Significant problems exist in understanding and implementing the Mental Capacity Act 2005 (MCA) despite it having been in place in England and Wales for more than 15 years. Although many guidelines exist on the assessment of capacity, it is difficult to apply such guidance in practice, given the complexity of actual situations. We may know the stages of the test for capacity, but do we really understand what they mean and how to assess them? In this, the first of two articles examining the MCA and challenges in its application, we add to existing legal guidance to explore capacity assessment in detail using a clinical scenario, and use case law and case studies to illustrate the subtleties and difficulties that may arise.

This article is the second of two looking at assessment of mental capacity in clinical practice. In it, we explore capacity assessments in the context of suicidal thoughts and acts. The laws governing doctors’ responsibility to suicidal patients in England and Wales are poorly understood, with tensions at the interface between the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). Dynamics of the clinical encounter (including the countertransference) further exacerbate uncertainty about how clinicians should balance patients’ autonomy with protection of life. We use a case example of a patient presenting with suicidality to describe good practice, based on a balance of legal and clinical principles and up-to-date case law. We discuss the difficulty in applying the MCA in relation to patients who appear to lack a consistent and coherent sense of self and others and consider whether the MCA is fit for purpose in determining whether someone with a personality disorder diagnosis should be permitted to end their own life.

This is a commentary on two articles on assessing mental capacity in everyday practice and in the case of the suicidal patient. It explores some of the conceptual problems with capacity, including the lack of a ‘right’ answer and the value-laden nature of capacity assessments in suicidal patients. In England and Wales, in addition to the Mental Capacity Act 2005 clinicians must also consider their duty of care as part of the European Convention on Human Rights as enacted in the Human Rights Act 1998.

Faster internet speeds and ever-present mobile phones present a new challenge to psychiatric wards – the ability for patients to live stream their in-patient stays. What are the benefits and the risks to the patient streaming and the ward as a whole? This article is to help start a conversation about this unique problem and how health professionals might go about addressing it.

‘Digital’ is an omnipresent yet often vague, misunderstood or feared topic in health services. There are many current and potential gains for individual patients and local populations, clinicians and organisations through optimisation of digital technologies. We argue that understanding the various aspects of digital psychiatry is an essential contemporary need. This is the first of two articles on the subject, exploring the gains and challenges of virtual/online assessments, including ethical considerations and the use of virtual reality and electronic prescribing.

Digital psychiatry has become increasingly important and understanding of certain aspects is essential for practising clinicians. This article discusses electronic patient records (EPRs), from their origins to current and future use, the growth and embedding of outcome measurements, the use of social media, and learning and research in virtual arenas.

Since 2018, the International Task Force on Benzodiazepines (ITFB), a group of academic psychiatrists and academic psychologists, has advocated that clinical guidelines should change to promote benzodiazepines from second- to first-line treatment for anxiety disorders, accept their use as maintenance treatment for anxiety conditions (in particular, panic disorder) and increase their use in gastrointestinal disorders. There is merit in much of what the ITFB argues, but in this article I analyse four major claims it has made in opinion editorials that I believe are not fully supported by the available evidence.

Benzodiazepines have attracted controversy from shortly after their introduction. They have been subject to periodic calls for their use to be re-evaluated on the basis that their risks have been overstated and their benefits underappreciated. Claims made in recent editorials from the International Task Force on Benzodiazepines in support of their wider use are critiqued in this issue. I examine here whether there is a case to change the conclusions of previous reconsiderations of the question.

Risk assessment in clinical practice is often characterised as a process of analysing information so as to make a judgement about the likelihood of harmful behaviour occurring in the future. However, this characterisation is brought into question when the evidence does not support the current use of risk assessment approaches to predict, or provide probability estimates of, future behaviour in a way that is usable in single instances arising in individual cases. This article sets out a broader and more clinically applicable description of risk assessment which takes account of the wider influences on how this clinical activity takes place. In so doing, it provides a framework to guide clinicians, researchers and authors of practice guidance who are interested in improving approaches to risk assessment.

In A Plea for the Insane (1918), Lionel Weatherly outlined the inadequacies of the Lunacy Act 1890 and of asylum care in England and Wales, and proposed solutions and ways to bring about improvements. It took courage to persist, but Weatherly was undeterred by controversy or criticism. This article reflects on his book and its context and timing at the end of the First World War, and considers whether we may be inspired to confront current healthcare crises with the same sort of passion and fervour as he did.

Acute behavioural disturbance is relatively common during the perinatal period. The management of agitation in pregnant women is similar to that in the general population, although with some additional considerations, such as modifications to restraint techniques, careful medication selection, monitoring of maternal and fetal well-being and the importance of a debrief. There are benefits of agreeing a pre-determined care plan for women who are at risk.