Mirroring the general population, the number of medical students, doctors and, indeed, psychiatrists disclosing being neurodivergent is rising. These individuals commonly have a variety of strengths that can enhance their work, but these strengths may go unrecognised. All too often such individuals have been labelled ‘doctors in difficulty’. We begin this article with a review of contemporary thinking regarding neurodiversity, before considering specific issues facing neurodivergent doctors, specifically psychiatrists. We explore neurodivergent strengths and the evidence regarding career outcomes and mental health. We discuss the stigma that many neurodivergent psychiatrists face in the medical sphere and how difficulties may be reframed as unmet needs. We highlight initiatives that aim to change workplace culture, before discussing the concept of reasonable adjustments, alongside a wide range of practical suggestions of adjustments to consider, using the Autistic SPACE framework and the Royal College of Psychiatrists’ reasonable adjustments guidance. Finally, we consider how those in senior leadership roles can contribute to this field and provide role modelling and signposting to further information and support for neurodivergent doctors and their supervisors and line managers.

Reduced access to dementia healthcare services by elders from ethnic minority backgrounds is often a manifestation of underlying systemic disadvantages within dementia assessment and treatment services. In this narrative review of current literature on UK dementia healthcare services we identify risk factors contributing to the inequalities faced by people with dementia from ethnic minorities, point to major knowledge gaps in dementia diagnosis, management and long-term care for these groups and highlight clinical challenges arising in delivering services to them. We describe the inequity in diagnostic rates, their poorer treatment outcomes and the lack of culture-specific support for people from ethnic minority communities. We present proposals for South Asian and the Black ethnic minority groups by which local healthcare systems may minimise some of these disadvantages. This will enhance our understanding of the aetiology and management of long-term conditions such as dementia by improving access to and dialogue with ethnic minority communities and healthcare providers.

This article provides a brief introduction (or recapitulation) of what variable types are and how the choice of the variable type may affect which research questions can be answered and the data analysis. The nine-item Patient Health Questionnaire and a simulated data-set are used as an illustration throughout.

Barricaded incidents, hostage-taking and sieges occur in the community, where police negotiators are usually called on to bring about a peaceful resolution. They occur also in prisons and psychiatric hospitals, where they will be managed by the institution’s staff, with police support if needed. Psychiatrists and other mental health professionals have been involved in providing training and on-call support for negotiators and decision makers in these crisis situations. This article describes definitions and goals in relation to such incidents, and outlines a five-phase framework for their management (training; first responders, preliminary interventions and inquiries; negotiations; resolution; aftercare), indicating the psychiatrist’s role during each phase. Ethical issues are also discussed.

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 post-traumatic stress disorder (PTSD) diagnosis encompasses heterogeneous presentations, many of the diagnostic criteria are not trauma-related and almost all PTSD symptoms are common to several psychiatric diagnoses. Flashbacks are the only symptom unique to PSTD. However, the absence of a consensus definition of flashbacks means that this term means different things to different people, causing misunderstanding and miscommunication, and presumably affecting treatment. This Refreshment discusses how flashbacks are defined in DSM-5-TR and ICD-11 (essentially, as reliving/re-experiencing when awake) and briefly describes the dual representation theory's account of flashbacks. In discussing what flashbacks are and are not, it aims to promote improved understanding, assessment and diagnosis of PTSDs.

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.

Paediatric functional gastrointestinal disorders (P-FGIDs) are common, affecting up to 25% of children worldwide. They are characterised by chronic abdominal pain and/or altered bowel habits without an underlying disease pathology. P-FGIDs are often associated with co-occurring anxiety and depression across all ages and treating P-FGIDs may provide an opportunity to develop a young person's wider emotion regulation capacities. Using a fictitious case vignette, we outline the range of psychosocial and biomedical treatments for the disorder and the need for an integrated and holistic approach. We propose that by intervening early and enabling children to be curious about, rather than fearful of, their bodily sensations, clinicians may be able to alter harmful illness trajectories in both pain and psychiatric domains.

Quality improvement (QI) is an evidence-based approach to analysing and improving healthcare systems. QI's success has led it to become a required competency expected of medical professionals in several countries. However, much of the QI literature to date has not focused on mental health. Moreover, many psychiatrists have no formal training in QI. To address this gap, this article introduces key QI concepts, including six dimensions of quality care, the Model for Improvement and plan–do–study–act cycles. Each QI concept is illustrated using a fictitious case study of an out-patient psychiatrist reducing chronic benzodiazepine use in their clinic.

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.

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.

Metabolic dysfunction is an established phenomenon in people with severe mental illness (SMI), and it has a higher prevalence than in the general population. It is associated with increased morbidity and mortality, and effective recognition and management are essential to enable good psychiatric care. Despite widespread awareness of this disparity for several decades, health outcomes continue to worsen, highlighting the need for more effective preventive and treatment measures. This article outlines the risk factors that contribute to metabolic dysfunction in this population, including genetic, environmental and pharmacological factors, and considers underlying metabolic pathophysiological processes as part of SMI itself. To aid discussions with patients, recognition and interpretation of metabolic risk factors are outlined, together with mitigating strategies. Novel areas of uncertainty are discussed, including the use of a ketogenic diet. This article advocates use of the term ‘metabolic psychiatry’, to increase awareness of the significant overlap between psychiatric illness and metabolic dysfunction.

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.

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 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.

Lunatic Asylums, published 130 years ago, is a fascinating insight into how these institutions were managed in the late Victorian era. This brief article considers what it reveals about the zeitgeist of the time and the book's author, the remarkable Charles Mercier.

Medical dramas such as Grey's Anatomy influence young people's career aspirations, creating unrealistic expectations. This article examines the gap between these portrayals and the reality of medical practice, highlighting challenges such as rigorous training and high stress. Using Italy's ‘numero chiuso’ (‘closed number’) system as a case study, it addresses the global issue of intense competition in medical school admissions. The article advocates for realistic education and better support to prepare future healthcare professionals.

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.

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.

Complex post-traumatic stress disorder (CPTSD) was adopted as a new diagnosis in ICD-11. Trauma-focused cognitive–behavioural therapy (CBT) is effective in treating PTSD but with CPTSD being a recently defined diagnosis, the evidence for its effectiveness in that disorder is not as clear, but it is still promising. This article reviews the diagnosis, psychopathology and some key differential diagnoses, and looks at the two CBT approaches that are currently used in clinical practice: the phase-oriented approach and the unimodal approach. The key aims of this article are to clarify the concept of CPTSD, its differentiation from borderline personality disorder and prominent comorbidities, how it develops and how CBT is used to treat it.