Psychiatry relies on narratives, observation and interpersonal data more than definitive tests. Errors in inference can lead to inappropriate treatment, avoidable adverse effects and delayed recovery. This article proposes an investigative framework for clinical reasoning tailored to community mental health services, in-patient wards and liaison teams by translating hypothetico-deductive reasoning into clinical practice: broad-then-focused enquiry, explicit competing hypotheses, a reliability hierarchy for weighing clues, proportionate action under uncertainty, and time-bound review. The framework is positioned alongside existing approaches and considers the emerging role of artificial intelligence as a complement to clinician-led formulation. With fictitious vignettes, diagrams and summary tables, the proposed framework aims to improve formulation quality, support safer decisions before diagnostic closure, and make reasoning transparent to patients and teams. As a proposal, it requires empirical evaluation against routine practice in clinical and educational settings before any claim of effectiveness can be made.

This article outlines the UK’s National Referral Mechanism (NRM) for victims of human trafficking and modern slavery and the psychiatrist’s roles and responsibilities within this framework. Individuals referred to the NRM often give harrowing and complex accounts of trauma and exploitation that are difficult to disclose in a single assessment. They present with a range of mental disorders, including depression, anxiety and post-traumatic stress disorder. Psychiatrists encounter such victims in many settings, including emergency departments, community and in-patient settings, the criminal justice system and when providing expert psychiatric reports, especially in immigration and asylum cases. Psychiatrists need to consider a range of issues when conducting assessments, providing or overseeing treatment and preparing psychiatric reports. These include diagnosis of mental disorder, identifying and managing treatment and recovery needs, and providing support to help reintegration into society. These issues are important for psychiatrists and mental health specialists, given the pivotal role they play in helping to ensure victims of trafficking and modern slavery are identified, referred to the NRM and receive the support and treatment they require.

It is well-known that physical exercise brings a range of benefits for physical and mental health. This review specifically considers the impact of physical activity on mental health and focuses on the increasing knowledge of the neurobiological actions of exercise. It outlines the effects of stressors on physiology and, consequently, mental health and explores the concept of neuroplasticity. It assesses the wide-ranging evidence from animal and human studies consistent with exercise modulating neuroplasticity processes, such as stimulation of long-term potentiation, synaptic growth and neurogenesis. Mechanisms underpinning these effects are presented: stimulation of angiogenesis, production of neurotrophic factors, modulation of stress and inflammatory responses, metabolic adaptation and epigenetic modification. Finally, the relevance of the evidence base to clinical practice is considered. In particular, it is noted that discussion of these positive impacts of exercise on ‘brain health’ may increase motivation to participate in physical activity in some patients.

The relationship between mental health and human rights is complex and bidirectional: human rights abuses can have a significant adverse effect on mental health, and those with mental disorders are vulnerable to violations of their human rights. This article begins with an overview of human rights instruments most relevant to psychiatric practice, including the European Convention on Human Rights (ECHR). It discusses some globally occurring human rights abuses and the complex relationship between human rights and mental health. It gives an update on developments in human rights considerations in psychiatric practice over the past decade, and examines emerging challenges that continue to shape the intersection between mental health and human rights. Drawing on a British Medical Association article that highlighted the threats posed to health and human rights by neoliberalism and inequality, forced migration, climate change, new technology and violent conflict, the article explores the impact of these issues on mental health, as well as the challenges related to mental health legislation. It concludes with practical considerations for psychiatrists to safeguard and promote human rights.

The reliable assessment of formal thought disorder (FTD), a collection of observable signs of suspected problems in generating organised thoughts, is the cornerstone of interviewing a person with psychosis. A significant gap persists between the success of assessments reported in published FTD rating scales and the practical constraints of a clinical interview. Validated rating scales largely focus on operationalised criteria for describing items; the procedural aspects of how to elicit these signs often remain implicit. We synthesise the principles and procedures of FTD assessment embedded in rating scales, translating their design into a framework for routine clinical use. Systematic employment of several manoeuvres can help elicit FTD signs: conversational stimulation, cognitive loading, social modulation and pointed clarifications to stress-test thought, language and communication processes. By making these procedures explicit, we aim to equip clinicians and trainees with a strategic, measurement theory-informed approach to the psychiatric interview when assessing for FTD.

As an increasing number of psychiatrists complete training in the UK and move into post-qualification specialist practice in Canada, challenges can arise with adaptation and professional recognition. In this reflection, we examine our experiences over the past 5 years working in and delivering undergraduate and postgraduate medical education in Canada. Patients recognise the unique value of UK psychiatry training; however, this training can also present challenges. We explore some of these issues across the domains of undergraduate medical education, postgraduate psychiatry education and post-qualification specialist practice, using a comparative narrative.

Hong Kong has two established medical schools, at the University of Hong Kong and at the Chinese University of Hong Kong (CUHK), and these are soon to be joined by a new school at the Hong Kong University of Science and Technology (HKUST). This article outlines undergraduate psychiatry education in the 6-year MBChB programme at CUHK and in a new medical school at HKUST.

Severe behavioural and psychological symptoms of dementia (BPSD), associated with risk to self and others, often necessitate urgent intervention. Despite well-documented risks, antipsychotics remain frequently prescribed for these symptoms, reflecting complex influences on prescribing decisions. This review critically explores these challenging contexts, including difficulties in defining severe BPSD, conflations and limitations of current evidence and clinical guidelines, and legal and policy frameworks that shape care. This article advocates the adoption of alternative paradigms, notably palliative approaches, to address the considerable distress associated with severe BPSD, while remaining attentive to sociological critiques. Its broader aim is to stimulate discussion on the development of more humane and holistic models of care in this challenging area of older adult psychiatry.

The predominant transdiagnostic perspective on persistent physical symptoms (PPS), as described by Felton et al in this journal, is largely shaped by cognitive–behavioural models. This commentary advocates expanding this perspective to include greater focus on a psychodynamic model that addresses interpersonal and emotional processes associated with the development and maintenance of PPS.

All doctors will encounter patients with intellectual disabilities and neurodevelopmental disorders, but most medical subspecialty training does not explicitly cover the needs of this population. This can leave doctors feeling underskilled and lacking in confidence to assess and manage these patients. It can also increase the risk of diagnostic overshadowing, adversely affecting patients’ health outcomes. This article reviews the current state of medical education in the psychiatry of intellectual disability and associated neurodevelopmental disorders in the UK. It follows the medical training pathway from undergraduate through to postgraduate level, highlighting the expected learning outcomes. Key challenges and gaps in training at each level are discussed, along with potential solutions. Looking more widely, the article finishes with a short description of the paediatric neurodisability specialty training pathway, and a description of the UK’s contribution to international medical training in intellectual disability.

Research on ovarian hormones increasingly reveals their important role in brain function. This includes reward processing, the umbrella phrase for functions that promote motivation for, response to and learning about rewards. This article seeks to provide a concise overview of how ovarian hormones influence reward function, with a specific focus on the ovarian hormone derivatives found in hormonal contraceptives. Despite the complexity of findings, the research suggests a general pattern in which oestradiol may promote multiple reward functions and progesterone often appears to play an inhibitory role. Allopregnanolone’s effects on reward functions appear to be concentration dependent and follow an inverted-U pattern. Limited research on hormonal contraceptives suggests that these agents may interfere with reward neurobiology, potentially contributing to deficits in sexual desire and positive mood, although some individuals may be more susceptible than others. Effects of ovarian hormones and their derivatives on reward processing have multiple clinical implications. These are discussed in relation to hormonal therapy in menopause, avoiding side-effects with hormonal contraceptives, and ongoing research on the use of progesterone in substance use disorders.

Although unique in its effectiveness, lithium shares with other psychotropic medications the potential to induce multiple side-effects that significantly influence tolerability, acceptability and patient adherence. We review the available evidence to provide a contemporary update for clinicians in treating lithium-induced side-effects. Most adverse effects of lithium are either transient or not severe enough to require discontinuation. Distressing side-effects can reduce gradually or become tolerable with a ‘watchful waiting’ approach or, if not tolerated, dose reduction. Side-effects leading to discontinuation may allow for later rechallenge. Side-effects such as stage 5 chronic kidney disease and the syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) merit discontinuation. There is a paucity of studies examining management of lithium side-effects, with most treatments for them based on small samples or case series/reports. Treatments will usually mirror recommended interventions from other treatment settings.

This clinical reflection explores the evolving landscape of teaching and training in old age psychiatry, highlighting recent reforms such as the 2022 UK curriculum revision, which emphasises person-centred, interdisciplinary and digitally enhanced care. It examines national and international initiatives addressing health inequalities, integration of artificial intelligence, and co-produced education. The article underscores the need for adaptable, inclusive and forward-thinking training to meet the complex mental health needs of an ageing global population.

Parkinson’s disease is a chronic neurodegenerative disorder with a range of movement-related and non-movement symptoms. Depression is a frequent complication and linked to faster cognitive decline, reduced daily functioning and poorer quality of life. This review looks at how often depression occurs in Parkinson’s disease, possible reasons behind it and the diverse ways it can be treated. A thorough evaluation using a biopsychosocial approach, supported by tools like the Patient Health Questionnaire, is essential. Treatment options include medications (e.g. selective serotonin reuptake inhibitors, tricyclic antidepressants and serotonin–noradrenaline reuptake inhibitors), talking therapies (e.g. cognitive–behavioural therapy and problem-solving therapy) and electroconvulsive therapy. Techniques such as transcranial magnetic stimulation and vagus nerve stimulation are being explored for individuals who do not respond to standard treatments. The findings highlight the importance of personalised, evidence-based care to improve the mental health and independence of people with Parkinson’s disease.

This reflection explores the unique challenges and opportunities in psychiatric medical education in the Middle Eastern region. The variation in aspects of teaching across the region can be explained by the influence of cultural and religious perspectives on the understanding of mental illness. Key barriers include pervasive stigma, shortages of teaching staff and limited clinical placements. Innovations like virtual learning and regional collaboration offer pathways to strengthen curricula, enhance competency-based assessment and further improve the future of psychiatry education.

Capacity assessments under the Mental Capacity Act 2005 (MCA) are a routine part of daily clinical practice in England and Wales. One element of these is the role of insight within the MCA’s capacity criteria. This article focuses on the issue of insight and capacity in a recent Court of Protection judgment, discussing how to assess insight in clinical practice and elucidating key issues regarding the role and assessment of insight within capacity assessments. The article includes a 10-point checklist for capacity assessments that was presented in the judgment, and a discussion of insight assessments that can guide documentation and be implemented in clinical practice.

Generative artificial intelligence (GenAI) shows promise for mental healthcare by increasing access to treatment. In this article, we analyse recent evidence on the use of GenAI chatbots as a treatment for common mental disorders. We examine key ethical and methodological considerations and discuss the specific risks for delusions. Adopting a precision psychiatry perspective, we propose that the therapeutic alliance can be improved by tailoring GenAI to mimic a user’s psychological traits, a version of socioaffective alignment.

Treatment-resistant schizophrenia (TRS) is a clinically challenging subtype of schizophrenia affecting up to 30% of patients, defined by persistent symptoms despite adequate trials of at least two antipsychotics. This review explores the complex neurobiology of TRS, highlighting the limitations of the dopamine hypothesis and emphasising the roles of glutamatergic, cholinergic and neurodevelopmental mechanisms. It outlines neuroimaging techniques (e.g. positron emission tomography, functional and structural magnetic resonance imaging, and proton magnetic resonance spectroscopy) used to explore neurotransmitter activity and structural brain changes in psychosis, and in TRS in particular, and gives an overview of their findings and utility. It also discusses frameworks like TRRIP and the INTEGRATE algorithm, which aim to facilitate earlier diagnosis and treatment. Integrating neuroimaging into practice may improve diagnosis and clinical outcomes and advance precision medicine approaches; emerging non-dopaminergic treatment options, such as xanomeline–trospium, may offer promising alternatives to standard clozapine treatment for TRS. Future research should prioritise biomarker discovery and the development of novel therapies beyond dopaminergic targets.

Clinical work with people who are seriously unwell and overwhelmed by psychotic functioning can be profoundly rewarding yet uniquely demanding. Beyond visible symptoms lie powerful unconscious forces that affect all involved. Drawing on psychoanalytic theory from Bion, Money-Kyrle, Menzies Lyth and Lucas, this article explores how psychotic processes such as splitting, projection, denial and rationalisation are transmitted to those providing care. Recognising and working with these dynamics not only deepens clinical understanding, enabling meaning to be found in apparently chaotic presentations, but also enhances the capacity to engage therapeutically with distress. Reflective practice, supervision and organisational containment are identified as essential clinical interventions to help clinicians understand the unconscious impact of psychotic processes and to preserve their capacity for thought and compassion.

Avoidant/restrictive food intake disorder (ARFID) is a condition characterised by an avoidance or restriction of food intake that has a detrimental impact on physical health, psychosocial functioning or both. ARFID has now been classified in ICD-11, alongside DSM-5; however, challenges remain for healthcare professionals in recognising ARFID in young people and identifying best practice for managing their care. This educational article aims to provide an update on the epidemiology and clinical presentation of ARFID in children and young people, with a particular focus on co-occurring neurodevelopmental conditions and psychiatric disorders. A multidisciplinary approach to assessment and management is key, working closely with the young person and the system around them. Physical and psychosocial risk assessment has been aided by the publication of the medical emergencies in eating disorders (MEED) guidelines. Crucially, there is a need for further research into ARFID in order to develop evidence-based standardised guidelines for assessment, management and transition to adult services if required.