snow syndrome (VSS) and exploding head syndrome (EHS). VSS is marked by continuous ‘static’ across the visual field, often accompanied by palinopsia, photophobia and entoptic phenomena. EHS involves sudden, loud auditory sensations – like explosions or crashes – occurring during transitions between sleep and wakefulness. Although distinct in modality, both share common challenges: subjective distressing symptoms, normal investigation findings, frequent misdiagnosis and psychiatric comorbidities such as anxiety, sleep dysfunction and depersonalisation. The article synthesises emerging evidence on their neurobiological underpinnings, including cortical hyperexcitability, thalamocortical dysrhythmia and impaired sensory gating, and on pharmacological and non-pharmacological treatment options. Enhancing clinical awareness and adopting a multidisciplinary approach are essential for improving diagnosis and care. This article aims to support psychiatrists in recognising, differentiating and managing these complex perceptual disorders.

Alexander Crichton’s Inquiry (1798) was one of the first systematic English-language works on mental disorder. Although a general physician rather than a specialist, Crichton sought to explain how emotions, attention and the nervous system interacted to produce disturbance. His description of inattention is now regarded as the earliest English medical account of what we would call an attention disorder. He drew extensively on German case reports, vivid accounts of melancholy, delusion and violence. He highlighted how delusion could coexist with calm, purposeful behaviour, influencing both medical and legal views of responsibility. Modern historians see Crichton as a synthesiser rather than an originator, but his Inquiry remains an ambitious attempt to ground the study of mental disorder in physiology, observation and compassion.

This article aims to help clinicians better assess and manage patients who show ‘problematic detachment’: interpersonal distancing that is resulting in functional impairment or distress. It considers both the possible relevant social contextual factors and the wide range of possible underlying psychopathologies that can result in problematic detachment, including mental illnesses, neurodevelopmental disorders and personality pathology. After giving a practical framework for diagnostic formulation, it summarises key aspects of best practice when working with such individuals. The article covers four key questions that the clinician must address. Is problematic detachment present? If so, what specific challenges underlie and maintain it in this person? Based on that, what diagnostic formulation makes sense for this individual? Finally, using this understanding, how can they best treat this individual?

Large language models (LLMs) like OpenAI’s ChatGPT, Google’s Gemini and Anthropic’s Claude can be useful tools in psychiatric practice, helping with tasks such as searching for information, managing administrative work and supporting education. This article demystifies how these tools work by explaining their core operational principles and noting their key limitations, including the risks of confabulation (fabricating information), sycophancy and knowledge cut-offs. It provides practical guidance on mitigating these risks through structured ‘prompt engineering’ and offers a safety framework for integrating LLMs into low-risk administrative and educational workflows. The article stresses the importance of approaching these technologies with caution by independently verifying information, adhering to UK data protection laws and upholding the principles of best practice in patient care. The goal is to help clinicians use these powerful but fallible technologies wisely, ensuring that patient safety and professional responsibility remain paramount as they explore these new tools.

This commentary responds to a case study of a drawing group on a perinatal psychiatric ward, framing it as a threshold practice: one that invites creative presence between clinician and mother, between symptom and symbol. The commentary highlights the therapeutic potential of shared non-verbal creative acts, but points to the potential for aesthetic coercion and the ethical tensions that arise when clinicians step into aesthetic space alongside patients. It argues that arts interventions in mental health require neither romanticisation nor reductive measurement, but a critical and generative mode of engagement attuned to thresholds, relationships and the fragile work of recovery.

Children with social communication difficulties or an autism diagnosis and co-occurring mental health needs can struggle to access and engage in psychological treatment. This can have a negative effect on well-being and recovery. A service improvement pilot study investigated the impact of a values-focused intervention on the well-being of this patient group. Here, an anonymised clinical case demonstrates the key phases of the intervention. Reflections highlight the importance of a flexible and person-centred approach for these young people.

Roger Smith’s Trial by Medicine: Insanity and Responsibility in Victorian Trials traced how Victorian Britain defined legal insanity. Through an interdisciplinary approach, Smith demonstrated how determinations of criminal responsibility were shaped by more than legal reasoning alone, with verdicts also influenced by professional ambition among expert witness groups often with divergent medical opinions, in addition to broader factors such as social class, gender and evolving moral values. Given its rigour and societal insights, it represents a landmark achievement in the field.