Depression, as a heterogeneous collection of disorders, is likely to include subgroups that are more genetic in origin. In common with other neuropsychiatric disorders such as schizophrenia, Alzheimer's disease and Huntington's disease, earlier age at onset in depression is associated with higher genetic loading and poorer long-term outcome. Adolescents and young adults with depression are also at high risk of developing a bipolar illness. This article reviews depressive illnesses that occur for the first time in adolescence and young adulthood. Case studies are used to discuss atypical presentations and the evolving concept of bipolar-spectrum disorders.

Migration and its associated processes can produce considerable stress on those who are migrating as well as on those around them. Depression should be a common sequel of the process, but is not consistently found to be so. This paper reviews the literature and suggests that various vulnerability factors, including culture shock and changed cultural identity, can play a role in the genesis of depression. Clinicians must be aware of patterns of migration and resilience factors in order to plan any intervention strategies. Stresses due to political and economic factors will have differing influences on the mental state of individuals. One possible contribution may be a discrepancy between aspiration and achievement, which can result in poor self-esteem, leading to depression.

Randomised controlled trials and surveys of patients' experiences indicate that the recognition and prompt treatment of early warning signs of relapse in selected patients with bipolar affective disorder are effective in lengthening the time to the next manic relapse and improving function. Improvements in patient coping mechanisms allied to these techniques can prevent some depressive episodes. The intervention is described in some detail and conditions under which it is most likely to be effective or to fail are reviewed. If the intervention is to be successful, patients must be carefully selected, early warning signs and symptoms must be analysed in detail, it must be a central feature of the care plan and the service must be ready to respond quickly to a patient's early warning symptoms.

People who survive into late life with chronic or relapsing illnesses, which had their onset in youth or middle age, have special needs. In the past, those most severely affected often lived out their lives in mental hospitals. The mental hospital closure programme led to discharges to alternative care, and the successes and failures of these have been monitored by some services. Subsequent generations are at risk of falling between the care of general psychiatry, rehabilitation psychiatry and old age psychiatry. These patients are uniquely disabled by a combination of personal, social, mental and physical health disadvantage. The Royal College of Psychiatrists has produced guidance to highlight the special needs of these ‘graduates', encouraging every locality to investigate its own performance in their care and bring it into line with best practice in the light of local strengths and resources.

‘Recovery’ is usually taken as broadly equivalent to ‘getting back to normal’ or ‘cure’, and by these standards few people with severe mental illness recover. At the heart of the growing interest in recovery is a radical redefinition of what recovery means to those with severe mental health problems. Redefinition of recovery as a process of personal discovery, of how to live (and to live well) with enduring symptoms and vulnerabilities opens the possibility of recovery to all. The ‘recovery movement’ argues that this reconceptualisation is personally empowering, raising realistic hope for a better life alongside whatever remains of illness and vulnerability. This paper explores the background and defining features of the international recovery movement, its influence and impact on contemporary psychiatric practice, and steps towards developing recovery-based practice and services.

Down's syndrome is the most common genetic disorder seen in clinical practice: about 94% occurs because of non-disjunction of chromosome 21 and 3–5% because of translocation. Individuals increasingly survive to middle and old age, probably because of advances in medical treatment and improved living conditions. People with Down's syndrome have an increased risk of developing Alzheimer's disease in middle age. Within ICD–10 and DSM–IV classifications there is no consensus on the diagnosis of dementia in people with learning disability. New treatments have been licensed for use in mild to moderate Alzheimer's disease (e.g. acetylcholinesterase inhibitors and memantine). The comorbid picture of Down's syndrome and Alzheimer's disease presents a unique challenge to the clinician in both diagnosis and management.

The risks and benefits of psychopharmacological treatment in pregnancy need careful consideration. Conventional antipsychotics and tricyclic antidepressants are relatively safe for the foetus. Selective serotonin reuptake inhibitors appear to be safe, but mood stabilisers such as lithium, sodium valproate and carbamazepine are associated with increased foetal malformations. Benzodiazepines in the first trimester are teratogenic, and in high dosage can also cause withdrawal symptoms, hypotonia and agitation in the newborn. Women taking atypical antipsychotics should be switched to conventional antipsychotics before they conceive. In women with long-term mental illness necessitating psychotropic medication, effort should be made to stop polypharmacy and non-essential medication (e.g. benzodiazepines) and to decrease the dose of essential drugs, after full assessment. There is rarely a valid reason to stop essential drug treatment during pregnancy.

Almost all psychiatric training programmes include a journal club. These clubs are experiencing a revival as a result of the introduction of a critical review paper into Part II of the MRCPsych examinations. Successful clubs are generally those with a single designated leader and mandatory attendance; provision of food is also helpful. A number of possible formats are discussed, designed to make the club an entertaining and stimulating experience.

Training in general and forensic psychiatry in the assessment and treatment of sex offenders is in need of considerable improvement. Although most sex offenders are not mentally ill, many are subject to substance misuse, abnormal personality traits, personality disorder, learning disability or dysphoric mood, and in some organic factors will be involved. Comprehensive assessment of sex offenders includes a full history and mental state evaluation, obtaining a collateral history from other sources, observation, psychometric testing, and psychophysiological methods of assessment, including penile plethysmography. Trials of the use of the polygraph are also under way. The treatment of sex offenders, especially those with paraphilias, may include medication with selective serotonin reuptake inhibitors or anti-libidinal agents. Ethical considerations can be problematic, but a balance can often be found between the welfare of the offender and the safety of the public.