SUMMARY Alzheimer’s disease is a progressive and incurable condition and the leading cause of dementia worldwide. Lim et al’s (2024) Cochrane Review on the acetylcholinesterase inhibitor galantamine and its effects in Alzheimer’s disease and mild cognitive impairment (MCI) concluded that the drug slows cognitive and functional decline in Alzheimer’s disease, but not in MCI. However, in several studies the handling of data after drop-out was a potential source of bias. In this month’s Round the Corner , we also propose that the characteristics of the patient sample limit the external validity of the findings, and that the research question, although valid, is of limited practical importance.
SUMMARY Educating medical students in the core skills of psychiatric examination and the implications of psychiatric comorbidities to medical care is of critical importance, given the increasing prevalence of a number of mental disorders and their increasing comorbidity with medical conditions. This article outlines psychiatry education in three of Singapore’s medical schools, where it forms a small yet integral part of the undergraduate and postgraduate curricula.
SUMMARY Burnout refers to a psychological condition arising from prolonged and ongoing interpersonal stressors, resulting in physical and emotional exhaustion. Its prevalence among healthcare workers has been increasingly recognised as a significant factor affecting their mental health, well-being, performance at work, and professional and personal relationships, as well as the functioning of organisations. In this article we outline the general concept of burnout, its clinical features and measurement. We give an overview of its epidemiology among healthcare workers, and highlight the contribution of individual and organisational risk factors, cultural influences and work–life balance to its emergence and maintenance. We conclude with recommendations for identifying the signs and symptoms of burnout and for providing timely support and evidence-based interventions to reduce harm to both workers and the organisation. Effective management of burnout is key to retaining a healthy and productive workforce, while meeting the challenges of service delivery in healthcare in general and the National Health Service in particular.
SUMMARY The number of academic psychiatrists has fallen in recent years, partly owing to limited academic opportunities for the future professors of psychiatry. In 2019, Koelkebeck et al looked at barriers and facilitators experienced by early career psychiatrists (ECPs) in developing academic capabilities. In a literature review that also used systematic review techniques, the authors searched two databases, the grey literature and conference proceedings, and contacted experts on the topic. Despite the limited number and quality of studies identified, and limitations in data analysis and presentation of results, this review is an important contribution to an under-researched field. The findings are relevant to the design of psychiatry training programmes in the UK and the provision of other academic opportunities to ECPs.
SUMMARY 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.
SUMMARY 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.
SUMMARY 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.
SUMMARY 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.
SUMMARY 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.
SUMMARY 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.
SUMMARY 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.
SUMMARY 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.
SUMMARY This commentary emphasises key ideas in psychodynamic approaches to psychosis, as described in an article in this journal by Rachel Gibbons. Drawing on the case made for an understanding of the psychological processes that underlie psychotic symptoms and how these affect clinical staff, this commentary reinforces the need for a ‘mind-based’ approach to understanding psychosis. The powerful impact of unconscious processes as an ordinary part of human communication is described and the argument made that attending to the countertransference is a key clinical tool in psychiatry, and should be considered a routine part of the mental state examination.
Most psychiatric disorders in adulthood originate in childhood or adolescence. Hence, managing mental health in children and adolescents is crucial. This clinical reflection aims to capture some of the contemporary and emerging trends in teaching and training in child and adolescent psychiatry worldwide. Future directions for child and adolescent psychiatry training programmes are also highlighted.
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.
Despite the recent advances in its diagnosis (heralded by the revisions in ICD-11 and DSM-5) and the introduction of new approaches to treatment, managing personality disorder remains challenging to the psychiatric practitioner. I believe that one of the main reasons for this is that the condition lacks an overall theory that might guide practitioners in their assessment of it and what they might do to intervene. In this article, I suggest that interpersonal theory might be such a candidate, enabling practitioners to manage this condition more effectively. My aim is to provide a brief introduction to this theory in the hope that practitioners might be encouraged to explore its implications more fully.
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.
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.
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.
