The Royal College of Psychiatrists is the main professional organisation of psychiatrists in the United Kingdom, and is responsible for representing psychiatrists, for psychiatric research and for providing public information about mental health problems. The college provides advice to those responsible for training and certifying psychiatrists in the UK.In addition to publishing many books and producing several journals, the College produces, for the public, information about mental health problems. Its offices are located at 21 Prescot Street in London, near Aldgate. The College's previous address was Belgrave Square.
Clozapine is the most effective therapy for treatment-resistant schizophrenia, although it can cause neutropenia. In many countries, neutrophil count monitoring is mandatory for people taking clozapine, who must remain above a minimum threshold to start and continue treatment. Some people have low neutrophil counts without increased infection risk, caused by a homozygous variant in ACKR1 and termed ACKR1/DARC-associated neutropenia (ADAN). When ADAN is confirmed, reduced neutrophil count thresholds are applied to allow people to start and continue clozapine. However, ADAN diagnoses are often missed, resulting in reduced access to clozapine and unnecessary discontinuation. We review the evidence for ACKR1 genetic testing to rapidly identify ADAN in people taking clozapine. With multidisciplinary input, we recommend internationally relevant test eligibility criteria, comprising pre-emptive and reactive testing strategies, and we conduct a health economic analysis, estimating total cost savings between £42,732 and £727,990 for the UK healthcare system during the first year of testing. Finally, we propose how to integrate these criteria into clinical practice to enable equitable access to clozapine. This Perspective considers the addition of ACKR1 genetic testing for identifying ACKR1/DARC-associated neutropenia in patients receiving clozapine, recommending eligibility criteria and testing strategies while estimating substantial cost savings for the UK healthcare system and enhancing equitable treatment access.
BACKGROUND:Alcohol withdrawal (AW) seizures are acute symptomatic seizures occurring in the context of alcohol cessation in dependent individuals. Although often self-limited, seizures are associated with an increased risk of complications such as delirium tremens, prolonged hospitalization, and neurocognitive decline. This review synthesizes recent findings on the neurobiological underpinnings, clinical features, genetic risk factors, and treatment strategies for AW seizures. METHODS:We conducted a focused narrative review using PubMed and Scopus databases, covering studies published between 2000 and 2024. Key words included alcohol withdrawal seizures, pathophysiology, GABA, NMDA receptors, kindling, carbamazepine, hippocampal neurogenesis, and genetic susceptibility. Additional references were identified through manual review of citations from the key articles. Only peer-reviewed studies in English were considered. Particular emphasis was placed on high-quality clinical trials, translational animal models, and recent reviews integrating neurobiological and therapeutic insights. RESULTS:AW seizures arise from a neuroadaptive imbalance between inhibitory GABAergic and excitatory glutamatergic systems, which is exacerbated by abrupt alcohol cessation. Hippocampal neurogenesis and dentate gyrus dysregulation have been identified as key contributors to seizure susceptibility. Genetic polymorphisms-particularly in SLC6A3 and APOE-appear to modulate individual vulnerability. While benzodiazepines remain the first-line treatment for AW seizures, carbamazepine has demonstrated efficacy as an adjunct or alternative in high-risk cases where benzodiazepines are contraindicated or ineffective. AW seizures are predictive of further withdrawal complications and long-term cognitive deficits, highlighting the importance of early recognition and personalized management strategies. CONCLUSIONS:AW seizures represent a critical clinical and neurobiological marker in the course of alcohol use disorders. Improved understanding of their pathophysiology and prognosis supports a stratified treatment approach incorporating both acute symptom control and long-term relapse prevention.
BACKGROUND:Mindfulness-based cognitive therapy (MBCT) was developed for relapse prevention in people with remitted depression but is increasingly used for those with difficult-to-treat depression (DTD). A key question regarding this broader application is whether ongoing depressive symptoms constrain therapeutic responsiveness or disrupt MBCT's proposed mechanism, decentering. We explored whether baseline depressive severity moderates clinical outcomes, whether changes in decentering mediate treatment effects, and whether this mediation varies by baseline severity. METHODS:Secondary moderation, mediation, and moderated mediation analyses were conducted using data from the RESPOND randomized trial (N = 234), comparing MBCT plus treatment as usual (TAU) with TAU alone in adults not remitted after high-intensity psychological therapy. Depressive symptoms (PHQ-9) and decentering (Experiences Questionnaire) were assessed at baseline, post-treatment (10 weeks), and follow-up (34 weeks). Analyses were conducted using structural equation modelling. RESULTS:Higher baseline severity predicted greater symptom improvement across both groups. Treatment-related increases in decentering partially mediated the effect of MBCT on depressive symptoms at follow-up. Although baseline severity did not moderate the treatment effect, it moderated the indirect effect, with decentering more strongly associated with symptom reduction among those with higher baseline depression. Severity did not moderate the acquisition of decentering skills. CONCLUSIONS:Concerns that more severe depressive symptoms limit the effectiveness of MBCT were not supported. MBCT's core mechanism remained operative under substantial symptom burden, with clinical impact amplified at higher severity. These findings reduce key uncertainties regarding the application of MBCT in DTD and support its use across a broad range of symptom severity.
BACKGROUND:Coroners' Prevention of Future Death reports (PFDRs, also known as Regulation 28 reports) provide an opportunity to understand factors contributing to mental health-related deaths. AIMS:To examine available mental health-related PFDRs, addressing three core questions: (a) What is the overall profile of these reports? (b) What relational patterns emerge from these reports? and (c) What concerns and preventive actions do coroners highlight in these reports, and how they evolved over time? METHOD:We collected all mental-health related public PFDRs available up to June 2025 (N = 586). Data extraction combined automated web scraping, optical character reading and large language model (LLM)-assisted (GPT-4o) parsing to capture demographics, settings, coroner areas, co-occurring categories, concerns and recommended actions. Descriptive statistics, category and recipient co-occurrence network analysis and thematic analysis were used to provide a comprehensive landscape of these reports. RESULTS:Report numbers increased steadily from 2013, peaking in 2021 and then declined. Some jurisdictions, including Manchester South, East Sussex and East London, consistently had more PFDRs issued. The deceased were typically young, male and had died mainly outwith hospital, most often at home; 78.0% of reports included at least one formal response from recipients, whereas 22.0% had no corresponding response available. The network analyses suggested that PFDRs seldom identified isolated issues. Coroners' concerns changed over time, from service access and resources to inter-agency coordination and then, more recently, to risk assessment and management. CONCLUSIONS:Mental health-related deaths examined by coroners arise within complex, evolving multi-sector contexts and do not frequently identify single errors. Minimising such deaths may require coordinated strategies across healthcare, social care and justice systems. Analysis of PFDRs allows identification of patterns that may inform such actions. PFDRs should be analysed routinely and patterns followed over time.
SUMMARY 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.
