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We review the origins and history of community psychiatry and the challenges posed to it by advancing technology and the neoliberal political economy and society that have prevailed since the 1990s. We summarise both achievements and shortcomings and argue that the term ‘community’ fails to acknowledge the gap between its original ambition and the outcomes of its implementation. We argue that, because of the changes that have taken place, the implementation of community psychiatry's objectives as conceived originally is likely to continue to fail. To sharpen current awareness and thinking and optimise future policy discourse and service strategies we revisit the concept of ‘metacommunity’. This is a historical descriptive label that aims to encapsulate the fundamental transformations that have taken place. These in turn demand of psychiatrists and other mental health providers both more socially critical thinking and mental health activism in the public sphere. Ultimately, beyond both community and metacommunity psychiatry, what is required is a democratic psychiatry.

To address some challenges facing psychiatrists today we discuss issues of happenstance and fulfilment in psychiatric careers through some of the record and reflections of four psychiatrists since the 1950s. We trace the changes in psychiatry attendant to the transition from the welfare to the neoliberal state and=its contemporary postmodern culture. We highlight the crucial importance of political-cultural as well as technological developments in determining psychiatric service management and provision, and clinical practice and career outcomes. In the light of this impact, in a global era that some highly respected authorities consider in apocalyptic terms, we advocate for the incorporation of training in political awareness and activism in the psychiatric curriculum and practice. We suggest that this is necessary for social justice and patient welfare and that it will help safeguard psychiatric professionalism, conscience and self-esteem.

The fiftieth anniversary of the Royal College of Psychiatrists, and the publication of a detailed multidisciplinary social history of British psychiatry and mental health in recent decades have offered an opportunity to take a helicopter view and reflect on the relation between psychiatry and changing British society. We argue that the time has come to move on from the rhetoric of deinstitutionalisation and community mental healthcare to lead public debate and advocacy for the needs of the mentally ill in the new era of ‘meta-community psychiatry and mental healthcare’. We need to respond effectively to the increasing awareness of mental health problems across society, aiming for a pluralist, integrated and well-funded reform led by joint professional and patient interests which could be unstoppable if we all work together.

Aggressive challenging behaviour is frequently reported in adults with intellectual disability and it is often treated with antipsychotic drugs. However, no adequate evidence base for this practice exists. We compared flexible doses of haloperidol (a typical, first-generation antipsychotic drug), risperidone (an atypical, second-generation antipsychotic), and placebo, in the treatment of this behaviour. 86 non-psychotic patients presenting with aggressive challenging behaviour from ten centres in England and Wales, and one in Queensland, Australia, were randomly assigned to haloperidol (n=28), risperidone (n=29), or placebo (n=29). Clinical assessments of aggression, aberrant behaviour, quality of life, adverse drug effects, and carer uplift (positive feelings about the care of the disabled person) and burden, together with total costs, were recorded at 4, 12, and 26 weeks. The primary outcome was change in aggression after 4 weeks' treatment, which was recorded with the modified overt aggression scale (MOAS). Analysis was by intention to treat. This study is registered as ISRCTN 11736448. 80 patients had adherence of 80% or more to prescribed drug. Aggression decreased substantially with all three treatments by 4 weeks, with the placebo group showing the greatest change (median decrease in MOAS score after 4 weeks=9 [95% CI 5–14] for placebo, 79% from baseline; 7 [4–14] for risperidone, 58% from baseline; 6·5 [5–14] for haloperidol, 65% from baseline; p=0·06). Furthermore, although no important differences between the treatments were recorded, including adverse effects, patients given placebo showed no evidence at any time points of worse response than did patients assigned to either of the antipsychotic drugs. Antipsychotic drugs should no longer be regarded as an acceptable routine treatment for aggressive challenging behaviour in people with intellectual disability.

There has been an increasing awareness of the importance of leadership and decision making, including scientists and academics, over recent times. By whom and how decisions are made can have serious implications across all levels of society. Several people have been successful in their life and have been inflicted by excessive pride and self-confidence. There are times when the manifestations of such behaviours demonstrate noticeable signs of narcissism and on extreme cases, hubris. Hubris is an old concept originated from the Greek mythology.  The risk of hubris affects politicians, leaders in business, scientists, academia, the military, entertainers, athletes and doctors (among many others). Power, especially absolute and unchecked power, is intoxicating and is manifested behaviourally in a variety of ways, ranging from amplified cognitive functions to lack of inhibition, poor judgment, extreme narcissism, deviant behaviour, and even cruelty. Hubristic behaviour of overconfidence, extreme pride together with an unwillingness to disregard advice makes powerful people in leadership positions to over-reach themselves with negative consequences for themselves and others. As the dangerous consequences of hubristic behaviours become more apparent and well described it is imperative that individuals, organisations and governments act to prevent such phenomena. Responsible leaders, including acclaimed scientists should exercise greater humility to the complexity and inherent uncertainty of their activities and strive to seek out and challenge hubristic behaviours.

This book considers how mental health services have evolved over the past three decades to meet the needs of people with intellectual disability, focusing on the ways that theories and policies have been applied to clinical practice. Nick Bouras and Geraldine Holt both have extensive experience in developing and running mental health services and bring together international contributors all with longstanding expertise in the fields of mental health and intellectual disability. They present the current evidence based practice as how people with intellectual disability can be best cared for in clinical settings. The book embraces a foreword by Professor David Goldberg and is divided into three sections: development of specialist mental health services, clinical practice, and training as an integrated component of service delivery. Chapters cover topics including: the association between psychopathology and intellectual disability international perspectives neuroimaging and genetic syndromes training professionals, families and support workers. Mental Health Services for Adults with Intellectual Disability provides an overview of the many improvements that have been made in services for people with intellectual disability, as well as examining the shortcomings of the services provided. It offers strategies and solutions for the wide array of interdisciplinary professionals who want to develop the range of resources on offer for people with intellectual disability. Nick Bouras is Professor Emeritus of Psychiatry at the Institute of Psychiatry, King's College London, United Kingdom. Geraldine Holt is Honorary Consultant Psychiatrist in Learning Disabilities at South London and the Maudsley NHS Foundation Trust and Senior Lecturer at the Institute of Psychiatry, London. Goldberg , Foreword. Bouras, Holt , Introduction. Part I: Development of Specialist Mental Health Services. Chaplin, Paschos, O’Hara , The Specialist Mental Health Model and other Services in a Changing Environment. Chaplin, Xenitidis , Services for People with Intellectual Disability and Offending Behaviour. Cain, Davidson, Dosen, Garcia-Ibañez, Giesow, Hillery, Kwok, Martorell, Novell-Alsina, Salvador-Carulla, Torr, An International Perspective of Mental Health Services for People with Intellectual Disability. Part II: Clinical Practice . Flynn, Gravestock , Assessment, Diagnosis and Rating Instruments. Hemmings , Service Use and Outcomes. Harding, Robertson , Neuroimaging and Genetic Syndromes. Pickard, Akinsola , The Association between Psychopathology and Intellectual Disability. Part III: Training as an Integrated Component of Service Delivery. Costello, Hardy, Tsakanikos, McCarthy , Training professionals, family carers and support staff to work effectively with people with intellectual disability and mental health problems.

The development of reliable, valid measures of psychopathology in people with intellectual disabilities is an important task. However, independent replication studies are rarely reported. To report data on the psychometric properties of the Psychiatric Assessment Schedule for Adults with Developmental Disabilities (PAS-ADD) Checklist. The PAS-ADD Checklist was completed for 226 adults as part of the assessment process for a specialist mental health service for people with intellectual disabilities. Internal consistency was acceptable. Factor analysis revealed one main factor that was characterised by items related to mood. The Checklist was sensitive to differences between diagnostic groups and had an overall sensitivity of 66%; its specificity was 70%. The PAS-ADD Checklist is a quick and easy to use screening tool. Although at present it is the best measure available, it should not be the only method used to identify psychiatric disorders in people with intellectual disabilities.