Objectives: This study was carried out to determine the prescribing of psychotropic medication of non-consultant hospital doctors in the management of delirium and to compare this with best practice guidelines.

Method: A structured questionnaire was forwarded to all non-consultant hospital doctors (n = 95) working at St Vincent's University Hospital and data was collected over a six month period. The questionnaire addressed type, dose and route of psychotropic medication use in delirium as well as adjunctive measures used to manage delirium.

Results: There was a 55% response rate (n = 52). Haloperidol and lorazepam were the two most frequently prescribed psychotropic agents used and over one third of respondents (n = 20) reported the use of risperidone. There was wide variation in doses used and a substantial proportion of NCHDs used higher than recommended starting doses for elderly patients with delirium. In addition, the intramuscular route was reported as the commonest route of administration with a majority of respondents reporting infrequent intravenous route of administration.

Conclusions: The drug choice reported by respondents followed best practice guidelines. However, the wide variation in drug doses used and frequency of parenteral route of administration (particularly intramuscular) indicate the need for increasing awareness of best practice international guidelines. Guidance and clarification regarding the use of atypical antipsychotic medication is required following concerns about their use in dementia.

Fifteen consecutive cases of moderate and severe depression were treated with moclobemide in recommended dosage and followed for six months. Eleven developed excitatory side effects including agitation, insomnia, restlessness and aggressivity; five patients reported unreality experiences. Subject to confirmation, these findings, together with indications of similar side effects in published studies and in non fatal overdose, raise the possibility that the potential of moclobemide to cause excitation in depressed patients refractory to other treatments may have been hitherto underestimated.

Caffeine remains the most widely used psychoactive drug and psychiatric populations tend to ingest more caffeine than the general community. It is important to assess caffeine intake in psychiatric patients as it may distort diagnostic signs and is known to interact with psychotropic medications. A blanket condemnation of caffeine use by psychiatric patients is, however, unwarrranted for while it may exacerbate some conditions (eg. anxiety disorders) it may prove beneficial to others (eg. schizophrenics) when used in moderate quantities. A scale for the estimation of caffeine intake is provided.

Objective: To examine the variables that influence of duration of untreated psychosis (DUP) prior to presentation in persons with a first episode of psychosis.

Method: Prospective examination of consecutive first presentations with DSM-IV psychosis attending a community based psychiatric service.

Results: One hundred and seventy-one patients had an average duration of untreated psychosis of 18 months and a median of five months. The mean duration of untreated mania was 1.5 months, median 0.75 months. DUP was predicted by social withdrawal and diagnosis in the total group and by prodrome in the schizophrenia/schizophreniform group. DUP was not associated with age at onset of psychosis, educational years or living status.

Conclusions: There are significant differences in DUP between diagnostic groups. Increased social withdrawal is associated with a longer DUP.

Eleven case histories, including diagnoses and outcome, are presented of patients who made, or were the subject of, allegations of sexual abuse, but where these allegations were subsequently withdrawn or disproved. How such situations come about is discussed, with special reference to the false memory syndrome, a term made popular by recent media coverage. Given the complexity of this ‘syndrome’, an argument is put forward that diagnostic guidelines be established so that direct studies of its natural history and treatments may be undertaken.

Low serum and urinary Cortisol has been a consistent finding in post traumatic stress disorder (PTSD). Glucocorticoid receptor numbers are increased. PTSD patients have a significantly lower adrenocorticotropic hormone (ACTH) in response to corticotrophin releasing hormone (CRH) when compared to a control group of normal volunteers. The dexamethasone suppression test exhibits an exaggerated suppression response of Cortisol to dexamethasone, when the dose utilised is lower than that utilised to test patients with depression. Increased urine levels of noradrenaline and dopamine has been noted in patients with PTSD. This is believed to be related to the hyperarousal state of PTSD.

The neuropsychiatric effects of corticosteroids are well described in the literature but relatively little is known specifically about their effects among older people. As the population ages, and increasing numbers of older people receive assertive medical treatment for physical conditions, more patients are likely to present to psychiatric services suffering from adverse neuropsychiatric effects associated with corticosteroid use. A review of the effects of corticosteroids among older people was carried out through Medline and PubMed searches and a review of article references. Very little has been specifically written about steroid use and the effects on older people. This paper briefly outlines the current level of knowledge of neuropsychiatric effects of steroids, and relates this to general treatment considerations for older subjects. Recommendations for further research and early identification of complications are made.

A case of musical hallucinosis is presented, which failed to respond to neuroleptics but responded to carbamazepine. Parallels with the Charles Bonnet syndrome are discussed.

Objectives: In an era of cost containment in the health services, it is important to endeavour to manage existing resources in the optimum way. This study examines admissions to an acute psychiatric unit in a general hospital in order to identify factors that characterise these admissions, which in turn may suggest appropriate interventions.

Methods: This was a retrospective casenote review of 105 consecutive admissions. Demographic information and clinical data concerning this admission and service contact in the preceding year was collected. Chi-squared tests were used to compare patients who were admitted during normal working hours with those admitted after 5pm and at weekends. Patients whose length of stay exceeded four weeks were compared with those who had a shorter admission.

Results: Eventually 101 patients were included in the study; of these 46.5% of admissions occurred during normal working hours. Admissions outside this time were more likely to be under 45 years (χ2 = 4.05, df = 1, p <0.05) and to be diagnosed with a depressive illness or schizophrenia/psychosis (χ2 = 19.12, df = 3, p <0.05). These admissions were of shorter duration (χ2 = 4.45, df = 1, p <0.05) and had not been in contact with the community psychiatric nurse (CPN) in the preceding year (χ2 = 4.09, df = 1, p <0.05). Length of stay >4 weeks duration was more likely in single patients (χ2 = 9.68, df = 2, p <0.01), those living outside the more urban areas (χ2 = 4.04, df = 1, p <0.05) and those who had a diagnosis of a depressive illness or schizophrenia/psychosis (χ2 = 13.43, df = 3, p <0.01). Patients with a diagnosis of alcohol or substance abuse were spending significantly shorter periods in hospital.

Conclusions: Further development of day hospitals is necessary to provide alternatives to inpatient treatment and facilitate earlier discharge for patients living throughout the catchment area. Alternative methods of service delivery such as outreach programmes should be considered for subgroups of patients who are unable or unwilling to access traditional services. Introducing outpatient detoxification programmes would have a substantial impact on admission patterns in the unit.

Objectives: To audit the incidence of a history of childhood sexual abuse (CSA) in women with diagnoses of drug and alcohol misuse disorders.

Method: A definition of CSA encompassing the US National Centre on Child Abuse and Neglect's definition of child sexual abuse was used. In the six month period of audit details of CSA were recorded from clinical data for all consecutive female new patients (n = 49) of the substance misuse service in St. Luke's Hospital, Armagh.

Results: Of the 49 new patients, information on childhood sexual abuse was available for 44 subjects. Sixteen (36.36%) of 44 had a positive history of CSA.

In 13 (81.25%) abuse occurred before the age of 16 years. Sexual intercourse was described by 50% and sexual contact by 50%. Only one patient had reported CSA to the police and only one patient had received counselling. There was a difference noted in the addiction profile of those with a history of CSA, 44% of this group had either alcohol dependence syndrome/harmful use of alcohol compared with 66% of the non-CSA group. The perpetrators were all male.

Conclusions: Our audit confirmed other work which showed a high incidence of childhood sexual abuse histories in addicted women. This is one of the areas which may not be properly addressed by conventional addiction treatment programmes, which are male centred and male dominated. It adds to the growing body of evidence that suggests adaptations must be made as increasing numbers of women present for addiction problems.

One of the most important questions facing psychiatry today concerns its relationship to the emerging international service user movement. I believe that this movement presents not only the greatest challenge to psychiatry, but also the greatest opportunity. As it becomes more organised and influential this movement is starting to play a major role in shaping the sort of questions that are being asked about mental health services and their priorities. Yet there is limited reflection in our profession about how we, as doctors, might engage positively with it. It seems that while we are comfortable working with individuals and organisations who accept the medical framing of mental problems, we are less willing to contemplate working with critical service users. These are people who reject the medical model because they feel harmed by a system that describes their problems using the language of psychopathology. If we are serious about having an inclusive debate on mental health we will have to overcome this impasse. We need to entertain the idea that people who reject the medical framing of their problems are nevertheless legitimate stakeholders. It is time that we learned how to talk to them and to listen to their ideas. The user movement, with its substantial critical component, is not going to go away.

One of the most important elements of the relationship between psychiatric services and the people who use them is the reality of psychiatric power. Many critical service users accept that legally sanctioned interventions may be necessary when individuals lose capacity to care for themselves and perhaps put themselves or others at risk. However they do not accept the fact that the Mental Health Act in Ireland gives sole authority to doctors to take decisions on such interventions without any obligation to consult other interested parties.