Up to a third of patients with schizophrenia develop treatment resistance. Clozapine has been established as the most effective antipsychotic medication for treatment-resistant schizophrenia. However, it is significantly underutilised in this population. Possible reasons include clinicians' lack of experience with the drug and negative attitudes towards it. African-Caribbean patients are less likely to be treated with clozapine compared with their White counterparts and more likely to have treatment discontinued due to perceived risk of agranulocytosis. This paper discusses the current evidence relating to the underuse of clozapine and factors responsible for this.

Engaging patients in first-episode psychosis services is critical in maximising the effect of early intervention and establishing a framework for longer-term treatment. Biopsychosocial assessments determine a working diagnosis and inform evidence-based treatment. Atypical antipsychotics should be used at doses that maximise therapeutic benefit and adherence while minimising side-effects. Patients are helped to construct a narrative of their illness, including a shared understanding of the contribution of biological and environmental risks, and early warning signs. Common comorbid conditions, including depression, suicidal ideation, substance misuse and anxiety, should be addressed. Management of comorbid borderline and antisocial personality disorders is difficult; their nexus with psychosis is discussed. Cognitive–behavioural therapy is a mainstay of treatment, with specific interventions developed for problems typical in first-episode presentations. Core psychosocial interventions include psychoeducation, vocational and educational support, family interventions and multimodal group programmes.

Agitation in psychiatric settings, particularly in psychosis, presents a staggering challenge for clinicians, who must both manage the patient's acute symptoms and simultaneously make an accurate diagnosis. Too often, the management of the former confounds the latter. Patients are very often sedated medically, which masks their underlying condition, rendering accurate diagnosis delayed and inherently difficult. Significant data are available regarding both pharmacological and non-pharmacological interventions for agitation that maximise symptom control while minimising confounding side-effects. In this article, a review of the historical evolution of agitation management in psychotic illness is presented, followed by an evidence-based clinical guideline for managing agitation in psychosis in the USA.

The US Supreme Court's complaint in 2005 about inconsistencies in research into adolescents' decision-making capacity did not take into account the different demands placed on adolescents by controlled situations and unstructured situations. Apparent inconsistencies in research into adolescents' capacity in treatment situations and in trial situations may simply be due to methodological differences between the two bodies of research. Apparent inconsistencies in the law regarding presumptions about adolescents' capacity are related to differences in societal objectives across decision-making contexts.

Clozapine remains underutilised as the only antipsychotic for treatment-resistant schizophrenia, despite liberal National Institute for Health and Clinical Excellence guidelines for its consideration. Bearing in mind its monitoring requirements and poor tolerability, suggestions are made for patients who fail to improve on other antipsychotic drugs. Clozapine may be offered to apparently unsuitable patients, although this is fraught with difficulty. A realistic appraisal of the alternatives is essential in this situation. Optimising plasma clozapine levels, alongside the use of rehabilitative interventions and adjuncts as necessary, will maximise efficacy, and there are numerous options to minimise side-effects. Clozapine requires a lengthier trial than other antipsychotics and discontinuation should be avoided if possible, as the results are generally very poor. Established successful clozapine treatment can induce substantial functional gains which accrue with time: patients are retained in treatment and relapse is prevented. Such optimal outcomes justify the initial effort expended by all.

Treatment of psychotic agitation is an area that is very poorly evidenced, principally because research evidence from patients with moderate agitation may not generalise to the more severely agitated patients. There is a significant gap between current treatment recommendations and what is seen in clinical practice. There are also big differences in clinical practice between different units treating seemingly similar patient groups. This commentary considers possible reasons for these findings and also discusses non-pharmacological interventions, which probably contribute more to the management of psychotic agitation than does the choice of one antipsychotic drug over another.

Recovery approaches are now being developed in forensic as well as general mental health services. These are welcome developments that offer new ways of working with a socially excluded group of patients. However, the theoretical basis of recovery, with its individual humanistic ethos, may struggle to articulate the unique problems of forensic service users. In this article, we describe those problems and propose a ‘third way’ of thinking that bridges the recovery agenda (which looks for the best in people) and the forensic agenda (which must consider the worst in people). We propose using a ‘narrative approach’, which sees the forensic service user's offence and cruelty as part of their human story. We link this explicitly with the work of Dan McAdams and his concept of the redemption narrative.

Delusions are a key symptom of psychosis and they are frequently distressing and disabling. Existing treatments, both pharmacological and psychological, are only partially effective. It is important to develop new treatment approaches based on theoretically derived and empirically tested processes. Delusions are associated with a reasoning bias: the jumping to conclusions (JTC) bias involves gathering limited information to reach decisions. It is proposed that this bias influences appraisals of psychotic experiences leading to the formation and persistence of delusions. Existing treatments do not influence JTC. A new intensive treatment approach – ‘reasoning training’ – is described. It aims to encourage participants to gather information, consider alternative explanations for events and review the evidence before reaching a decision. Preliminary data suggest that it is possible to change the JTC bias and that this improves belief flexibility and may reduce delusional conviction. The concepts and methods of this new approach have implications for clinical practice.

Transference reveals the mental state of the other to us through our countertransference. Our emotional responses to the transference relationship are different depending on the degree of disturbance evoked in us. Reflecting on our countertransference can convey emotional insight into the nature and meaning of the transference as a way of understanding the emotional experiences of the other.

It has become acceptable for psychiatrists to say that they simply do not know how electroconvulsive therapy (ECT) works. This frame of mind runs the risk that there will be no expectation that psychiatrists remain familiar with seminal studies on the mode of action of ECT. This article is intended as a reminder of these studies and illustrates how the original theories have evolved. This evolution has been brought about largely by modern brain imaging techniques in human studies and in patients treated with ECT. These new findings will be set in the context of contemporary ideas about the neuroanatomy of mood disorders and the cellular mechanisms of the long-term effects of antidepressant treatments.

We present a narrative review of evidence-based treatment for obsessive–compulsive disorder (OCD), covering first-line pharmacological treatment, augmentation strategies, approaches for treatment-refractory OCD and the management of OCD in special populations (children and adolescents, pregnant and breast-feeding women, and elderly people).

There is an increasing prevalence of hepatitis C, particularly among intravenous drug users. Estimates of infection with the hepatitis C virus (HCV) in patients with severe mental illness in the USA have ranged from 8.5% to 19.6%. Alcohol use and misuse is the single biggest contributory factor to the development of fatal liver disease in people with hepatitis C. Neuropsychiatric symptoms are present in HCV infection, independent of any treatment. Despite such alarming observations, the success rate of antiviral treatment in chronic hepatitis C has improved considerably in recent years. This article explores psychiatrists' involvement in advocating for treatment inclusion, assessing patients' capacity to make treatment-related decisions and supporting the medical team in managing the complex journey a patient undertakes from being at high risk to receiving treatment for neuropsychiatric symptoms.

The challenge of managing repeated self-harm and the high risk of morbidity and mortality are compounded in forensic patients, where there are additional risks of harm to others, absconding and security breaches. There is an urgent need for clinically sound, practice-based and theoretically grounded strategies for managing these associated risks. This is essential as available UK guidelines appear inadequate for this group of patients. This article promotes a pragmatic approach to assessing the risk of self-harm clinically to arrive at hierarchical risk judgements. It further suggests an algorithmic approach to managing these risks and provides testable strategies that can be adapted for use in various secure institutions.

It has been suggested that a recovery-focused approach and treatment under the Mental Health Act are mutually exclusive, hence the limited applicability of ‘recovery’ in forensic psychiatry. This is heightened if recovery is seen as a ‘model’ that does or does not fit, and lessened if seen as ‘values-in-action’ that need reinterpretation in context.

Interpersonal psychotherapy is an evidence-based therapy, originally developed to treat major depression. It is cited in numerous good practice guidelines. The biopsychosocial signs of depression are understood in the context of current social and interpersonal stressors, defined in terms of role transitions, disputes, bereavements and sensitivities. In therapy, the patient learns to understand the interactions between symptoms and interpersonal difficulties and the ways in which they are mutually reinforcing. Patients are helped to break this pattern and achieve a reduction in depressive symptoms and improvement in interpersonal functioning through improved communication, expression of affect and proactive engagement with the current interpersonal network. The therapeutic relationship is used as a tool for exploring and modelling external relationships. This article outlines the background to interpersonal psychotherapy, the process of therapy and the expansion of the evidence base.

The Defence Mental Health Services (DMHS) provide an occupationally focused service for the UK armed forces when deployed and when at home. Although much of the work is similar to that carried out by National Health Service community mental health teams, there are many unique aspects to working with the military. Although carrying out operational duties is a key function of the armed forces, the majority of cases managed by the DMHS are not related to traumatic exposures; instead, adjustment, mood and substance use disorders form the bulk of the case work. However, DMHS personnel carry out a considerable amount of psychological education and command liaison functions to support the concept that the psychological welfare of troops is primarily a chain of command responsibility. This article outlines the structure and function of the DMHS and its approach to risk management.