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Coronavirus disease 2019 (covid-19) has sparked a rapid transformation in learning and how information is delivered. In July 2020 we ran a virtual educational event, the National Psychiatry Summer School, with sponsorship from the Royal College of Psychiatrists. This free event over two days comprised eminent speakers, hundreds of attendees, and international participation. It highlighted the challenges and opportunities digital conferences can offer. We hope our reflections and learning will inspire others to create and run high quality, accessible virtual events. Virtual learning is here to stay—not to replace but to enhance opportunities for medical education. Organising a successful conference (whether online or face to face) requires commitment. Consider carefully who you will work with and allocate the workload across this reliable, enthusiastic team who share your vision. Establish roles with set responsibilities and timelines, agreed from the outset. Collaborating with institutions or individuals outside your existing network can increase creativity, reduce individual workload, and divide costs to produce a high quality event. In a virtual setting, organising committees can be from across the world, allowing collaboration with non-UK based universities, societies, charities, or special interest groups. Diversity can be increased at all levels—from representation of speakers and voices to breaking down traditional barriers of geography. Be clear about the aims of your event—namely, what it is for and who might attend. Create a theme for the event and invite speakers who fit. Think, has this been done before? If so, why is yours different, and why is it needed? Set the date of your conference. Although we prepared ours in a month, it would be better to plan as far ahead as possible. Find out what is taking place near the proposed date to avoid clashes with established events, examinations, and holidays. As a virtual conference usually costs less …

SummaryWomen in academic publishing and academic psychiatry face many challenges of gender inequality, including significant pay differentials, poor visibility in senior positions and a male-dominated hierarchical system. We discuss this problem and outline how the BJPsych plans to tackle these issues it in its own publishing.

SummaryThe National Health Service (NHS) was created 70 years ago to provide universal healthcare to the UK, and over the years it has relied upon international medical graduates (IMGs) to be able to meet its needs. Despite the benefits these professionals bring to the NHS, they often face barriers that hinder their well-being and performance. In this editorial, we discuss some of the most common challenges and the adverse effects these have on IMGs’ lives and careers. However, we also propose practical measures to improve IMGs’ experiences of working in psychiatry.

Women in academic publishing and academic psychiatry face many challenges of gender inequality, including significant pay differentials, poor visibility in senior positions and a male-dominated hierarchical system. We discuss this problem and outline how the BJPsych plans to tackle these issues it in its own publishing.

SummaryThe COVID-19 pandemic has brought untold tragedies. However, one outcome has been the dramatically rapid replacement of face-to-face consultations and other meetings, including clinical multidisciplinary team meetings, with telephone calls or videoconferencing. By and large this form of remote consultation has received a warm welcome from both patients and clinicians. To date, human, technological and institutional barriers may have held back the integration of such approaches in routine clinical practice, particularly in the UK. As we move into the post-pandemic phase, it is vital that academic, educational and clinical leadership builds on this positive legacy of the COVID crisis. Telepsychiatry may be but one component of ‘digital psychiatry’ but its seismic evolution in the pandemic offers a possible opportunity to embrace and develop ‘digital psychiatry’ as a whole.

SummaryFor several decades, mental health services within the UK's National Health Service were provided by specialist mental health trusts. More recently many of these trusts have integrated community physical health services into their operations. We describe here how two integrated mental health trusts in England were able to make an enhanced response to the COVID-19 pandemic.

SummaryThere is an urgent need to provide evidence-based well-being and mental health support for front-line clinical staff managing the COVID-19 pandemic who are at risk of moral injury and mental illness. We describe the evidence base for a tiered model of care, and practical steps on its implementation.

Delivery of high-quality care is dependent on staff with the right skills, experience and motivation. National Health Service (NHS) staff are performing in extraordinary ways while being scrutinised by a watchful media that currently describes them as heroes and a presently enthusiastic public that regularly claps them. Nonetheless, it is inevitable that exposure to significant stressors will lead to some experiencing mental health problems. Like the rest of the population, staff are likely to be anxious about the future while contending the challenges of societal shut-down, which makes it difficult to destress by having a drink with a friend, playing sport or being part of social gatherings. Some will no doubt worry about their exposure to COVID-19 that could directly endanger them and their families. News of unexplained higher mortality in BAME groups and inadequate hospital supply chains for personal protective equipment (PPE) may also cause disquiet. At work, staff wearing burdensome PPE will find that patients die despite their best efforts. Distress resulting from feeling that a life could have been saved if only you knew more, had better equipment, experience or training, or if there were not so many patients to deal with may result in ‘moral injury’. This describes the suffering that occurs when circumstances clash with one’s moral or ethical code.1 Our understanding of moral injury remains somewhat immature, but many people with moral injuries develop mental illnesses such as depression or post-traumatic stress disorder (PTSD).2 Leaders will know that protecting staff mental …

SummaryHealth and social care face growing and conflicting pressures: mounting complex needs of an ageing population, restricted funding and a workforce recruitment and retention crisis. In response, in the UK the NHS Long Term Plan promises increased investment and an emphasis on better ‘integrated’ care. We describe key aspects of integration that need addressing.Declaration of interestD.K.T. and S.S.S. are on the editorial board of the British Journal of Psychiatry and executives of the Academic Faculty at the Royal College of Psychiatrists. A.J.B.J., H.P. and Z.M. have roles at the Royal College of Psychiatrists that include evaluation of integrated care systems. A.J.B.J. is married to Dr Sarah Wollaston, Member of Parliament for Totnes and Chair of the Health Select Committee.

SUMMARYMentoring is becoming increasingly recognised as a tool for supporting the junior workforce and for helping trainees to achieve their full potential. In this article we explore the benefits and barriers to mentoring in psychiatry from a trainee's perspective, and highlight differences between the role of a mentor and clinical and educational supervisor.

Background: A qualitative service evaluation was undertaken of a Day Treatment Service (DTS). The service consists of partial hospitalisation for individuals with acute mental ill health using a ro...

Objective: Psychiatrists and clinical psychologists assess and treat individuals with a wide-range of mental health needs, and the differences between them are not always well understood by other professionals or the public. Most work on perceptions in mental health has evaluated issues such as diagnosis, risk, prognosis, and blame. Little has evaluated and contrasted broader perceptions of psychiatrists and psychologists. We qualitatively explored views of members of the public, in order to identify such wider understanding.Method: Nine individuals with no experience of mental ill-health were interviewed using a semi-structured interview guide. Transcripts were thematically analysed.Results: Three core themes were identified: perception of roles, stigma, and increasing future awareness. There was frequent misunderstanding of these professions. In general, however, psychiatrists were seen as more authoritarian and with a medication focus, though their interventions were believed to be effective. Psychologists were perceived as friendlier and having a better rapport, though participants thought they only typically looked at ‘minor’ difficulties.Discussion: Public perceptions matter. There is a lack of clarity in the public mind about our roles. These data should aid professionals’ self-reflection of potential transference issues, and to consider local applicability and variation of our findings. The two professions should consider public psychoeducatative programmes to inform and encourage engagement.

Individuals with schizophrenia typically suffer a range of cognitive deficits, including prominent deficits in working memory and executive function. These difficulties are strongly predictive of functional outcomes, but there is a paucity of effective therapeutic interventions targeting these deficits. Transcranial direct current stimulation is a novel neuromodulatory technique with emerging evidence of potential pro-cognitive effects; however, there is limited understanding of its mechanism. This was a double-blind randomized sham controlled pilot study of transcranial direct current stimulation on a working memory (n-back) and executive function (Stroop) task in 28 individuals with schizophrenia using functional magnetic resonance imaging. Study participants received 30 min of real or sham transcranial direct current stimulation applied to the left frontal cortex. The ‘real’ and ‘sham’ groups did not differ in online working memory task performance, but the transcranial direct current stimulation group demonstrated significant improvement in performance at 24 h post-transcranial direct current stimulation. Transcranial direct current stimulation was associated with increased activation in the medial frontal cortex beneath the anode; showing a positive correlation with consolidated working memory performance 24 h post-stimulation. There was reduced activation in the left cerebellum in the transcranial direct current stimulation group, with no change in the middle frontal gyrus or parietal cortices. Improved performance on the executive function task was associated with reduced activity in the anterior cingulate cortex. Transcranial direct current stimulation modulated functional activation in local task-related regions, and in more distal nodes in the network. Transcranial direct current stimulation offers a potential novel approach to altering frontal cortical activity and exerting pro-cognitive effects in schizophrenia.

Background: Psychotic illnesses, such as schizophrenia, are typically enduring and disabling conditions, impacting individual, family, and societal outcomes. Individuals with these face greater vulnerabilities in developing alcohol-use disorder (AUD). Furthermore, the nature of psychoses, often manifesting with paranoia, cognitive impairment, a lack of insight, sub-optimal treatment adherence, and stigma from others, means that they can pose unique treatment challenges when these two conditions comorbidly occur. These challenges mean that the standard literature on the effectiveness of the opioid antagonist naltrexone in AUD does not necessarily translate to this vulnerable population. Methods: Following PRISMA guidelines, we herein systematically reviewed the evidence for naltrexone in individuals with both psychosis and AUD. Overall, there is a paucity of research in this important area, with only nine reports meeting search criteria, only four of which were randomized control trials. Studies compared naltrexone with: placebo, another pharmaceutical agent, or upon changes to baseline drinking behaviour. One study evaluated the long-acting injectable formulation of this drug. Results: Most studies, including the methodologically more robust ones, supported naltrexone’s effectiveness over placebo in terms of reduction in drinking days and numbers of drinks consumed on such days in this cohort. Work comparing naltrexone to other pharmaceutical interventions showed approximate equivalence with disulfiram, and modest superiority over acamprosate. Conclusions: On this limited evidence base, this review endorses the use of naltrexone as both safe and effective in those with both psychotic illnesses and AUD. Several key issues remain to be elucidated. Critically, study designs meant that they were limited to individuals with good engagement with services, and levels of adherence were attained that are unlikely to be replicated in this cohort in real-world settings. Finally, effects of specific psychosis symptomatology, not least paranoia and insight, upon naltrexone use, and the reverse directional potential of ‘double dysphoria’ from an opioid antagonist remain largely unexplored.

Background Schizophrenia is characterized by prominent cognitive deficits, impacting on memory and learning; these are strongly associated with the prefrontal cortex. Objective/hypothesis To combine two interventions, transcranial direct current stimulation (tDCS) over the prefrontal cortex and cognitive training, to examine change in cognitive performance in patients with schizophrenia. Methods A double blind, sham-controlled pilot study of 49 patients with schizophrenia, randomized into real or sham tDCS stimulation groups. Subjects participated in 4 days of cognitive training (days 1, 2, 14, 56) with tDCS applied at day-1 and day-14. The primary outcome measure was change in accuracy on working memory and implicit learning tasks from baseline. The secondary outcome measure was the generalization of learning to non-trained task, indexed by the CogState neuropsychological battery. Data analysis was conducted using multilevel modelling and multiple regressions. Results 24 participants were randomized to real tDCS and 25 to sham. The working memory task demonstrated a significant mean difference in performance in the tDCS treatment group: at day-2 (b = 0.68, CI 0.14–1.21; p = 0.044) and at day-56 (b = 0.71, 0.16–1.26; p = 0.044). There were no significant effects of tDCS on implicit learning. Trend evidence of generalization onto untrained tasks of attention and vigilance task (b = 0.40, 0.43–0.77; p = 0.058) was found. Conclusions This is the first study to show a significant longer-term effect of tDCS on working memory in schizophrenia. Given the current lack of effective therapies for cognitive deficits, tDCS may offer an important novel approach to modulating brain networks to ameliorate cognitive deficits in schizophrenia.

SummaryIn this second part of a two-article review on malingering we consider the challenges of presenting clinical and psychometric findings. Numerous clinical and demographic factors are statistically associated with malingering but applying them to an individual case risks challenges to the expert psychiatric witness's evidence. Although psychometric data can usefully help strengthen or challenge a diagnosis, expert witnesses must recognise and report the limitations of these tests. We recommend that psychiatric expert witnesses do not try to look for or to link any external incentives with clinical findings, and indeed we suggest that they should, other than exceptionally, avoid using the term ‘malingering’. It is the job of the court, not the expert witness, to ascertain an individual's credibility and motives. We suggest a framework for presenting expert psychiatric evidence in this area.Learning Objectives• Appreciate clinical and sociodemographic factors associated with malingering, and the challenges to applying these in individual cases• Understand the legal scrutiny to which the reporting of psychometric data might be exposed• Appreciate the roles of the expert witness and the court, and have a suitable framework for reporting expert psychiatric evidence in such cases

SUMMARYPsychiatry intertwines mind and brain, sometimes in a strained marriage. Psychiatrists feel the criticism of a ‘narrow’ biological or medical (and medication) focus, and we are very aware of the limitations of all treatments and diagnostic systems. Many understandably move towards a more social approach, seeing individuals in their wider lives. But there are dangers in losing the brain, something unique to our specialty in the world of mental health. This reflective piece calls for us to rediscover the joy of the science of the brain, which augments, not conflicts with, psychosocial approaches.

SummarySociety is undergoing a shift in gender politics. Science and medicine are part of this conversation, not least as women's representation and pay continue to drop as one progresses through more senior academic and clinical levels. Naming and redressing these inequalities needs to be a priority for us all.Declaration of interestNone.

SUMMARYMalingering is the intentional feigning of illness for external gain. The author has written several papers on the epidemiology, assessment, testing and reporting of this. However, practice in this field can raise considerable challenges, not least the inability to determine motivation for lying, and potential damage from ‘false positives’, where individuals fabricate some aspects of their testimony, yet still have underlying psychiatric problems. This brief article lays out the author's reflections on this complex area.DECLARATION OF INTERESTNone.

SummaryEvolutionary science can serve as the high-level organising principle for understanding psychiatry. Evolutionary concepts generate new models and ideas for future psychiatric study, research, policy and therapy. The authors accordingly make the case for the inclusion of evolutionary biology in the postgraduate education of psychiatric trainees.

Clozapine is the treatment of choice for medication refractory psychosis, but it does not benefit half of those put on it. There are numerous studies of potential post-clozapine strategies, but little data to guide the order of such treatment in this common clinical challenge. We describe a naturalistic observational study in 153 patients treated by a specialist psychosis service to identify optimal pharmacotherapy practice, based on outcomes.Medication and clinical data, based on the OPCRIT tool, were examined on admission and discharge from the national psychosis service. The primary outcome measure was the percentage change in mental state examination symptoms between admission and discharge and the association with medication on discharge. Exploratory analyses evaluated the specificity of individual medication effects on symptom clusters.There were fewer drugs prescribed at discharge relative to admission, suggesting an optimisation of medication, and a doubling of the number of patients treated with clozapine. Treatment with clozapine on discharge was associated with maximal decrease in symptoms from admission. In the group of patients that did not respond to clozapine monotherapy, the most effective drug combinations were clozapine augmentation with 1) sodium valproate, 2) lithium, 3) amisulpride, and 4) quetiapine. There was no support for a dose-response relationship for any drug combination.Clozapine monotherapy is clearly the optimal medication in medication refractory schizophrenia and it is possible to maximise its use. In patients unresponsive to clozapine monotherapy, augmentation with sodium valproate, lithium, amisulpride and quetiapine, in that order, is a reasonable treatment algorithm. Reducing the number of ineffective drugs is possible without a detrimental effect on symptoms. Exploratory data indicated that clozapine was beneficial across a range of symptoms domains, whereas olanzapine was beneficial specifically for hallucinations and lamotrigine for comorbid affective symptoms.

SummaryThis article explores the growing interface between social media and academic publishing. We discuss how the British Journal of Psychiatry (BJPsych) and other scientific journals are engaging with social media to communicate in a digital world. A growing body of evidence suggests that public visibility and constructive conversation on social media networks can be beneficial for researchers and clinicians, influencing research in a number of key ways. This engagement presents new opportunities for more widely disseminating information, but also carries risks. We note future prospects and ask where BJPsych should strategically place itself in this rapidly changing environment.Declaration of interestJ.R.H., J.F.H. and D.T. are on the editorial board of the BJPsych. D.T. runs its social media arm.

SummaryMalingering is the dishonest and intentional production of symptoms. It can cause considerable difficulty as assessment runs counter to normal practice, and it may expose clinicians to testing medicolegal situations. In this first part of a two-article review, we explore types of psychiatric malingering and their occurrence across a range of common and challenging scenarios, discussing presentations that may help delineate true from feigned illness. A framework is provided for undertaking an assessment where malingering is suspected, including recommendations on clinician approach, the use of collateral information, and self-evaluation of biases. The uses, and limitations, of psychometric tests are discussed, including ‘general’, malingering-specific and ‘symptom validity’ scales.Learning Objectives• Understand the challenges of determining ‘real’ from ‘malingered’ symptomatology across a range of psychiatric conditions• Have a rational strategy for approaching a clinical assessment where malingering is suspected• Appreciate the role and limitations of various psychometric tests that can be used in such assessments

Background Clozapine is the only medication approved for those patients with schizophrenia who do not achieve a clinical response to standard antipsychotic treatment, yet it is still underused. Furthermore, in the case of a partial or minimal response to clozapine treatment, there is no clarity on the next pharmacologic intervention. Methods The National Psychosis Service is a tertiary referral inpatient unit for individuals with refractory psychosis. Data from 2 pooled data sets (for a total of 325 medical records) were analyzed for treatment trajectories between admission and discharge (2001-2016). Effectiveness of pharmacologic treatment was determined using change in symptoms, assessed using the Operational Criteria (OPCRIT) system applied retrospectively to the medical records. Analysis was focused on identifying the optimal medication regimens impacting clinical status during the admission. Results Less than a quarter of the patients were on clozapine treatment at the time of admission; this rate increased to 63.4% at the time of discharge. Initiating clozapine during admission (n = 136) was associated with a 47.9% reduction of symptoms as reflected by their OPCRIT score. In cases in which clozapine monotherapy did not achieve sufficient improvement in symptoms, the most effective clozapine augmentation strategy was adding amisulpride (n = 22, 60.8% reduction of symptoms), followed by adding a mood stabilizer (n = 36, 53.7% reduction). A less favorable option was addition of quetiapine (n = 15, 26.7% reduction). Conclusions Many people with longer-term and complex refractory illness do respond to clozapine treatment with suitable augmentation strategies when necessary. Furthermore, it is possible to advance clozapine prescribing in these complex patients when they are supported by a skilled and dedicated multidisciplinary team. The optimal therapeutic approach relies on confirmation of diagnosis and compliance and optimization of clozapine dose using therapeutic drug monitoring, followed by augmentation of clozapine with amisulpride or mood stabilizers. There is some preliminary evidence suggesting that augmentation strategies may impact differentially depending on the symptom profile.

Bupropion has been used as an antidepressant for over 20 years, though its licence for such use varies and it is typically a third- or fourth-line agent. It has a unique pharmacology, inhibiting the reuptake of noradrenaline and dopamine, potentially providing pharmacological augmentation to more common antidepressants such as selective serotonergic reuptake inhibitors (SSRIs). This systematic review and meta-analysis identified 51 studies, dividing into four categories: bupropion as a sole antidepressant, bupropion coprescribed with another antidepressant, bupropion in ‘other’ populations (e.g. bipolar depression, elderly populations) and primary evaluation of side effects. Methodologically more robust trials support the superiority of bupropion over placebo, and most head-to-head antidepressant trials showed an equivalent effectiveness, though some of these are hindered by a lack of a placebo arm. Most work on the coprescribing of bupropion with another antidepressant supports an additional effect, though many are open-label trials. Several large multi-medication trials, most notably STAR*D, also support a therapeutic role for bupropion; in general, it demonstrated similar effectiveness to other medications, though this literature highlights the generally low response rates in refractory cohorts. Effectiveness has been shown in ‘other’ populations, though there is an overall dearth of research. Bupropion is generally well tolerated, it has very low rates of sexual dysfunction, and is more likely to cause weight loss than gain. Our findings support the use of bupropion as a sole or coprescribed antidepressant, particularly if weight gain or sexual dysfunction are, or are likely to be, significant problems. However there are notable gaps in the literature, including less information on treatment naïve and first presentation depression, particularly when one considers the ever-reducing rates of response in more refractory illness. There are some data to support bupropion targeting specific symptoms, but insufficient information to reliably inform such prescribing, and it remains uncertain whether bupropion pharmacodynamically truly augments other drugs.

Aims and methodA retrospective evaluation was undertaken of the clinical and economic effectiveness of three in-patient rehabilitation units across one London National Health Service trust. Information on admission days and costs 2 years before and 2 years after the rehabilitation placement, length of rehabilitation placement and the discharge pathway was collected on 22 service users.ResultsThere were statistically significant reductions in hospital admission days in the 2 years following rehabilitation compared with the 2 years before, further reflected in significantly lower bed costs. Longer length of rehabilitation placement was correlated with fewer admission days after the placement. A substantial proportion of the sample went into more independent living, some with no further admissions at follow-up.Clinical implicationsThe findings suggest that in-patient rehabilitation is both clinically and cost effective: if benefits are sustained they will offset the cost of the rehabilitation placement.

SummaryClinical neuromodulation began in psychiatry with electroconvulsive therapy (ECT), but in recent years several new techniques have been developed: repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), vagal nerve stimulation (VNS), trigeminal nerve stimulation (TNS) and deep brain stimulation (DBS). Each works in a different way, although the principle remains to effect therapeutic change through physically modifying brain activity. Their use in different clinical groups varies between techniques, as does their underlying evidence base. Most support currently exists for rTMS, with a more modest, but growing database for tDCS. Understandably, but problematically, most research in the other techniques has, to date, been in unmasked open trials. This article describes the mechanism of action and current evidence base for each technique, and notes the challenges facing future work in this potentially important field and new clinical avenue.

Purpose – Opiod users are at high risk of suffering from drug overdoses. Naloxone has been used for decades in emergency treatment settings to reverse the symptoms of opioid overdose. Pilot studies and regional programmes have been rolled out to make naloxone more widely available. This review of user/carer administration of naloxone – so-called “take home naloxone” – aims to provide health professionals and interested readers with an up-to-date evidence base, clinical implications and practical concern considerations for such community management. The paper aims to discuss these issues. Design/methodology/approach – A review and analysis of the recent literature on naloxone. Findings – The evidence base suggests training and education is effective in preparing users for wider naloxone distribution. Furthermore, studies of varying quality indicate that naloxone may prove useful in reducing overdose-related deaths. However, even after implementation ineffective response techniques continued to be used at times and there remained a heistance to call medical services post overdose. Intranasal naloxone may reduce some of the risks associated with intramuscular naloxone. Ethical considerations, including provision of a needle and syringe kit to the community, should be considered. Studies suffered from a lack of follow-up data and methodological difficulties are associated with establishing opioid-related deaths post implementation. Two running trials in the UK might mitigate these concerns. Research limitations/implications – Future research is needed to address wider context of an overdose and targeting associated risk factors. Originality/value – Clinicians and other professionals will be informed on the most up-to-date evidence base and which areas are improtant to consider when take-home naloxone is introduced in their services.

Clinical trials in psychiatry inherit methods for design and statistical analysis from evidence-based medicine. However, trials in other clinical disciplines benefit from a more specific relationship between instruments that measure disease state (e.g. biomarkers, clinical signs), the underlying pathology and diagnosis such that primary outcomes can be readily defined. Trials in psychiatry use diagnosis (i.e. a categorical label for a syndrome) as a proxy for the underlying disorder, and outcomes are defined, for example, as a percentage change in a univariatetotal scoreon some clinical instrument. We label this approach to defining outcomesweak aggregationof disease state. Univariate measures are necessary, because statistical methodology is both tractable and well-developed for scalar outcomes, but we show that weak aggregate approaches do not capture disease state sufficiently, potentially leading to loss of information about response to intervention. We demonstrate how multivariate disease state can be captured using geometric concepts of spaces defined over routine clinical instruments, and show how clinically meaningful disease states (e.g. representing different profiles of symptoms, recovery or remission) can be defined as prototypes (geometric locations) in these spaces. Then, we show how to derive univariate (scalar) measures, which capture patient's relationships to these prototypes and argue these representstrong aggregatesof disease state that may be a better basis for outcome measures. We demonstrate our proposal using a large publically available dataset. We conclude by discussing the impact of strong aggregates for analyses in traditional and novel trial designs.

Most individuals with schizophrenia suffer some cognitive dysfunction: such deficits are predictive of longer-term functioning; and current dopamine-blocking antipsychotics have made little impact on this domain. There is a pressing need to develop novel pharmacological agents to tackle this insidious but most disabling of problems. The acetylcholinergic system is involved in cognitive and attentional processing, and its metabotropic and nicotinic receptors are widespread throughout the brain. Deficits in acetylcholinergic functioning occur in schizophrenia, and high rates of tobacco smoking have been posited to represent a form of self-medication. The nicotinic acetylcholine receptor (nAChR) has emerged as a putative target to improve cognitive deficits in schizophrenia, and this study systematically reviewed the emerging data. Nineteen studies were identified, covering three compound classes: agonists at the α7 and α 4β2 nAChRs, and positive allosteric modulators. Overall data are underwhelming: some studies showed significant improvements in cognition but as many studies had negative findings. It remains unclear if this represents drug limitations or nascent study methodology problems. The literature is particularly hindered by variability in inclusion of smokers, generally small sample sizes, and a lack of consensus on cognitive test batteries. Future work should evaluate longer-term outcomes, and, particularly, the effects of concomitant cognitive training.

Aims and methodIt has been observed that some individuals self-diagnose with a bipolar affective disorder and many are later diagnosed with a borderline personality disorder. There is a background context of clinical and neurobiological overlap between these conditions, and fundamental debates on the validity of current diagnostic systems. This qualitative study is the first work to explore the views of patients caught at this diagnostic interface. We predicted that media exposure, stigma and attribution of responsibility would be key factors affecting patient understanding and opinion.ResultsSix core illness-differentiating themes emerged: public information, diagnosis delivery, illness causes, illness management, stigma, and relationship with others. Individuals did not ‘want’ to be diagnosed with a bipolar disorder, but wished for informed care.Clinical implicationsUnderstanding patient perspectives will allow clinical staff to better appreciate the difficulties faced by those we seek to help, identify gaps in care provision, and should stimulate thought on our attitudes to care and how we facilitate provision of information, including information about diagnosis.

Antipsychotic medications revolutionized the care of psychosis, but they have brought with them significant side effects and issues around adherence; these latter factors, and informed co-working with patients, are primary drivers for specific medication choices. The data remain limited for polypharmacy and above-maximum dose prescribing, though there may be individuals for whom this is considered. Long-acting injectables (LAIs or ‘depots’) have a good evidence base, and are probably underutilized, though clozapine remains our drug of choice in refractory illness. Forensic-population data show that medications significantly reduce recidivism, including of violent crime. Whilst side effect data are disheartening for both patient and clinician, there are rational management strategies for them all. Novel future therapies being evaluated include acetylcholinergic and glutamatergic enhancers, anti-inflammatory drugs, and the neural peptide oxytocin, to improve negative and cognitive functioning; neuromodulation through rTMS and tDCS are also showing early promise.

Background: Europe is in the midst of the largest refugee migration since the Second World War; there is an urgent need to provide an updated systematic review of the current best evidence for managing mental distress in refugee populations.Aims: The aim of this review is to provide an exhaustive summary of the current literature on psychosocial interventions, both trauma- and non-trauma-focused, for refugee populations experiencing post-traumatic stress disorder (PTSD), depressive or anxiety symptoms. To produce recommendations for future research and current clinical practice.Method: Searches were conducted in PubMed, PsychINFO (Hosted by Ovid), PILOTS and Social Services Abstracts; 5305 articles were screened and 40 were included.Results: This review found medium to high quality evidence supporting the use of narrative exposure therapy (NET). A lack of culturally adapted treatments was apparent and there was less evidence to support standard cognitive behavioural therapy (CBT), Eye Movement Desensitisation and Reprocessing (EMDR) and multidisciplinary treatments.Conclusion: NET produced positive outcomes in refugees from a diverse range of backgrounds and trauma types. There is a general dearth of research in all intervention types: further research should include more "real-world" multidisciplinary interventions that better model clinical practice. Recommendations for evaluating local need, and creating a culturally sensitive workforce are discussed.

SummaryCognitive and memory testing are a common part of clinical practice, but professional concerns are sometimes raised that the individual being tested might be feigning deficits. Most clinicians have limited experience and training in detecting malingering in such cognitive testing, and the very issue raises considerable ethical dilemmas. Nevertheless, psychiatric work faces ever greater potential for legal scrutiny, and failure to appropriately evaluate potential malingering risks professional embarrassment and distress. There is a need for clinicians to make themselves aware of the ways in which malingered behaviour might be evaluated through the clinical history, the use of routine psychometric testing and, particularly, the use of symptom validity (‘malingering’) tests. This article describes these factors and gives guidance on the appropriate reporting of findings.Learning Objectives•Better understand the complexities in cognitive assessment where malingering is suspected.•Understand the types and limitations of the major symptom validity tests.•Be better prepared to produce documentation and reports stating test findings.

Three interacting challenges are facing all aspects of health care in the United Kingdom: financial restraint in the context of a global economic downturn; a move to services being commissioned and decommissioned by primary care Clinical Commissioning Groups; and a need to provide evidence based practice through ‘payment by results’. Psychoanalytic psychotherapy faces more difficulty than most services in mental health, with long and frequent criticisms of it being expensive and under-researched; and it is not as well understood by GPs as cognitive behavioural therapy, with which it is frequently unfavourably compared. This review provides an overview of the existing evidence for psychoanalytic psychotherapy, identifying strengths and areas that are under explored. We also argue that psychoanalytic psychotherapy has a unique clinical role but this will need to be clearly stated in the future, and promoted by clinicians to encourage future commissioning in the UK.

Background Individuals with schizophrenia typically suffer a range of cognitive deficits, including in executive functioning (EF) and working memory (WM) [1,2]. Such difficulties are strongly predictive of functional outcomes, but there is a lack of effective therapeutic interventions [3]. Transcranial direct current stimulation (tDCS) is a novel neuromodulatory technique with emerging evidence of potential pro-cognitive applications; however there has been a dearth of understanding of mechanistic effects of this intervention [4]. The aim of this study was to evaluate the neurophysiological effects of tDCS during WM and EF assessment in individuals with schizophrenia. Methods We utilized functional magnetic resonance imaging (fMRI) to evaluate the impact of tDCS on WM and EF in individuals with schizophrenia, randomized to receive either ‘real’ or ‘sham’ (placebo tDCS). Participants completed a WM (blocked 0–3 back) and an EF (color-word Stroop) during 30 min of 2mA tDCS applied to Broadman area 10/46 (anode 35cm2); with cathode placed on right supraorbita. Sham stimulation was applied for 30 sec. tDCS was applied during fMRI (online) [5]. In addition to whole brain, we also conducted task relevant region of interest analysis (ROI) to compare mean frontal and prefrontal (Broadman are 10/46 mask) and anterior cingulate cortex (ACC) activity between the two groups during tDCS. All analyses were restricted a p-value of 0.05, following family wise-error correction (FWE). Results There were no between-group differences in socio-demographic or clinical characteristics (Tab 1.) Participants did not differ on WM task performance during online tDCS (Tab 2). However, there were significant between-group differences in manipulation of information with the real tDCS performing significantly better than sham, controlled for baseline (b=0.68, CI 0.14 - 1.21; p=0.044) after consolidation [6]. During WM the ROI analysis demonstrated increased activation underneath the site of the anode in the medial frontal gyrus in the real tDCS group, as compared to sham. There was a positive correlation between with consolidated performance and the activity in the medial frontal gyrus. Further, tDCS demonstrated significantly reduced activation in the left cerebellum. During EF task, increased performance was associated with decreased activity in the ACC [5]. Discussion This is the first tDCS study to examine the brain activity during WM and EF assessment in individuals with schizophrenia using fMRI This data suggests that biasing the membrane potential of neuronal populations in the frontal cortex seems to improve their response to other inputs i.e. decreased BOLD activation in the WM and EF network. Although the mechanism of action of tDCS is not clear yet [6], one may speculate that if the BOLD response represents synaptic activity [7], including input from other areas, then tDCS might increase the probability that a synaptic input will generate a response in an output neuron, without the need of any additional energy expended by the cell. tDCS offers a potential new therapeutic approach to the treatment of cognitive deficits.