I comment on two papers by Koenig and colleagues that advocate the integration of religion into routine psychiatric practice. In my opinion, their selective overview of research, although useful, lacks balance. It omits any mention of the literature on worldwide scandals over child sex abuse (and other abuses of power) perpetrated and facilitated by religious authority within several faith groups. There is no mention of damaging ‘religiously informed’ treatments such as sexual orientation conversion therapy, which is still practised in the UK despite widespread condemnation. Their recommendations for clinical practice conflate association with causation. They do not offer practice guidance on managing the impact of power imbalances associated with religion in multicultural societies. In summary, despite more than a decade of research and debate, there are still no generally accepted ways of avoiding boundary violations where psychiatrists introduce religion into their clinical practice.

The private ownership of firearms for participation in shooting sports, subject to a rigorous process of certification by the police, is not uncommon in the UK. Primary care medical involvement in this process is currently a contentious issue. The mental health of firearms owners is clearly germane to public safety: suicide is by far the greatest concern, alongside security breaches. Homicide committed with legally held firearms is very rare: there is very little cross-over between legitimate shooting sports and crime involving firearms. The perpetrators of family annihilation and single-incident mass killings using firearms in the UK have not been known to psychiatry, although a minority have been found to be mentally disordered post hoc. Regarding suicidality, there is little if any difference between those at risk who own firearms and those who do not, excepting that firearm suicide attempts are highly likely to be fatal. Guidance is offered in this article on the identification of patients who own firearms, the evaluation of risks and how to manage these in practical terms.

Jones et al's review of the assessment and management of the neuropsychiatric manifestations of Parkinson's disease serves as a practical guide to clinicians. This commentary outlines some of the underlying neuroscience and psychological sequelae of this range of conditions, offering a takeaway message to the clinician with an interest in Parkinson's neuropsychiatry.

Psychiatrists live and work in complex, clinically challenging times. Their paperwork is geared increasingly towards defensive practice, key performance indicators and risk assessment forms. Somewhere in the process, detailed understanding of patient experience and clinical formulation based on key psychiatric expertise and skill in mental state examination have taken a backseat. I review the history behind the Present State Examination, the realisation in the 1980s of the need for a common psychiatric language internationally and the current position on phenomenology in psychiatry curricula in the UK. I conclude that it is time to think seriously about a return to basics in psychiatric phenomenology and psychopathology.

Ann Mortimer's article on gun control and licensing in the UK makes some important points concerning the role of the psychiatrist during the licensing process and the complexities surrounding this. However, the risk-assessment framework (describing low, medium and high risk) that she proposes is problematic.

Bright light therapy is an accepted and commonly used treatment for seasonal affective and circadian rhythm disorders. In the past 20 years, researchers have examined the effectiveness of bright light therapy in improving depression and agitation in older adults with dementia. This article provides clinicians with a summary of the neurophysiology of bright light therapy, bright light research considerations, an evidence-based bright light protocol, problems related to bright light therapy, and clinical implications for bright light therapy in older adults with dementia. Bright light exposure is a safe, non-pharmacological treatment that is currently underutilised in this population. Clinicians may find bright light therapy beneficial as a primary or adjunctive treatment in reducing depression and agitation in older adults with dementia.

Sialorrhoea (hypersalivation) is a common adverse effect of clozapine. If severe, it can affect patients' quality of life and adherence to the treatment. Clinicians therefore need to proactively manage this effect. At present, no drugs are licensed to manage clozapine-induced sialorrhoea, although there are many off-label treatment options, with variable effectiveness. Anticholinergic medications are commonly prescribed for it, but they have limited effect and can worsen constipation. This article gives a brief overview of other practical and pharmacological management options.

General adult psychiatrists are largely responsible for the care of patients with personality disorders in community and in-patient settings, and this can be associated with diagnostic and management challenges. In the first of two articles focusing specifically on borderline personality disorder (BPD), we summarise the core clinical features of the disorder and discuss appropriate diagnostic practice.

Suicide is a complex issue that is sparking increasingly more debate in contemporary society. There is need for an open discussion on the concept of rational suicide, specifically in relation to psychiatric disorders, so as to resolve the conflict between the duty of care of psychiatrists and the autonomy of patients. To be able to conduct such a discussion in an objective manner, we must first be made aware of the potential prejudices that we harbour on the topic of suicide as a result of our societal and historical background. A historical and philosophical approach to the topic, through careful examination of the topic of suicide in the texts of Plato, helps create such an awareness.

This article considers sexuality in older adults and the associated stereotypes and stigmas that lead to this area being underappreciated. Normal physiological changes in ageing are discussed and how they can cause sexual dysfunction. The elderly population has a higher burden of comorbid physical illness and this review considers evidence on the interplay between physical health and sexual health. Mental illness is also strongly linked with sexual functioning and is discussed, as is the evidence on psychotropics and sexual side-effects. Attitudes on sexuality in long-term care settings are highlighted and approaches to managing sexual disinhibition are included.

In this article we re-examine the conclusions of our article on advance statements in adult mental healthcare that was published in 2010 in the light of new literature published in the intervening decade. We explore the results of studies on the implementation and effectiveness of advance statements in adult mental health services, and then summarise recommendations for legislative changes from the Independent Review of the Mental Health Act 1983 that are relevant for England and Wales.

There is considerable work being carried out in neuroscientific laboratories to delineate the mechanisms underlying single-gene disorders, particularly those related to intellectual disability and autism spectrum disorder. Many clinicians will have little if any direct experience of this type of work and so find the procedures and terminology difficult to understand. This article describes some of the laboratory techniques used and their increasing relevance to clinical practice. It is pitched for clinicians with little or no laboratory science background.

Psychopathology is an integral part of the theory and practice of psychiatry. This commentary explores the importance of psychopathology, especially with regard to clinical practice. The concept of lifeworld is introduced as an important component of attributing meaning to a person's experience of mental disorder. It is also argued that the advance of neuroscience does not preclude the importance of psychopathology.

The principal manuals for psychiatric diagnosis have recently been updated (ICD-11 was released in June 2018 and DSM-5 was published in 2013). A common diagnostic quandary is the classification of people with chronic low mood, especially those with repeated self-harm (‘emotionally unstable’ or ‘borderline’ personality disorder). There has been a great interest in use of type II bipolar affective disorder (‘bipolar II disorder’) as a less pejorative diagnostic alternative to ‘personality disorder’, despite the radically different treatment options for these disorders. DSM-5 (but not ICD-11) clearly distinguishes between borderline personality disorder and bipolar II disorder, indicating that intense emotional experiences (such as anger, panic or despair; irritability; anxiety) should persist for only a few hours in people with a personality disorder. Both manuals now use the term ‘borderline personality disorder’ rather than ‘emotionally unstable personality disorder’. The diagnostic criteria for cyclothymic disorder remain confusing.

We consider some advances in relational and affective neuroscience and related disciplines that attempt to resolve some fundamental aspects of the mind–brain problem. We consider the key role of affect in generating consciousness and in meeting our essential survival needs; the neural correlates of relating; how self and other are represented in the brain and awareness of self and other is generated through interoceptive predictive processes. We describe some leading models of the generation and purpose of consciousness, linking theories of affective and cognitive consciousness. We discuss psychiatric and psychotherapeutic innovations arising from this research, new integrated biopsychosocial interventions and the obstacles to be overcome in applying these models in practice.

The classification of mood and personality disorders has become unnecessarily complicated. It has become bogged down by well-meaning but unhelpful subcategories that puzzle the will of clinicians to make useful judgements. The answer is to think of bipolar, depressive and personality disorders as each constituting a spectrum of severity and not to be too preoccupied with individual labels. It would also be useful to avoid the diagnostic chimera of borderline personality disorder, a condition that defies proper classification.

People with intellectual disability can have a range of common mental health difficulties that sit at the interface of two psychiatry subspecialties: intellectual disability and general adult psychiatry. Clinical presentations, comorbidities and complexities can affect the setting of boundaries between the two disciplines. This article touches on current concepts, drives for inclusion of people with intellectual disability in mainstream psychiatry services and some of the difficulties at the interface. It focuses on potential solutions for managing this interface between the two subspecialties.

Most human actions, including suicide, are motivated by variable mixes of rational and irrational factors. Notwithstanding debates about rational suicide, the vast majority of people who die by suicide suffer deeply beforehand. Those who present to mental health services in suicidal crises do so in search of treatment, care and support. It is a privilege to try to provide it.

Caring for people in distress or illness is emotionally draining and physically demanding. This article focuses on the experiences and needs of health service staff as professional carers. It overviews the current circumstances in the UK and links readers to the findings of: the Stevenson/Farmer Review of 2017; the report of the General Medical Council on the state of medical education and practice of 2018; and the British Medical Association survey of doctors and medical students published in 2019. We review the sources of stress that affects healthcare practitioners and introduce the concepts of emotional labour, psychological safety and psychosocial resilience. We draw attention to the vital importance of social support and leadership to protecting healthcare staff. We conclude this review of the topic by outlining a stepped model for actions that aim to: develop staff of healthcare services and help them to thrive at work; support staff who are struggling at work; and intervene to care for staff who are distressed or unwell whether they are continuing to work or not.

This article aims to clarify what ‘care closer to home’ means to a community psychiatrist. Care closer to home can be operationalised as primary care liaison and the article reviews experience across England of how a liaison service can work with the recently organised primary care networks. Key competencies needed for liaising with primary care are discussed using seven questions, including bias mitigation, reducing bed-days, consultation skills, knowledge of emerging treatments and reducing administrative overheads while improving access.