Domestic abuse – abusive behaviour perpetrated by an adult towards another adult to whom they are personally connected (e.g. partners, ex-partners or family members) – damages mental health, increases mental health service use and challenges clinical management. Training and guidance for mental health professionals on identifying and responding to patients exposed to domestic abuse are available, but there has been less development of resources for mental health professionals in identifying, assessing and responding to perpetrators of domestic abuse. In this article, we describe a framework for responding to domestic abuse perpetration in clinical settings in general adult mental health services, aimed at improving practice. This could support mental health professionals in sensitive enquiry and assessment for domestic abuse perpetration, and guide appropriate responses, as part of routine training and continuing professional development.

The categorisation of personality pathology into discrete disorders has been an enduring standard. However, dimensional models of personality are becoming increasingly prominent, in part owing to their superior validity and clinical utility. We contend that dimensional models also offer a unique advantage in treating mental illness. Namely, psychotherapy approaches and the components of dimensional models of personality can both be arranged hierarchically, from general to specific factors, and aligning these hierarchies provides a sensible framework for planning and implementing treatment. This article begins with a brief review of dimensional models of personality and their supporting literature. We then outline a multidimensional framework for treatment and present an illustrative fictitious clinical case before ending with recommendations for future directions in the field.

This article discusses sceptical arguments about measurement scales. Measurement scales are part of a promising agenda of openness, transparency and patient and public involvement (PPI) in medical research, but have received critical, sometimes hostile attention from anthropologists. This is because scales repackage localised cultural assumptions about distress as something universal and pan-human and have the capacity to reshape people's interior lives in unhelpful, possibly harmful ways. We take as an example the Patient Health Questionnaire-9 (PHQ-9). Use of the PHQ-9 is currently mandated by major funders. But its history suggests flawed PPI and a lack of openness. The article suggests a constructive role for anthropology in mental health research, using ethnographic evidence and theory to show how, although they have their uses, mental health scales should not be regarded as inert or harmless.

In 1978, William Alwyn Lishman's Organic Psychiatry: The Psychological Consequences of Cerebral Disorder was published, fostering the development of neuropsychiatry and leading to the recognition of Lishman as the father of neuropsychiatry. This article is a narrative account of his personal struggles, as well as conceptual dilemmas he dealt with while writing this book, and how through its four editions it has evolved to become an anchor for psychiatrists as they seek to develop understanding of the workings of the brain, and a beacon for them when they discuss clinical implications of diagnosis with patients and families.

Although fundamental advances in the life sciences raise the exciting possibility of novel translational therapies, optimal evidence-based usage of established treatments should be the bedrock of current clinical care. The authors argue that there are instances where well-established treatments are ‘underused’ in psychiatry; electroconvulsive therapy, clozapine and lithium are exemplars of this. This article explores possible reasons for, and strategies to address, this underuse.

Metabolic dysfunction has been long associated with severe mental illness (SMI), often viewed as a comorbidity to be managed. However, emerging evidence suggests that metabolic dysfunction, particularly at the mitochondrial level, may be a foundational element in the pathophysiology of neuropsychiatric disorders. This commentary expands on the current understanding by exploring the brain energy theory of mental illness, which posits that mitochondrial dysfunction is central to both metabolic and psychiatric conditions. The roles of insulin resistance, chronic stress and environmental factors are highlighted as shared biopsychosocial determinants that contribute to deterioration in both metabolic and mental health. The therapeutic potential of the ketogenic diet is discussed, particularly its ability to improve mitochondrial function and alleviate psychiatric symptoms. This shift in perspective, from viewing metabolic dysfunction as a secondary concern to recognising it as a root cause of SMI, has significant implications for clinical practice and research. By focusing on bioenergetic deficits and mitochondrial health, psychiatry may advance towards more effective, integrated treatment approaches that target the underlying cellular dysfunctions driving both metabolic and mental illnesses.

E-mental health tools are a promising solution to reducing the high prevalence of perinatal mood and anxiety disorders and addressing barriers faced by women seeking professional help. This article summarises the main e-health tools used in perinatal mental healthcare, including examples of evidence-based tools for assessment, prevention and treatment of such disorders. We also highlight the main characteristics of the development process of e-mental health tools, which are based on cognitive–behavioural therapy, as well as the ethical concerns to be considered with their use and integration in healthcare systems.

Natoli et al present a comprehensive higher level framework aligning dimensional personality pathology assessment with treatment delivery through a hierarchical model. Their approach integrates common therapeutic factors with trait-specific interventions, offering a promising pathway for clinical implementation. Despite strong evidence supporting the superiority of dimensional models and the field's shift towards dimensional classification, they remain largely unused in clinical practice after a decade, despite evidence of clinical utility and learnability. Although the authors’ framework demonstrates how dimensional approaches could work in practice, particularly through matching severity to treatment intensity and traits to specific interventions, healthcare systems require evidence of improved clinical outcomes before undertaking systemic change. Without controlled trials demonstrating enhanced treatment effectiveness, dimensional models risk remaining theoretically superior but practically unused. While healthcare systems remain tethered to categorical diagnostic approaches, the authors’ framework offers a practical pathway for implementing dimensional models – one that now requires testing in real-world settings.

The article reviews some basic statistical concepts used in medicine, including the mean, standard deviation, sensitivity and specificity. Using this background the authors describe how these can be applied to cognitive tests, taking the Montreal Cognitive Assessment (MoCA) as an example. Two different approaches to using the MoCA in diagnosing dementia are considered: one using a fixed cut-off score, the other taking account of normative data about the effects of age and educational level on MoCA scores. It is recommended that clinicians assessing cognitive function should not rely on a fixed cut-off score, but where possible compare the patient's result with those of people of comparable age and educational background, although normative data of this kind are not always available.

Delirium frequently occurs among hospital in-patients, with significant attributable healthcare costs. It is associated with long-term adverse outcomes, including an eightfold increased risk of subsequent dementia. The purpose of this article is to inform clinicians of the best practices for spotting, stopping and treating delirium and provide guidance on common challenging clinical dilemmas. For spotting delirium, suggested screening tools are the 4 ‘A's Test (in general medical settings) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Prevention is best achieved with multicomponent interventions and targeted strategies focusing on: (a) avoiding iatrogenic causes; (b) brain optimisation by ensuring smooth bodily functioning; (c) maintaining social interactions and normality. Non-pharmacological approaches are the first line for treatment; they largely mirror prevention strategies, but the focus of empirical evidence is on prevention. Although sufficient evidence is lacking for most pharmacological approaches, an antipsychotic at low doses for short durations may be of utility for highly distressing or high-risk situations, particularly in hyperactive delirium, but only as a last resort.

Clinical guidelines recommend avoiding the use of medications to manage personality disorder. In clinical practice, however, substantial amounts of medication are used. In this article, we summarise the recommendations of guidelines published in various countries in the past 15 years. We review the evidence from randomised controlled trials and recent reviews, discuss the discordance between guidance and clinical practice and give recommendations on what a clinician should consider if they choose to prescribe in cases of severe disturbances in mood or behaviour despite the lack of evidence.

The Mental Health Act assessment or interview is a commonplace process in psychiatric services during which significant decisions are made about a person’s care and liberty. Individuals have reported negative experiences of being subjected to these assessments, at times even influencing their ongoing relationship with healthcare and recovery. A 2018 independent review of the Mental Health Act 1983 (MHA) for England and Wales identified numerous areas for practice improvement, including the identification of epistemic injustice as part of current MHA processes. Nevertheless, the assessment process has received little attention on how it is conducted, with scant clinical guidance, training or research available on the subject. In this article the authors propose seven principles that assessors can incorporate into interviews to improve the way in which the MHA assessment is conducted. These principles have been drawn from a dialogical and relational approach to psychiatric care called Open Dialogue. A dialogical approach to MHA assessment could improve experiences of being assessed, information gathered, and, by preserving therapeutic relationships, give better longer-term outcomes.

The large volume of seemingly conflicting guidance on the management of borderline personality disorder (BPD), combined with the ongoing shortage of specialised resources, can make the task feel like an exclusive undertaking that the general psychiatrist is underprepared for. In this article, we distil current evidence to submit that sound psychiatric management principles used to treat all serious and enduring mental disorders (diagnostics, comorbidity management, rational pharmacotherapy and dynamic risk management) are readily applicable and particularly therapeutic for BPD. We offer actionable practice guidance that we hope will render the clinical management experience a more lucid and rewarding one for both practitioner and patient.

Although most people experiencing psychosis are not violent, a diagnosis of a psychotic disorder is associated with an increased likelihood of violence. Some progress has been made in delineating the nature of this association, but it remains unclear whether specific types of psychotic experience make a specific contribution to the propensity for violence. Just as the phenomenological approach has produced a fuller understanding of psychotic experiences (that can inform improved aetiological and interventional frameworks), the authors assert that such an approach (with its closer attention to the full extent of the patient's subjectivity) has the potential to advance our understanding of the relationship between psychosis and violent behaviour in a way that has clinical applicability. This article examines this potential by overlaying approaches to the phenomenology of psychosis with a framework for the subjectivity of violence to demonstrate how a fuller explanatory formulation for violent behaviour can be derived.

Until recently, statistical consultants did not have to worry about being replaced by artificial intelligence. There was no statistical analogue to ‘Dr Google’ before ChatGPT arrived on the scene. Although ChatGPT (most of the time) adequately responds to basic queries such as the assumptions of different statistical tests or summarises relevant manuals on statistical software providing clear instructions with point-and-click software such as SPSS, there are many important aspects of statistical consulting that ChatGPT does not cover. This tutorial article is about these aspects: a summary of what statistical consulting is, its purpose and possible settings during the empirical research cycle, the role and responsibilities of the consultant and the client, how to ensure a good consulting experience, how to prepare for a consulting session, typical questions and more. The article was written for researchers who are considering contacting a statistician for the first time and aims to facilitate a good and fruitful consulting experience for all parties involved.

Primary hyperparathyroidism (PHPT) is the presence of hypercalcaemia with an elevated or inappropriately normal parathyroid hormone level. In clinical psychiatry this is often detected on routine blood investigations. This article aims to help mental health professionals understand the relevance of PHPT to psychiatry and offers some guidance about further management of patients presenting with this endocrine abnormality in mental health settings. PHPT can be associated with both mental and physical health problems in some individuals, making it a crucial diagnosis that should not be overlooked.

Navigating the complex relationship between violence and psychosis can frequently be challenging. Psychiatrists may find assessing and managing the risk of violence in this context daunting. In their article on the topic, Anderson et al helpfully summarise the role that psychopathology can play in this process. However, although careful elucidation of an individual's experiences may assist in the nuanced formulation of their risk and could offer a specific focus for interventions, the approach has potential shortcomings in certain settings. For some phenomena the link with violence is unclear and it may be constellations of symptoms that are important. Causal pathways are not always linear and there may be important mediators linking psychopathological features to behavioural outcomes. In the resource-limited settings in which many contemporary health services operate, a detailed assessment of psychopathology may be hampered by time or other constraints. Alternative, more scalable solutions may therefore be needed in particular scenarios.

Qualitative research methods, defined as the collection and analysis of non-numerical data to understand concepts and experiences, are often used to inform mental health practice and policies. When utilising qualitative research methods, it is important that the researcher uses an explicit theoretical framework to guide the study. A theoretical framework informs how researchers engage with a topic or problem, report on their work with participants, describe key concepts and address assumptions within the research questions and procedures. In this article, we describe the basic concepts underpinning three of the most commonly used frameworks in mental health research: positivism, interpretivism and critical realism. We also describe how these theoretical frameworks may guide the qualitative process, including the theoretical and methodological approaches chosen and the ways in which these theoretical frameworks can be applied in practice. To enhance understanding of these frameworks, we include examples of how such frameworks can be used in qualitative mental health research.

This article examines the complex phenomenon of self-harm, exploring its motivations, theoretical underpinnings and the intricate transference and countertransference reactions that arise in clinical settings. It aims to integrate psychiatric understanding with contemporary theories of the impact of trauma on both the body and the mind, to deepen the knowledge of self-harm and increase the effectiveness of treatment approaches. The article argues for a nuanced view of self-harm and emphasises the need for compassionate, well-informed care. By addressing the psychodynamics of self-harm, the article seeks to improve therapeutic outcomes and foster an empathetic and effective clinical response. Fictitious case studies are used to illustrate these concepts, demonstrating the critical role of early attachment experiences and the challenges faced by healthcare providers in management.

Suicidal and self-harming behaviours present a significant challenge for mental health services. Recent national guidelines advocate abandoning tools based on box-ticking and a move towards a personalised psychosocial assessment. This article examines evidence from theoretical and empirical research in this area and attempts to integrate it by introducing the source–problem–solution–motive (SPSM) model. The model, which builds on the contributions of other suicidologists, specially Jean Baechler, could be used as a framework for the assessment and management of these behaviours. The four stages of the model provide a comprehensive approach that enables an exploration of the internal logic of the behaviour. The model covers ‘because’ and ‘in-order-to’ motives. This allows a personalised approach, but also a structured one that can be taught and generalised.