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Community treatment orders are a legal mechanism to extend powers of compulsion into outpatient mental health settings in certain circumstances. Previous ethical analyses of these powers have explored a perceived tension between a duty to respect personal freedoms and autonomy and a duty to ensure that patients with the most complex needs are able to receive beneficial care and support that maximises their welfare in the longer-term. This empirical ethics paper presents an analysis of 75 interviews with psychiatrists, patients and family carers to show how these ethical considerations map onto the different ways that community treatment orders are used and experienced in practice. A complex and nuanced account of how the requirements to respect patients’ autonomy, to respect patients’ liberty and to act beneficently should be interpreted in order to make judgements about the ethics of community treatment orders is presented. The article argues that, due to such complexity, no general ethical justification for community treatment orders can be provided, but a justification on the basis of the promotion of patients’ autonomy could provide an ethical reason for community mental health practitioners to make use of a community treatment order in some limited circumstances.

Background: The UK guidelines on the treatment of personality disorder recommend avoiding compulsory treatment except in extreme situations. Little is known about how often patients with personality disorder are detained or how this compares with the treatment of other mental disorders. Objectives: Our aim is to test the hypothesis that people with personality disorder are infrequently detained under the Mental Health Act (MHA) and that risk factors associated with detention are the same as those for people with other mental disorders. Method: We used a retrospective, quantitative study of MHA assessments. Results: Of the 2 087 assessments undertaken, 204 (9.8%) patients had a diagnosis of personality disorder; 40.7% of assessments in the personality disorder group resulted in detention, as did 69.7% of patients with other mental disorders. A higher proportion of people with personality disorder received no intervention following assessment compared with those with other mental disorders (20.6% vs. 4.7%, p

Background: Continuity of care (COC) is central to the organization and delivery of mental health services. Traditional definitions have excluded service users, and this lack of involvement has been linked to poor conceptual clarity surrounding the term. Consequently, very little is known about the differences and similarities in the conceptualization of COC by mental health service users and professionals. Objective: To explore and compare mental health service users’ and professionals’ definitions of COC. Methods: Using an exploratory, qualitative design, five focus groups with 32 service users each met twice. Data were analysed thematically to generate a service user-defined model of COC. In a cross-sectional survey, health and social care professionals (n = 184) defined COC; responses were analysed thematically. Service user and professional definitions were conceptually mapped and compared to identify similarities and differences. Results: There was crossover between the service user and professional derived models of COC. Both contained temporal, quality, systemic, staff, hospital and needs-related elements of COC. Service users prioritized access, information, peer support and avoiding services; health professionals most frequently referred to staff, cross-sectional and temporal COC. Service users alone identified service avoidance, peer support and day centres as COC elements; professionals alone identified cross-sectional working. Conclusions: Important similarities and differences exist in service user and professional conceptualizations of COC. Further research is necessary to explore these differences, prior to integrating service user and professional perspectives in a validated COC framework which could enable the development and evaluation of interventions to improve COC, informing policy and practice.

‘The move into the community’ considers deinstitutionalization. Nearly every large mental hospital in the UK and most in the US and Western Europe have closed. The emptying of the institutions was partly due to the discovery of antipsychotic and antidepressant drugs, but changes in social attitudes towards the mentally ill, radical rethinking within psychiatry, and financial considerations were also influential. The first twenty years of community care were relatively successful. However, closures often ran ahead of provision of adequate alternative services. Stigma, an exaggerated sense of risk from the mentally ill, family break-up, high social mobility, and increasing levels of drug and alcohol use have made community care of the mentally ill more difficult.

‘Asylums and the origins of psychiatry’ outlines the historical care of the mentally ill. If the mentally deranged could not be cared for within the family, they were sent to private madhouses for the rich and workhouses for the poor. The asylum movement began in earnest in the 1820s, aiming to provide moral therapy in a calm, spacious, rural environment. However, conditions deteriorated with overcrowding. The 19th century saw increasing research into mental health, especially in German-speaking Europe, with three of psychiatry’s most influential figures being Kraepelin, Bleuler, and Freud. Meanwhile, asylums had become even more overcrowded and neglected. Not until the 1920s did specific effective treatments become available.

Psychiatry deals with consciousness, choice, motivation, free will, relationships—everything that makes us human. ‘What is psychiatry?’ emphasizes that psychiatry is a branch of medicine that deals with mental illnesses. The definition of psychiatry is not based on theory, as in psychology or psychoanalysis, but on practice. The current view of mental illnesses and available treatments will determine what a psychiatrist is, and what he or she does. The hallmark of the psychiatrist’s trade is the interview. Psychiatric diagnoses rely on making a judgement about why someone is doing something, not just the observation of what they are doing. The most common psychiatric disorders, both organic and functional, are described.

‘Psychiatry under attack’ focuses on the contradictions inherent in psychiatry. The mind–brain relationship is the big issue in psychiatry. It would be simple if psychiatry were just about ‘brain diseases’, but psychiatry concerns ‘mental’ illnesses. While many mental illnesses involve disorders of the brain, not all brain diseases are mental illnesses. Psychiatry originally viewed mental illnesses as inherited weaknesses. However, Freud and his followers shifted the balance to ‘nurture’. The ‘anti-psychiatry movement’ of the 1960s and 1970s, led by Szasz, Foucault, and Laing, condemned psychiatry as confusing at best and an instrument of social oppression at worst. There is now less opposition to psychiatry though disquiet remains about aspects of its practice.

The nature of psychiatric practice lays it open to potential misuse. ‘Open to abuse’ highlights the unequal power relationship with dependent and vulnerable patients whose opinions and complaints can so easily be dismissed. The diagnostic process is inevitably subjective, relying on psychiatrists’ assessments of the patient’s motives and mental state, with no concrete indicators for diseases such as blood tests. The history of psychiatry is littered with shameful episodes of political abuse, hare-brained theories, and dangerous and barbaric treatments. The visibility of modern-day psychiatry, plus a well-informed public and a willingness to admit mistakes, are the most reliable safeguards against such abuses. Psychiatry is now engaged in evidence-based medicine—facts and figures taking precedence over theories and opinion.

‘Into the 21st century’ explains how there is an increased focus on how our body, and not just the brain, influences our mental health. Rapidly advancing computer technology, including artificial intelligence and virtual reality, is beginning to provide new treatment possibilities, not just support and simplify the old ones. The development of sophisticated imaging has supercharged the area of neurosciences and the increased understanding of genetics and the new science of epigenetics provide psychiatry with greater tools to identify and manage mental illnesses. A paradox with our increasingly technological and scientific advances is that the core dilemmas of psychiatry appear not to be diminishing. Psychiatry will survive the 21st century, but certainly it is changing.

Background: Identification of people with hypertrophic cardiomyopathy (HCM) who are at risk of sudden cardiac death (SCD) and require a prophylactic implantable cardioverter defibrillator is challenging. In 2014, the European Society of Cardiology proposed a new risk stratification method based on a risk prediction model (HCM Risk-SCD) that estimates the 5-year risk of SCD. The aim was to externally validate the 2014 European Society of Cardiology recommendations in a geographically diverse cohort of patients recruited from the United States, Europe, the Middle East, and Asia. Methods: This was an observational, retrospective, longitudinal cohort study. Results: The cohort consisted of 3703 patients. Seventy three (2%) patients reached the SCD end point within 5 years of follow-up (5-year incidence, 2.4% [95% confidence interval {CI}, 1.9–3.0]). The validation study revealed a calibration slope of 1.02 (95% CI, 0.93–1.12), C-index of 0.70 (95% CI, 0.68–0.72), and D-statistic of 1.17 (95% CI, 1.05–1.29). In a complete case analysis (n= 2147; 44 SCD end points at 5 years), patients with a predicted 5-year risk of Conclusions: This study confirms that the HCM Risk-SCD model provides accurate prognostic information that can be used to target implantable cardioverter defibrillator therapy in patients at the highest risk of SCD.

Background Patient reported outcome measures (PROMs) are widely used in mental healthcare research for quality of life assessment but most fail to capture the breadth of health and non-health domains that can be impacted. We report the psychometric validation of a novel, multi-dimensional instrument based on Amartya Sen’s capability approach intended for use as an outcome measure in mental health research. Methods The Oxford Capabilities Questionnaire for Mental Health (OxCAP-MH) is a 16-item self-complete capability measure that covers multiple domains of functioning and welfare. Data for validation of the instrument were collected through a national randomised controlled trial of community treatment orders for patients with psychosis. Complete OxCAP-MH data were available for 172 participants. Internal consistency was established with Cronbach’s alpha; an interclass correlation coefficient was used to assess test-retest reliability in a sub-sample (N = 50) tested one week apart. Construct validity was established by comparing OxCAP-MH total scores with established instruments of illness severity and functioning: EuroQol (EQ-5D), Brief Psychiatric Rating Scale (BPRS), Global Assessment of Functioning (GAF) and Objective Social Outcomes Index (SIX). Sensitivity was established by calculating standard error of measurement using distributional methods. Results The OxCAP-MH showed good internal consistency (Cronbach’s alpha 0.79) and test-retest reliability (ICC = 0.86). Convergent validity was evidenced by strong correlations with the EQ-5D (VAS 0.52, p

This chapter considers legal mechanisms for directing that the treatment of a mentally disordered offender should take place under the civil commitment scheme. Mentally disordered offenders should be dealt with in the least restrictive manner and receive timely transfer of their care to general mental health teams. We discuss factors likely to influence the responsible authorities when deciding whether to direct offenders to treatment under the civil scheme. The scope of the powers that would continue to be available over the person’s treatment is a key factor. With insufficient powers, authorities might be reluctant to direct an offender to the civil scheme. Yet, if strong powers were available, that would pose a threat to the rights of ordinary civil patients under that scheme. Some way must therefore be found to finesse the differing interests of offenders and ordinary civil patients in the design of the civil scheme. .

‘Depression’ provides an overview of the psychiatric approach to clinical depression. The chapter begins with an account of the clinical phenomenology of depression and how the various symptoms and signs are captured in modern classificatory and diagnostic schemes of mood disorder. Adequate aetiological formulations of depression require the use of many different scientific approaches, ranging from genetics and brain imaging to neuropsychology and sociology. The chapter covers relevant examples from the various fields and explains how an integrated conceptual scheme can provide a richer understanding of the origin of depressive conditions, as well as leading to improved treatment approaches. The efficacy of various forms of treatment for depression, ranging from psychotherapies and pharmacology to electroconvulsive therapy, is described. There follows advice on how effective evidence-based treatments are best integrated with good clinical management.

‘Intellectual disabilities’ covers the life course, with a focus on the assessment and treatment of the intellectual disabilities at younger ages. This chapter outlines current understanding of the aetiology of the more common intellectual disabilities. The clinical features are discussed for severe/profound, moderate, and mild intellectual disability, and the more common psychiatric presentations for those with intellectual disabilities. Mood disorders, anxiety disorders, and dementia are discussed in greater detail, as are the more common presentations of intellectual disability, with sections on Down’s syndrome and fragile X. The importance of prevention of mental health problems and better understanding and management of more challenging behaviours are discussed alongside other treatments for psychiatric disorders.

‘Psychiatric services’ is concerned with the provision of psychiatric care for populations. It deals mainly with the needs of and provisions for people aged 18–65 years (‘adults of working age’), and focuses on the situation in the United Kingdom. (A more global perspective is provided in Chapter 23.) The chapter begins with an account of the historical development of psychiatric services, followed by descriptions of the commonly available psychiatric services and of the problems they encounter. It outlines the components of services, both those within primary care and those within specialized secondary care. These include services for acute disorders and those for complex long-term disorders (rehabilitation services). Service adaptations for patient groups with special needs (e.g. deafness, eating disorders) are also presented. The difficulties encountered by community care services are examined, as are emerging international service principles.

‘Paranoid symptoms and syndromes’ focuses on the recognition and significance of paranoid symptoms, and on paranoid syndromes (delusional disorders). The latter are related to, but usually considered to be distinct from, schizophrenia. The area has a complicated conceptual and terminological history, and this is outlined before explaining how paranoid symptoms and syndromes are currently defined and classified. Specific paranoid syndromes, such as morbid jealousy, erotomania (de Clérambaut’s syndrome), and several other eponymous syndromes, are then described. Finally, the principles of assessment and treatment of delusional disorders are outlined

‘Reactions to stressful experiences’ covers emotional and physiological elements of the response to stress and the way in which maladaptive coping patterns and inappropriate defence mechanisms can lead to clinical disorders. Stress reactions are often short-lived and respond to support from friends and family. However, particularly severe stresses can lead to the condition of post-traumatic stress disorder (PTSD), an important source of morbidity and disability, whose clinical features, psychology, neurobiology, and treatment are described in detail. The chapter also covers adjustment to threatening and traumatic life events, such as childhood abuse, sexual assault in women, the refugee experience, serious physical illness, and bereavement. These events can produce various kinds of adverse psychological consequences over the lifespan, and the chapter shows how these psychiatric sequelae can be recognized, theoretically understood, and best managed according to current evidence-based practice.

The chapter ‘Schizophrenia’ covers all aspects of this disorder. It first describes in detail the major and varied clinical features, before reviewing the diagnosis and classification of schizophrenia and how these have varied over time. The section on aetiology includes description of the recent major genomic advances, plus consideration of environmental and psychological factors. The neurobiology and pharmacology of schizophrenia are discussed before a summary is given of the neurodevelopmental model. Returning to clinical matters, the chapter then reviews the course and prognosis of schizophrenia before a detailed description of treatment and management. It concludes with the important issue of how schizophrenia is discussed with patients and carers.

‘Symptoms and signs of psychiatric disorders’ introduces psychiatry from the perspective of the clinical features that characterize and define its disorders, providing an essential first step in an understanding of the subject. The chapter starts with an introduction to psychopathology and an outline of the conceptual and practical issues involved. It then describes the cardinal symptoms of mental disorders, grouped according to the main headings used in a mental state examination. The chapter includes definitions of important and sometimes misunderstood terms, such as paranoia and delusions. The chapter is written from a practical perspective and assumes no prior knowledge of the subject.

‘Drugs and other physical treatments’ provides coverage of the current drug and physical treatments used in the management of general psychiatric disorders. Following a historical introduction and general principles governing drug use and prescription, agents are considered according to the major psychotropic classes, namely: anxiolytic and hypnotic, antipsychotic, antidepressant, mood stabilizer, and psychostimulant. Each class is described according to its pharmacology, followed by the indications, pharmacokinetics, adverse effects and clinical use of individual compounds. Subsequent sections describe the indications, practical management, and adverse effects of electroconvulsive therapy, as well as other treatments designed to influence brain activity directly. Included here are descriptions of neurosurgery and various neurostimulation techniques (deep brain stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, and vagal nerve stimulation), together with the evidence for their effectiveness as well as their proposed indications and adverse effects.

‘Child psychiatry’ covers the developmental period and includes how to assess and treat emotional and behavioural difficulties from infancy to 18 years. This chapter outlines the epidemiology of the different psychiatric presentations during childhood, with reference to both ICD-10 and DSM-5 classification systems. Aetiology of child psychiatric disorders is covered in detail both as part of the general chapter information and as part of the section for each specific disorder within the chapter, including attention-deficit hyperactivity disorder, autism spectrum disorder, and anxiety and depressive disorders. The specific learning disorders are also covered in this chapter. How to assess children as well as their families and the broader social and school context are discussed, including the role of different psychological assessments. The emphasis of treatment is different for child populations, with greater utilization of psychological treatments, both for the individual child as well as their families and broader systems, including schools.

‘Forensic psychiatry’ describes the branch of psychiatry concerned with the diagnosis and treatment of mentally disordered offenders, but also refers to all legal aspects of psychiatric practice, including the use of civil law. This chapter outlines current thinking in criminology and the causes of crime. It focuses on the association between mental disorder and crime, specific offender groups and the psychiatric aspects of specific crimes. It also explores psychiatric aspects of being a victim of crime. It covers the role of the psychiatrist in the criminal courts and the treatment of mentally disordered offenders and the management of violence in a range of health care settings. Lastly, it covers the status of risk assessment and the principles of preparing a psychiatric report for the courts.

‘Anxiety and obsessive–compulsive disorders’ covers the range of anxiety disorders encountered in adult general psychiatry, including generalized anxiety disorder, the phobic disorders, panic disorder, and agoraphobia. The chapter contains descriptions of the relevant clinical phenomenology, epidemiology, diagnosis, and classification, as well as aetiological formulations based on experimental psychological and neurobiological concepts. The chapter also provides an account of available treatment modalities, ranging from psychological treatments such as cognitive behaviour therapy to psychopharmacological approaches. Management strategies for the various disorders, based on current evidence-based guidelines, are outlined. A similar approach is followed for the description of obsessive–compulsive disorder as well as the related conditions of hoarding disorder and trichotillomania.

The psychiatric interview is at the heart of psychiatry, since it provides the cornerstone of diagnostic assessment as well as being central to establishing a therapeutic relationship. This chapter, ‘Assessment’, describes the goals, principles, and practice of psychiatric interviewing. There is a detailed review of the various components of a full psychiatric assessment (the history, mental state examination, physical examination and investigations), as well as descriptions of how the assessment process is tailored to suit different situations (e.g. in emergency departments, in primary care, or in the community). The chapter proceeds to discuss how the information collected during the assessment is recorded and communicated. The chapter ends with a description of the major standardized assessment methods and ratings scales used in psychiatry.

‘Global psychiatry’ discusses the global mental health movement. Across the globe, and especially in low- and middle-income settings, there is a high prevalence of untreated psychiatric illness. In lower resourced settings there is often the need to address the added influence of poverty. The chapter discusses the question of how to scale up services and models, including using lay mental health workers and also integration of mental health care into primary health care settings to better meet the needs of those suffering from psychiatric illnesses across the globe. Four areas are discussed in more detail—the HIV/AIDS pandemic, perinatal mental illness, child and adolescent mental health, and humanitarian emergencies.

This book provides an up-to-date, authoritative, and highly readable overview of psychiatry, suitable for all psychiatrists, as well as medical students, general practitioners, and other mental health professionals. Written by experienced clinicians, the new edition has been substantially rewritten and updated. The first three chapters cover the symptoms and signs of psychiatric disorders, psychiatric classification (including DSM-5), and how to conduct a psychiatric assessment. Chapters on ethics and the law (including the Mental Health Act), aetiology, and evidence-based approaches, set the scene for description of the major syndromes of adult psychiatry. In each chapter, description of the cardinal clinical features is accompanied by the latest evidence on epidemiology, aetiology, treatment, and outcome. Subsequent chapters cover child psychiatry, the psychiatry of old age, intellectual disability, forensic psychiatry, substance misuse, suicide, and self-harm, and psychiatry in medical settings. After a new chapter on global mental health, two chapters cover psychological and psychopharmacological treatments: their indications, efficacy, side effects, and mechanisms. The final chapter describes how psychiatric services are organized.

‘Psychological treatments’ is concerned with various kinds of counselling, psychotherapy, behavioural and cognitive therapies, and related techniques. Psychotherapy and psychological treatments have been an integral aspect of psychiatry from its beginning. The chapter describes the development and classifications of different psychological treatments and draws attention both to their differences but also the common factors on which they all draw. Some psychological treatments, such as counselling and crisis intervention and supportive psychotherapy, are part of routine psychiatric practice. The chapter also describes more specialized forms, including interpersonal psychotherapy, cognitive behaviour therapy, dynamic therapies, plus group and family therapies. Adaptations for treatment of elderly patients and children are covered and, lastly, superseded treatments of significant cultural and historical interest are outlined and the special ethical problems attending psychological treatments addressed.

‘Suicide and deliberate self-harm’ are important aspects of psychiatry. Suicide is among the 10 leading causes of death in most countries for which information is available and is the second most common cause of death in young people. This chapter outlines the epidemiology and methods employed for suicide, with attention to its variation across different cultures and over time. It presents the schemes for the assessment of suicide and policies for its prevention. Deliberate self-harm overlaps with suicide but is different in several important aspects, which are described, along with the range of strategies for managing deliberate self-harm as experienced in the hospital setting.

‘Dementia, delirium, and other neuropsychiatric disorders’ covers the disorders that share an ‘organic’ basis in the brain. It begins with a discussion of the concept of ‘organic’ in this context. A practical section follows, in which the clinical presentations of regional brain pathology are outlined, and the assessment of the ‘neuropsychiatric patient’ is discussed. Delirium, amnestic disorders, and dementia are then covered in turn. In each case, the causes, pathology, and epidemiology of these syndromes are discussed. Particular weight is given to the major forms of dementia, reflecting their prevalence and the recent advances in their understanding. Treatment of delirium is covered, but treatment of dementia is deferred until Chapter 19. Subsequent sections provide overviews of the other neuropsychiatric disorders, including cerebrovascular disorders, head injury, epilepsy, and intracranial lesions.

‘Psychiatry and medicine’ considers the relevance of psychiatry to the rest of medical practice. It covers the application of psychiatric knowledge and expertise in primary care and other general medical settings and also the psychiatric conditions associated with specific medical disorders. It addresses mind–body dualism and the epidemiology of psychiatric disorders in medical settings. It discusses the changing thinking around the classification and diagnosis of somatoform disorders and medically unexplained symptoms and the relationship with dissociative disorders. It outlines the nature of consultation–liaison services and deals in detail with both common comorbidities and the psychiatric aspects of medical and surgical conditions, including the organic disorders not covered in Chapter 14, and those related to women’s health.

‘Personality and personality disorders’ covers how personality influences and is influenced by psychiatric disorders, and also the disorders of personality. Personality refers to the wide range of ensuring qualities and behaviours that characterize an individual and that we generally use to recognize them. This chapter covers the varied theories of personality, both of personality types and personality development. It covers the classification of abnormal personalities and the range of personality disorders, along with their diagnostic criteria and how this classification is currently being subject to potentially radical reorganization. While the diagnosis of personality disorders remains controversial it is an essential tool in clinical psychiatry. Its course, impact, and treatment and management strategies are outlined, with particular attention paid to the impact of personality disorders on the outcome of other psychiatric and medical conditions and the ethical problems such disorders present.

‘Misuse of alcohol and drugs’ covers the clinical and scientific aspects of substance misuse and dependence, including definitions and classifications in ICD-10 and DSM-5, as well as the important issue of comorbidity with other psychiatric disorders (‘dual diagnosis’). The first section covers alcohol use problems, ranging from epidemiology, aetiology, and public health to the identification and evidence-based management of individual patients. There follows a description of substance use problems associated with a range of other drugs, including those medically prescribed, such as opiates, benzodiazepines, and gabapentin, as well as recreational substances such as stimulants, MDMA, psychedelics, and ‘legal highs’. The clinical features of problem drug use are linked to the pharmacology and neural effects of particular substances together with descriptions of current strategies designed to lessen the harms of substance use for both the individual and society.

‘Classification’ introduces concepts of mental illness before briefly reviewing the reasons for, and criticisms of, psychiatric classification. Key issues of reliability, validity, and stigma associated with classification are covered. After an overview of the history of classifications, the organizing principles of the two current major classification systems used in psychiatry (ICD-10 and DSM-5) are then outlined: the World Health Organization’s International Classification of Diseases (‘ICD-10’), and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (‘DSM-5’). Additional schemes, used in particular countries, are also briefly mentioned. Finally, the chapter summarizes how psychiatric classification may develop in the future, with particular reference to ICD-11, which is due in 2018 or 2019.

‘Psychiatry of the elderly’ covers the disorders which most affect older people. After an introduction to normal ageing and its psychological and biological correlates, the epidemiology of psychiatric disorders in the elderly is outlined. The principles and practice of psychiatry of the elderly are then described, focusing on the major disorders (other than dementia, which was covered in Chapter 14). We summarise the main features of assessments, services, and treatments, and how these differ from younger age groups. The treatment and management of dementia is an important aspect of psychiatry in the elderly, and both pharmacological and behavioural interventions are covered in detail.

‘Ethics and civil law’ is concerned with the ways in which general ethical principles, relating to matters such as confidentiality, consent, and autonomy, are applied in the care of people with mental disorders. The chapter also covers the law as it applies to psychiatry in the United Kingdom. Ethical principles require extra careful attention in psychiatry because some patients lack capacity and because of the power of involuntary treatment. The ethical principles of beneficence, non-maleficence, autonomy, and dignity are outlined with their inherent potential conflicts. The Mental Health Act for the detention of patients who are unable to recognize their need for treatment is also covered, as are some aspects of civil law that relate to the practice of psychiatry.

‘Bipolar disorder’ provides an account of the clinical and scientific aspects of bipolar disorder (‘manic depressive illness’). Identification of varying degrees of mood elevation is critical to the diagnosis of bipolar disorder to allow its distinction from unipolar depression, and the phenomenology and classification of manic states is described in detail. The range of aetiological factors involved in the development of bipolar illness is covered, from genetics and brain structure to psychology and life events. The efficacy of treatments both psychological and pharmacological in bipolar disorder is assessed, including new approaches with psychoeducation, atypical antipsychotic drugs, and anticonvulsant mood stabilizers. An additional section covers the clinically challenging treatment of bipolar depression. The evidence from clinical trials is then placed in the context of good clinical management of both the acute phases of bipolar illness as well as longer-term maintenance treatment.

Purpose Community treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients’ social outcomes and broader welfare. We tested the association between the duration of CTO intervention and patients’ long-term social outcomes. Methods A sub-sample (n = 114) of community-based patients from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48 months after randomisation. Multivariate regression models were used to examine the association between the duration of the CTO intervention and social outcomes as measured by the social network schedule, Objective Social Outcomes Index, Euro-Qol EQ-5D-3L (EQ-5D), and Oxford Capabilities Questionnaire for Mental Health. Results No significant association was found between the duration of CTO intervention and social network size (IRR = 0.996, p = .63), objective social outcomes (B = -0.003, p = .77), health-related quality of life (B = 0.001, p = .77), and capabilities (B = 0.046, p = .41). There were no between-group differences in social outcomes when outcomes were stratified by original arm of randomisation. Patients had a mean of 10.2 (SD = 5.9) contacts in their social networks, 42% of whom were relatives. Conclusions CTO duration was not associated with improvements in patients’ social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use.

Background In 2008, the Mental Health Act (MHA) 2007 amendments to the MHA 1983 were implemented in England and Wales. The amendments were intended to remove perceived obstacles to the detention of high risk patients with personality disorders (PDs), sexual deviance and learning disabilities (LDs). The AMEND study aimed to test the hypothesis that the implementation of these changes would lead to an increase in numbers or proportions of patients with these conditions who would be assessed and detained under the MHA 2007. Method A prospective, quantitative study of MHA assessments undertaken between July–October 2008–11 at three English sites. Data were collected from local forms used for MHA assessment documentation and patient electronic databases. Results The total number of assessments in each four month period of data collection varied: 1034 in 2008, 1042 in 2009, 1242 in 2010 and 1010 in 2011 (n = 4415). Of the assessments 65.6% resulted in detention in 2008, 71.3% in 2009, 64.7% in 2010 and 63.5% in 2011. There was no significant change in the odds ratio of detention when comparing the 2008 assessments against the combined 2009, 2010 and 2011 data (OR = 1.025, Fisher‘s exact Χ2 p = 0.735). Only patients with LD and ‘any other disorder or disability of the mind’ were significantly more likely to be assessed under the MHA post implementation (Χ2 = 5.485, P = 0.018; Χ2 = 24.962, P > 0.001 respectively). There was no significant change post implementation in terms of the diagnostic category of detained patients. Conclusions In the first three years post implementation, the 2007 Act did not facilitate the compulsory care of patients with PDs, sexual deviance and LDs.

This chapter covers the spectrum of routine monitoring, audit, service evaluation, and formal research. Routine monitoring is an essential task for all mental health professionals, and techniques to make it more palatable are explored, including using routine data for clinical supervision and monitoring team targets. Regular audit is described as an essential tool for logical service development and quality improvement. In the discussion of research, the importance of choosing the correct methodology and of paying attention to detail are stressed. In community psychiatry, sampling bias, regression to the mean, and the Hawthorne effect pose important risks. The hierarchy of research methods is outlined with randomized controlled trials (RCTs) at the top, preferably with either single- or double-blinding. Careful statistics and systematic reviews support evidence-based practice. In addition to experimental quantitative trials, there is a place for cohort and case control trials, as well as for qualitative trials to generate hypotheses.

In ACT, it was originally proposed that every patient should be looked after by the whole team and not have an individual case manager or key worker. Its originator, Len Stein, was convinced that key working fostered pathological dependence, and the idea has gained considerable prominence. We reject this proposal and explore the practical differences between the whole-team approach and more usual forms of multidisciplinary care. There is clearly a range of practice that can be adapted for different teams depending on the specific needs of their group of patients.

The chapter describes ways of understanding, predicting, and managing suicidality and self-harm in people with severe and enduring mental illness in contact with community outreach teams. Data on incidence are presented with evidence on associations with factors such as demographics, diagnosis, co-morbidity, and life events as a way of identifying risk factors. Validated tools and frameworks for assessment are presented and critiqued with research evidence for the effectiveness of interventions. The chapter concludes with a case study, care plan, and risk management plan of a man whose life has been devastated by psychotic illness.

This chapter covers interventions with people who need encouragement with cooking or shopping due to motivational, cognitive, and information-processing difficulties associated with severe mental illness. Community outreach allows an in vivo approach to supporting these tasks that enable people to survive outside of hospital and which contribute to their quality of life. Functional assessment, activity analysis, and collaborative goal setting are discussed, together with ways of measuring progress. The evidence base for interventions such as social skills training is critiqued. A case study and summary care plan illustrate typical approaches with patients in the community.

This chapter takes the assertive community treatment (ACT) model of community outreach as a starting point and examines what can and what cannot be varied and still achieve good results. ACT has a special place in community outreach as it was the first model of care confirmed by research, and controversy has raged about the need, or otherwise, for ‘model fidelity’. The chapter identifies the core ingredients—small caseloads, in vivo psychosocial treatments, mainstreaming, flexibility, 24/7 availability—and examines the evidence for and against them. It pays particular attention to the roles of support workers and the medical member of the team. Later developments such as flexible assertive outreach (FACT) are also described.

This chapter deals with the controversial issue of personality disorder, whether these are meaningful diagnoses and, if so, how they affect management. The classification is entirely pragmatic: the definitions and classification in both ICD-10 and DSM-V are outlined along with proposals to abandon categories in favour of a dimensional approach. The issue of treatability is explored, but we conclude that ignoring personality and personality disorders is not a viable alternative for outreach workers. Most of the chapter deals with the management of dissocial personality disorder (usually in men) and borderline personality disorder (usually in women). Specific psychotherapies are not dealt with here; the focus is on how to use team work to manage individuals with severe mental illness and disorders of personality.

This chapter aims to guide practitioners and managers in setting up and reviewing community outreach services for people with severe mental illness from a non-technical service planning perspective. Examples of different service configurations within a comprehensive local system are given, with some observations on their relative merits and drawbacks from evaluations. Service models and structures are important for providing a framework for delivering quality care, yet from the perspective of the service user, many of these service details—integrated care, specialization, caseload size, staffing mix, ownership of beds, and degree of shared caseload—are invisible. For people with severe mental health problems, patients and carers value the principles of good community-based care, such as access, responsiveness, consistency, and continuity.

The chapter describes ways of managing self-neglect in psychotic patients living in their own homes. Incidence in the general and mentally ill populations is poorly reported in the literature. The impact of the negative symptoms often found in schizophrenia on behaviour and activities of daily living, as well as consequences for physical health and social inclusion, are presented. The case study in this chapter illustrates ways to document assessed risk and to formulate interventions. Interventions need to be presented practically and sensitively within established relationships.

This chapter discusses the politics, incidence, assessment, and management of challenging, hostile, and violent behaviour from the perspective of practising community outreach with people with more severe and enduring mental health problems. As a way of establishing risk factors, data are presented on incidence of hostility in both community and inpatient settings along with the research evidence on associations between severe mental illnesses, such as psychosis, substance misuse, and violence. Methods and frameworks for risk assessment are presented and critiqued. Risk management techniques with individuals are demonstrated and illustrated through case studies. Community team training, policies, procedures, support, and supervision are presented as examples of best practice.