Domestic abuse often begins or escalates during the perinatal period, increasing the risk of adverse pregnancy outcomes and death of the woman and infant. The hidden nature of domestic abuse, compounded by barriers to disclosure, means many clinicians are likely to have unknowingly encountered a patient who is being abused and missed a vital opportunity for intervention. This educational article presents the experience of a woman who was abused during pregnancy. It describes how to facilitate a disclosure and conduct an assessment and illustrates safeguarding duties alongside interventions.

Health inequalities in psychiatry are well established, with people living in poverty and those from minoritised groups receiving different care and experiencing worse health outcomes. Psychiatric patients experience significant differences in life expectancy compared with the general population. This article explores changes within psychiatric services and public health interventions that could address health inequalities and asks why this has not happened yet.

The COVID-19 pandemic has increased rates of psychological distress and burnout in healthcare staff. How can we understand our experiences of the pandemic? We reflect on the experiences of psychiatry trainees in two north London mental health trusts. From a psychoanalytic understanding, states of extreme anxiety can lead to a manic defence and functioning in the paranoid–schizoid position. This position is derived from object relations theory and is characterised by binary thinking, splitting, projection, defensiveness and ‘knee-jerk’ decision-making. This can affect our perceptions, responses to others, relationships and ability to function and, therefore, our clinical practice and well-being. We consider the importance of recognising these processes and of organisational containment and having space to reflect. This supports functioning in the depressive position, a state of mind where we can tolerate anxiety, address difficult realities and develop new ideas. We hope these understandings are helpful to our colleagues in all professions.

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis predominantly presents with psychiatric symptoms. Psychiatrists need to be alert to this diagnostic possibility, especially in female adolescents and young adults, as exemplified by the real (de-identified) case outlined below. Earlier diagnosis and immunotherapy improves long-term outcomes. Collaboration with neurology colleagues is essential for optimal care. ‘Red flags’ for autoimmune encephalitis and ‘diagnostic clues’ act as helpful aide memoires for this uncommon condition. The gold standard for testing is the detection of NMDAR antibodies in cerebrospinal fluid, but serum can be tested as a more accessible (but less reliable) preliminary step. The results of routine blood tests, magnetic resonance imaging of the head and electroencephalograms can be normal or show non-specific changes. Diagnostic criteria exist to define probable and definite cases. Immunotherapy for anti-NMDAR encephalitis is effective for many patients, but recovery is prolonged and relapses can occur.

The Earth's climate is in a complex state of change as a result of human activity. The interface between climate change and physical health has received significant attention, but its effects on mental health and illness are less understood. This article provides an insight into the psychiatric sequelae of climate change, suggests strategies that psychiatrists can use to take action, and argues that it is their responsibility to do so.

The dominance of Western orthodox models of psychiatry has led to colonisation of the mind and marginalisation of diverse cultural conceptualisations of distress and forms of caring. Compounded by a crisis of care and chronic underfunding, this has also diminished our practice here in the UK. This article probes the biases that UK psychiatry must unlearn and what lessons it can learn from decolonising praxes originating in the Global South. This is a call to action. We must transform our mindsets and advocate for contextualised, collective, integrative and socially just mental healthcare in the UK.

The COVID-19 pandemic starting in 2020 has had massive mental health consequences worldwide. It has caused generalised fear and anxiety about catching, spreading and suffering from the virus. This article describes a fictionalised patient's presentation of life-threatening obsessive–compulsive disorder (OCD) associated with fears of catching COVID-19. The fears resulted in refusal to eat and drink, with subsequent weight loss that required paediatric admission. The scenario portrays the association between COVID-19 and life-threatening OCD symptoms and goes on to illustrate the patient's good response to standard OCD treatments.

One of the most challenging experiences psychiatrists will face in their careers may well be the death of a patient by suicide. This is likely to happen at least once during a psychiatrist's career, and often more. It can be an intensely complex and painful event with a wide range of emotional responses. Reflecting on the death and accessing good support helps clinicians process the emotional impact. It can also increase their resilience in the longer term by giving them a greater understanding of both their own and their patients’ limitations, and in this way strengthen their capacity for compassion as clinicians. Using an illustrative case study, this article provides an insight into the experience of losing a patient to suicide and signposts to sources of support.

The National Health Service (NHS) was created 70 years ago to provide universal healthcare to the UK, and over the years it has relied upon international medical graduates (IMGs) to be able to meet its needs. Despite the benefits these professionals bring to the NHS, they often face barriers that hinder their well-being and performance. In this editorial, we discuss some of the most common challenges and the adverse effects these have on IMGs’ lives and careers. However, we also propose practical measures to improve IMGs’ experiences of working in psychiatry.

Treatment-resistant depression is a complex condition often requiring specialist psychiatric care. Many different psychiatric, physical and social factors can lead to a poor response to initial treatment of depression, and a careful assessment is required to determine the most appropriate management option. This can be particularly complex in the older population, who often have multiple physical and social comorbidities. We have used a fictional case to illustrate this, alongside an anonymised vignette of someone with personal experience of this condition. We have also provided an overview of the current evidence for treatment options, as well as a discussion of potential aetiological factors. By the end of this article, readers should understand the ambiguity of this diagnostic term, the aetiological factors that need to be assessed and the rationale for the treatment options available. They should be able to recognise how these ideas apply to the geriatric population.

The online environment brings both challenges and opportunities. The skills learned in journal clubs remain highly relevant where the ability to critique rapidly generated information and apply evidence to patient care is vital. Creativity and flexibility are needed to ensure that learners’ needs are met and efforts are made to involve those who may not be naturally drawn to online environments. This article explores how journal clubs have been approached in the past, both in person and more recently online, considers techniques for maintaining engagement in online teaching and proposes new approaches for future journal clubs.

The pressure on mental health services has not gone unremarked and is of widespread concern in England and Wales. This can have implications when a bed is being sought for a patient who has undergone a Mental Health Act assessment and is deemed to meet the criteria for being formally admitted to hospital. Once the 24 h period for assessment under section 136 of the Act has lapsed, the ongoing detention of the patient can lead to a legal grey area. Through a fictional example this paper examines the relevant case law and statute that may be used to continue the detention and explores the ethical problems that this may cause.

Liaison psychiatrists have identified that conducting capacity assessments in general hospital patients with alcohol-related brain damage (ARBD) can be challenging. This educational article uses the fictitious case of a man with ARBD, alcohol dependence and significant self-neglect, focusing on assessment of his capacity to decide about moving into a care home on discharge. We provide an overview of clinical, legal and ethical literature relevant to decision-making and capacity assessment in individuals with ARBD, with the aim of guiding clinicians approaching complex capacity assessments.