Objectives: Psychotherapeutic skills are essential to practice psychiatry effectively, but previous surveys of trainees in Ireland show that they have not been getting adequate training in psychotherapy. This survey of college tutors was carried out to coincide with the establishment of the College of Psychiatry of Ireland which is introducing new psychotherapy training requirements. The survey aims to ascertain if trainees had fulfilled the Royal College of Psychiatrists' psychotherapy training requirements, models of psychotherapy available and the availability of psychotherapy qualifications amongst consultants and senior registrars.

Methods: A questionnaire was posted to all registered tutors in the Republic of Ireland.

Results: The postal questionnaire was sent to the 62 registered college tutors in the 13 training schemes. There is one tutor in each training hospital. The response rate was 79%. Our survey reveals that no psychotherapy training was available according to 16.3% of tutors. Only 22.5% of tutors were aware of trainees who had met college training requirements in the previous two years. 79.8% of tutors reported that there were consultants and senior registrars with qualifications in psychotherapy who could offer training if time and resources permitted.

Conclusions: Current training requirements are not being fulfilled. There are consultants and senior registrars who have psychotherapy qualifications to provide psychotherapy training but there are inadequate resources and time to formalise training. It is unlikely that the implementation of training requirements by the new college will be realisable without a review of training delivery.

Objectives: This paper aimed to examine the outcome of hostel treatment including the effect on hospitalisation rates.

Methods: The work of the four medium/long term Gloucester hostels developed between 1983 and 1993, to provide 24-hour nursed care to ‘new long stay’ patients in Gloucester is described.

Results: Fifty-eight patients with predominately severe mental illness were admitted to the hostels up to 1999, and demographic/illness data is presented. Mean duration of hostel stay was 4.8 years, and one third of patients were readmitted to hospital (most briefly) during their hostel admission, one patient 11 times. Thirty-four patients were discharged from hostels, 29 to less dependent settings, but four referred to hospital care. There was a significant reduction in the number of admissions and duration of hospitalisation in the time between discharge from the hostel to the present or death, as compared with the same time frame for each individual prior to entering the hostel system.

Conclusions: The data adds further support to the potential value of 24 hour nursed care for patients with severe mental illness.

Bipolar disorder (BPD) essentially has its onset during adolescence and early adulthood. It has the capacity to be highly disruptive, dislocating individuals from their normal developmental trajectory and potentially causing significant long-term co-morbidity and chronicity. At a societal level the burden created is greater than schizophrenia. This is not helped by the very substantial delays in its diagnosis and appropriate treatment. Thus, there is a clear rationale for intervening earlier and at a younger age. However, the field of early intervention in BPD is in its infancy. One approach that conceptually provides a basis for early intervention is the Clinical Staging Model (used widely in general medicine). This article outlines how this model helps in an understanding of the emerging stages of BPD. It also summarises the interventions that might be appropriately introduced if a person progresses from an early to a late stage of the illness. Early intervention has a well-established record in psychotic disorders. If it can be realised for BPDs, then it may hold out hope of better outcomes for the next generation of young people at risk.

Abnormalities of circadian rhythms in depressed patients have been noted, including decreased amplitude, distorted waveform, day-to-day instability, and unusual 48 hour periods. Consistent electroencephalographic sleep recording in these patients show a shortened rapid eye movement latency and slow-wave sleep (stages 3 and 4), resulting in an increase in rapid eye movement sleep. This phenomenon appears to be a dependable, measurable marker for diagnosing primary depression. Total sleep deprivation appears to significantly improve mood in a high percentage of depressed patients. Current pharmacological research suggests that drug treatment such as lithium would not affect the intra sleep cycles of the REM stagebut would shift the phase backward and lithium would also shift the phase of circadian rhythm of the daytime sleepiness backward. This paper highlights some of the new approaches for investigating the molecular substrate for the control of circadian rhythmicity and sleep in man and critically examines the hypothesis of the alteration of this mechanism in psychopathology, particularly depression. What is known of the endogenous clock mechanism is discussed with known molecular circadian mechanisms with a view towards understanding how circadian information is transmitted to the rest of the central nervous system and how it is affected in depression.

Objectives: This study explores the gender difference in patterns of drug use, risk behaviour, health and well-being among 934 new attenders at a Dublin syringe exchange.

Method: Over the period May 1997 to April 1998 data was collected by means of structured interviews with all clients who presented for the first time at Merchant's Quay health promotion unit. All information collected was based on clients' self-reported behaviour.

Results: Of the new clients, 24.3% were female and 75.7% were male. The female clients were significantly younger than their male counterparts (p < 0.0001). The women were significantly more likely to report having a sexual partner who was an injecting drug user (OR 9.04, 95% CI, 5.9-13.9) and to be living with an injecting drug user (OR 1.69, 95% CI, 1.2-2.3). They were also significantly more likely to share injecting equipment with their sexual partner (OR = 3.83, 95% CI, 2.7-5.5) and to report recently sharing injecting paraphernalia (OR = 1.79, 95% CI, 1.3-2.5). However, the interval between initiating intravenous drug use and first presenting at the Merchant's Quay health promotion unit was significantly shorter for female clients (p < 0.0001).

Conclusions: One of the most important concerns with regard to illicit intravenous drug use is that of needle sharing, and the associated risks of infection with human immunodeficiency virus and hepatitis. This study highlights the greater personal involvement of women with other drug users, and its consequences in terms of healthrelated problems and risk behaviour. There is a need to address this issue, by taking advantage of the fact that women present for treatment at a younger age than their male counterparts and at a much earlier stage in their injecting career.

Insight is an elusive concept in psychiatry with a long history of divergent definitions and methods of measurements. Although insight was previously presumed to be a binary construct that an individual could possess or lack, there is an emerging consensus that insight is a multi-dimensional construct consisting of a spectrum of phenomena. Over recent years there has been increasing interest in the topic of insight, especially in relation to psychotic disorders where insight is frequently diminished. In this educational review we will discuss the history associated with the construct of insight, current theories in relation to insight, the association of insight with clinical symptoms and prognosis with particular reference to psychosis, the various methods of measuring insight, the aetiology of insight and present deficiencies in our understanding of insight.

Objectives: The aim of this study was to examine the prevalence of, and factors associated with violence in a drug treatment centre.

Method: This study is a retrospective audit of all incident forms completed at an urban drug treatment centre between December 1991 and July 1996 with reference to case notes for additional clinical information on individuals involved in violent incidents.

Participants included all patients attending the centre in the aforementioned time period who were involved in violent incidents. Information was obtained about the prevalence and severity of violent incidents and patient details including main drug of abuse, route of use, reason for attendance, comorbid axis 1 diagnosis, history of previous incidents and HIV status at the time of the incident.

Results: One per cent of all patients were involved in violent incidents. Less than one quarter of incidents involved serious injury or assault. Most perpetrators were male intravenous heroin users on a methadone maintenance programme. Nurses and doctors were most frequently the victims of incidents. Ten per cent of patients had a history of previous incidents and almost half the perpetrators were HIV positive. A comorbid axis 1 diagnosis was found in 9% of perpetrators (n = 6), mainly alcohol dependence syndrome.

Modern methods of investigation in conscious subjects have shown that in normal brain, language is catered for by several essential areas localised in the frontal and temperoparietal cortex and by widely dispersed neurones that serve subsidiary, specialised linguistic functions. These sensory specific, phonological, articulatory and semantic ‘modules’ are activated in parallel. A relatively limited amount of language heard during the sensitive period, when one or other cerebral hemisphere usually becomes dominant for language, is all that is required for any normal child to develop fluency. The specific details of the code, or ‘set’, developed are dependent on the language of the child's environment; they are culturally acquired, but the propensity for language is inborn. During this sensitive period, two languages may be as easily accommodated as one. In stark contrast to the acquisition of natural bilingualism, after about the age of 10 years, any new language is acquired with difficulty for it must be translated into the individual's established language or languages. If a nation is to become bilingual, full advantage of the evanescent sensitive period must be taken by regularly exposing the pre-school child, rather than the older child undergoing formal education, to two languages.

Neurodevelopment is an area of psychiatry which has attracted huge interest in the last few decades. There is substantial evidence that perinatal events can contribute to later development of mental disorder. In the current perspective article we propose a novel polyvagal theory which attempts to link prenatal events with neurodevelopment and the later onset of psychiatric disorder.

We wish to describe a case of gamma hydroxyl butyrate (GHB) withdrawal, including seizure activity in a 34 year old male, who had been taking the substance over a two year period. The syndrome has many aspects in common with alcohol withdrawal (delirium tremens) and benzodiazepine withdrawal (long duration of symptoms), however detoxification presents many challenges for clinicians.

A patient with epilepsy developed panic and agoraphobia. A large right temporo-parietal, arteriovenous malformation was detected. The relationship between these disorders is discussed.

The manifestations of obsessive–compulsive disorder (OCD) may vary across cultures. This is article discusses six case presentations of Arabic Muslim people suffering from OCD and is closely associated with practising religious rituals which tend to dominate the clinical picture. This is particularly relevant to sensory phenomena, which are often perceived as abnormal perceptions or hallucinations. We conclude that these phenomena are not uncommon in OCD and have relevant cultural, diagnostic and therapeutic issues in some cases.

Objectives: Treatment resistant depression (TRD), commonly encountered in clinical practice, leads to socioeconomic disability and therapeutic pessimism. This paper reviews evidence for pharmacological approaches used in TRD.

Method: Electronic literature searches were performed using Medline and Psychlit using broad search terms relating to TRD.

Results: Agents that potentiate both serotonin and noradrenaline may allow more patients to achieve full remission. Attention must be paid to dose titration and length of treatment courses in TRD. Augmentation with lithium and switching within antidepressant class or between classes can often improve symptoms but efficacy of other augmentation approaches remains uncertain. Antidepressant combinations and addition of atypical antipsychotics can be useful but combinations of predominantly serotonergic antidepressants should be avoided. Electroconvulsive therapy retains an important role in TRD but pharmacological treatments need to be continued concomitantly.

Conclusions: Good improvement is seen in TRD after vigorous antidepressant treatment but most patients continue to have lower grade symptomatology.

Neuropsychiatric sequelae in patients with epilepsy have been vastly studied and documented. These may be affective, cognitive or psychotic. Certain risk factors may predispose some epileptics more to these sequelae. In general, good epileptic control may minimize these outcomes. We present in this report, a case of postictal psychosis (PIP), superimposed on delirium, in a 68-year-old woman, with history of a single previous psychotic illness following a cluster of seizures. This report shows a collaborative management of the neuropsychiatric complications of temporal lobe epilepsy (TLE), by the neurology, geriatric medicine and psychiatry teams.

Using urine specific gravity testing to estimate fluid intake Compulsive Water Drinking (CWD) was found to occur, without an age or sex bias, in 19.1% of rehabilitation inpatients in a Canadian psychiatric hospital. Chart review indicated that Water Intoxication had not been a major problem for these patients during their hospitalisation. Nursing opinion appeared to be a relatively weak test for CWD. In a comparison with age and sex matched control patients no significant association with alcohol abuse for the CWD patients or their relatives was found.