In this clinical reflection, we report on stigma and ageism and their impact on those experiencing signs and symptoms of borderline personality disorder (BPD). We highlight the need for increased collaboration between those with lived experience of the disorder and healthcare providers. This is an important issue in BPD as the impact of structural stigma is significantly affecting the quality of life and short- and long-term trajectories of those with BPD, especially during adolescence.

Internet-delivered cognitive and/or behavioural therapy (I-C/BT) for post-traumatic stress disorder (PTSD) addresses problems of access to evidence-based psychological treatments and is becoming more widespread. This commentary explores the effectiveness of I-C/BT for PTSD compared with waiting-list/treatment as usual controls as reported in Simon et al’s (2021) Cochrane Review and in subsequent studies. The results suggest that I-C/BT may reduce PTSD symptoms immediately post-treatment, without long-term effects. However, the very low certainty of evidence and inconsistent quality of I-C/BT interventions prohibits recommendations until further high-quality research becomes available.

Kushner's monograph (published in 2000) explores clinicians’ developing understanding of a syndrome first described 200 years ago. This article highlights changing concepts of the disorder, its aetiology and treatment over its long history, as described by Kushner, and considers the current differential diagnosis of DSM-5 ‘Tourette's disorder’. It points out Kushner's astute observation that the clinical syndrome originally described by Itard and Gilles de la Tourette as ‘maladie des tics’ is not what is defined in the 21st century as Tourette syndrome.

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.

Lewin and colleagues’ article in this journal gives a good overview of how artificial intelligence (AI) is contributing to the reshaping of mental healthcare. However, a deeper focus on the synergies between different approaches to AI and its goals is needed. This commentary aims to further consider the unique implications of digital mental health approaches, including predictive, explainable and generative AI, for both research and clinical objectives.

Machine learning, an artificial intelligence (AI) approach, provides scope for developing predictive modelling in mental health. The ability of machine learning algorithms to analyse vast amounts of data and make predictions about the onset or course of mental health problems makes this approach a valuable tool in mental health research of the future. The right use of this approach could improve personalisation and precision of medical and non-medical treatment approaches. However, ensuring the availability of large, good-quality data-sets that represent the diversity of the population, along with the need for openness and transparency of the AI approaches, are some of the challenges that need to be overcome. This article provides an overview of current machine learning applications in mental health research, synthesising literature identified through targeted searches of key databases and expert knowledge to examine research developments and emerging applications of AI-enabled predictive modelling in psychiatry. The article appraises both the potential applications and current challenges of AI-based predictive modelling in psychiatric practice and research.

Panic disorder, characterised by sudden episodes of intense fear or anxiety, affects 1–4% of the population. Symptoms include rapid heartbeat, chest pain and fear of dying. Panic disorder often co-occurs with substance dependence and major depression. This review article examines pharmacological treatments, focusing on antidepressants and benzodiazepines, but also considering antipsychotics and anticonvulsants. It overviews the history of antidepressants and benzodiazepines in the treatment of panic disorder and their mechanisms of action. The results of a recent Cochrane Review network meta-analysis are then presented and contrasted with six current national and international treatment guidelines. Rankings of the various drugs in terms of efficacy, tolerability and safety are summarised, along with levels of evidence and lines of recommendation as a treatment option (first-, second or third-line, or reserved for treatment-resistant cases).

Clozapine remains the gold-standard medication for treatment-resistant schizophrenia, yet its use in young people is limited despite emerging evidence supporting efficacy. In this journal, Walker et al highlight the unmet need for training and education on clozapine prescribing in child and adolescent populations, reinforcing concerns raised by leading experts about real-world implementation barriers. In this commentary on their article, we consider some of these concerns, particularly regarding therapeutic benefit and metabolic and haematological safety. We conclude that, given the severe consequences of treatment delay and the prognostic burden associated with early-onset schizophrenia, a proactive, algorithmic and well-supervised approach to clozapine initiation in youth is essential.

Section 63 is one of the most widely used provisions of the Mental Health Act 1983 (MHA). Case law has evolved and established that a range of physical health treatments, ancillary to the core mental disorder, can be subsumed and authorised under s.63. This article reviews two court judgments whereby unique treatments were authorised under s.63 – the provision of clinically assisted nutrition and hydration, and renal dialysis. In doing so, it elucidates key issues around implementing s.63 and assessing potential ancillary treatments for clinical practice.

Clozapine is the only medication specifically recommended for treatment-resistant schizophrenia, but research suggests that it is universally underprescribed, particularly among children and adolescents. This article discusses clinicians’ reluctance to prescribe clozapine for all age groups, and outlines its benefits for treatment-resistant schizophrenia in young people. It summarises guidelines on clozapine therapy for adults, including initiation, monitoring and adverse and side-effects, and describes how they can be applied to a younger population. Psychiatrists who care for younger people have consistently highlighted a wish for more learning opportunities focusing on clozapine, such as the content of this article.