Treatment of alcohol use disorders typically involves a combination of pharmacotherapy and psychosocial interventions. About one-quarter of people with alcohol dependence (‘alcoholics’) who seek treatment remain abstinent over 1 year. Research has consistently shown that less intensive, community treatment (particularly brief interventions) is just as effective as intense, residential treatment. Many psychosocial treatments are probably equally effective. Techniques for medically assisted detoxification are widespread and effective. More recent evidence provides some support for the use of drugs such as acamprosate to prevent relapse in the medium to long term.

Gamblers Anonymous (GA) is perhaps the least used of the twelve-step approaches to dealing with addictions. This relative lack of visibility and use, at least in the UK, is reflected in healthcare professionals' lack of awareness and knowledge of gambling addiction and its treatment, including GA. In this article, we introduce the basic tenets of GA and discuss how these translate into treatment.

Over the past decade, important research has been performed into the therapeutic use of dihydrocodeine, injectable opioids (diamorphine) and supervised disulfiram in addiction treatment. There have also been interesting developments regarding baclofen for alcohol problems and use of stimulants in adult Attention-deficit hyperactivity disorder (ADHD). However, evidence for the effectiveness of medication to promote alcohol abstinence remains modest at best.

Rates of suicide and self-harm are rising in many countries, and it is therapeutically important to explore the personal stories and relationships that underlie this behaviour. In this article psychoanalytic and psychodynamic principles and concepts in relation to violence towards the self are introduced and the various unconscious meanings of suicide and self-harm are explored within a relational context and attachment framework. We describe how a psychodynamic approach may enhance the risk assessment and treatment of patients presenting with self-harm and suicidality, particularly examining the role of transference and countertransference within the therapeutic relationship.

Substance misuse worsens the prognosis for people suffering psychosis and places them at risk of being denied appropriate mental health service interventions. To increase the chances of its success, the plan of management for patients with coexisting psychosis and substance misuse should be based on a valid formulation of their problems, which in turn is dependent on the clinician having (a) a thorough understanding of the bidirectional and changing ways that substance use and mental illness symptoms can interact, (b) an awareness of their own biased implicit assumptions about causality in explaining these interactions and (c) a framework for assessment and formulation. This article addresses these three areas with reference to the evidence base and to clinical experience in a way that guides mental health clinicians in the assessment of patients with coexisting psychosis and substance misuse.

It is estimated that 29% of adults in the UK smoke (Office for National Statistics, 2000). Each year smoking kills 120 000 people (13 deaths per hour), making it the single most common preventable cause of death in Britain (Callum, 1998). Around half of all smokers will die prematurely because of their addiction (Peto et al, 1994). Their overall life expectancy is, on average, 8 years less than for non-smokers (Callum, 1998). Smoking also costs the National Health Service (NHS) £1500 million, with around 1000 admissions every day for smoking-related illnesses (Parrott et al, 1998). (However, the UK treasury earns £8 billion in tax on tobacco sold in the UK alone, in addition to the enormous revenue from overseas markets.)

Motivational interviewing is a form of psychotherapy in which ambivalence towards an aberrant behaviour is targeted. Rather than challenge the behaviour directly, the clinician encourages the patient to devise a list of problems that are caused by the behaviour and to identify solutions. There are many trials of motivational interviewing, although it has been most studied as treatment for substance misuse. The effect sizes for motivational interviewing are small, they probably diminish over time, the trials often use multiple outcome measures and the outcomes of some very large trials have been disappointing. Large effects are occasionally reported, although these tend to be from small trials conducted by highly motivated research groups and the results tend to diminish when the trials are repeated or enlarged. Nonetheless, motivational interviewing is a well-validated approach supporting and enabling engagement in therapeutic process. It could be argued that even though it might not be as efficacious as a primary/stand-alone means of changing patients’ behaviour, it can still be highly effective when combined with other approaches or used as a conduit to a more intensive therapy.

Nitrous oxide (N2O) misuse is widespread in the UK. Although it is well-known that it can cause devastating myeloneuropathy, psychiatric presentations are poorly described. There is little understanding of who it affects, how it presents, its mechanism of action and principles of treatment. We begin this article with a case study. We then review the literature to help psychiatrists understand this area and deal with this increasing problem, and make diagnosis and treatment recommendations. We describe a diagnostic pentad of weakness, numbness, paraesthesia, psychosis and cognitive impairment to alert clinicians to the need to urgently treat these patients. Nitrous oxide misuse is a pending neuropsychiatric emergency requiring urgent treatment with vitamin B12 to prevent potentially irreversible neurological and psychiatric symptoms.

Alcohol use disorders (AUD) are common, particularly in patients attending mental health services. Clinicians are often hesitant to explore with patients their relationship with alcohol and the role that it has in their presenting complaint, despite being ideally placed to optimise on a ‘teachable moment’ and initiate treatment, where necessary. This article provides an overview of AUD and their identification and management options.

Smoking rates in people with depression and anxiety are twice as high as in the general population, even though people with depression and anxiety are motivated to stop smoking. Most healthcare professionals are aware that stopping smoking is one of the greatest changes that people can make to improve their health. However, smoking cessation can be a difficult topic to raise. Evidence suggests that smoking may cause some mental health problems, and that the tobacco withdrawal cycle partly contributes to worse mental health. By stopping smoking, a person's mental health may improve, and the size of this improvement might be equal to taking antidepressants. In this article we outline ways in which healthcare professionals can compassionately and respectfully raise the topic of smoking to encourage smoking cessation. We draw on evidence-based methods such as cognitive–behavioural therapy (CBT) and outline approaches that healthcare professionals can use to integrate these methods into routine care to help their patients stop smoking.

We review how research over the past decade both supports existing knowledge about the risk factors that children in the UK affected by parental substance misuse face, and adds to our knowledge about the protective factors, protective processes and evidence of resilience which can reduce the likelihood that children will experience poor outcomes. Further research is needed to understand what areas of resilience are most important to target and how other variables, such as gender or age, may influence how protective factors affect the development of resilience. Longitudinal research is also needed to better understand how an individual's resilience may change over time. Finally, there remain many considerable challenges which practitioners, service providers, commissioners and policy makers face in better meeting the needs of this population of children.

The clinical and public mental health aspects of alcohol misuse in older people (both men and women) have increasing relevance for both old age and addiction psychiatrists. Clinical presentations are often complex and involve a number of different psychiatric, physical and psychosocial factors. The assessment, treatment and aftercare of alcohol-related and comorbid other mental disorders will also involve a broad range of interventions from a wide range of practitioners. Given its growing clinical relevance, there are particular areas, such as alcohol-related brain damage and drug interactions with alcohol, that deserve special attention.

The interpersonal dynamics between patient and doctor remain a daily challenge for clinicians, and reflective practice is a tool that allows them better understanding of how patients engage with treatment. The interpersonal dynamics consultation is a form of group-based reflective practice for patients with difficult relational (interpersonal) styles. It includes the whole multidisciplinary team in a systematic consultation in order to arrive at new understanding and management plans for these patients. Interpersonal dynamics consultations have been used successfully for many years in mental healthcare, and this article has arisen from a project exploring their application in physical healthcare settings. The project works to promote effective working at the interface of physical and mental healthcare and facilitates the important translational work of making psychiatry and psychotherapeutic ideas applicable in a broader context. This article outlines the interpersonal dynamics consultation model and illustrates its use in three fictitious cases from different medical specialties.

Mind–body dualism is often considered to be incompatible with modern psychiatry for two reasons. First, it is claimed that dualism is falsified by recent advances in neuroscience. Second, dualism is thought to lead to an unhelpful attitude towards patients and their illnesses. I reflect on and challenge both lines of thought and argue that there is no inherent conflict between dualism and psychiatry.

Methodological issues such as social desirability bias, subjective outcome measures, therapist enthusiasm and fidelity to the intervention remain a major problem in assessing the effectiveness of psychosocial treatments for substance misuse. Alcoholics Anonymous and other 12-step programmes are still widely used, although it is difficult to formally assess their effectiveness. Motivational interviewing is perhaps the most commonly used professional psychosocial treatment for substance misuse, but brief interventions based on this technique report a disappointing effect size (∼0.2). Contingency management is perhaps the most effective reported modality, although it remains politically controversial. Cognitive—behavioural therapy and community reinforcement have been widely studied, but the results are often disappointing (effect sizes seldom exceed 0.5, despite very large trials). Residential rehabilitation remains an established treatment, but patient selection prevents formal cost-effectiveness studies.

Stress is the most important proximal precipitant of depression, yet most large genome-wide association studies (GWAS) do not include stress as a variable. Here, we review how gene × environment (G × E) interaction might impede the discovery of genetic factors, discuss two examples of G × E interaction in depression and addiction, studies incorporating high-stress environments, as well as upcoming waves of genome-wide environment interaction studies (GWEIS). We discuss recent studies which have shown that genetic distributions can be affected by social factors such as migrations and socioeconomic background. These distinctions are not just academic but have practical consequences. Owing to interaction with the environment, genetic predispositions to depression should not be viewed as unmodifiable destiny. Patients may genetically differ not just in their response to drugs, as in the now well-recognised field of pharmacogenetics, but also in how they react to stressful environments and how they are affected by behavioural therapies.

Sexual and relationships difficulties are not uncommon among psychiatric patients. A presenting complaint of anxiety or depression may relate to an underlying sexual or relationship difficulty; commonly used psychotropic medications cause sexual side-effects that can have a significant impact quality of life, relationship maintenance and treatment adherence; patients may exhibit unusual or excessive sexual behaviours when acutely unwell, including risky use of apps to meet sexual partners and accessing online pornography in unsafe ways; patients may have used technology such as the internet to harm others or they may be victims of such harm; the internet and social media might even be influencing sexual expression, for example gender identity. Therefore, psychosexual history-taking remains a key competency for psychiatrists. They must also understand the new language used to describe sexuality, sexual behaviours and the use of social media, apps and so on to form relationships. This article outlines the key areas to consider in carrying out a structured psychosexual assessment. It also gives an overview of current sexual terminology, observed influences of the internet on sexuality and sexual behaviour, and its implications for mental health and potential sexual offending.

Owing to the continuing shortage of organs, the demand for transplantation outstrips supply. Liaison psychiatrists, as part of a multidisciplinary team, have a key role in the assessment of transplant candidates and participate in the decision-making process regarding ‘listing’ the patient for transplantation. Psychiatric and psychosocial factors affect prognosis post-transplantation and there are absolute and relative contraindications to transplantation. The skills of the liaison psychiatrist are employed throughout the patient's illness journey, in the pre-, peri- and post-transplantation periods.

Psychiatry uses some of the most controversial treatments in medicine. This may be partly because several are administered under coercion and opposed to the patient's expressed will, under the protection of the relevant mental health legislation. Electroconvulsive therapy (ECT) is perhaps the archetypal controversial treatment; although it is considered to be effective, the research supporting it is much less impressive than one would expect. The prescription of stimulant drugs for childhood attention-deficit hyperactivity disorder (ADHD) and substitution therapy (such as methadone maintenance) in addictions treatment remain topical and appear to be subject to political interference. ‘Treatment’ for homosexuality and psychosurgery were common in the past but are now rare. These issues are discussed to give insight into how once common controversial treatments can decline and become obsolete. However, seclusion and covert medication remain in practice and are highly scrutinised.

This article aims to clarify what ‘care closer to home’ means to a community psychiatrist. Care closer to home can be operationalised as primary care liaison and the article reviews experience across England of how a liaison service can work with the recently organised primary care networks. Key competencies needed for liaising with primary care are discussed using seven questions, including bias mitigation, reducing bed-days, consultation skills, knowledge of emerging treatments and reducing administrative overheads while improving access.