Psychosis is often a traumatic experience that can lead to significant suffering. However, people may also experience posttraumatic growth following psychosis. Posttraumatic growth refers to the positive changes that people experience following a struggle with an adversarial event and has been shown to occur in at least five domains, including a greater appreciation for life; improved relationships with others; greater personal strengths; new life possibilities and spiritual/existential growth. Studies have shown that mental health services can play a key role in facilitating posttraumatic growth. However, there are no recommendations that clinicians can follow to best support posttraumatic growth following psychosis specifically. Without guidance, clinicians risk invalidating people’s experiences of, or providing improper support for, posttraumatic growth. To address this knowledge gap, we reflect on current research and clinical guidelines to recommend ways that clinicians can support posttraumatic growth following psychosis.

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.

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.

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.

A case of acromegaly presenting as psychotic depression is described. The relationship between psychiatric symptoms and acromegaly is reviewed and the importance of considering an organic diagnosis in a psychiatric syndrome arising de novo in later life is highlighted.

Objectives: There is a paucity of data concerning the prevalence of alcohol use disorders and binge drinking in the general hospital adult population in Ireland. We therefore examined the point-prevalence of alcohol use disorders and of binge drinking in the adult inpatient population of the acute wards of an Irish university teaching hospital. The secondary aim was to examine gender, age, and patient group (medical/surgical) as risk factors.

Method: We administered the Alcohol Use Disorders Identification Test (AUDIT) to all consenting patients (n = 126) on the acute adult medical and surgical wards over one day.

Results: 76% of all inpatients on the acute medical and surgical wards were interviewed (n = 126) using the AUDIT.

Of the subjects 28% screened positive for an alcohol use disorder. Of these 91% were identified as binge drinkers.

A further 8% of the subjects screened positive for binge drinking but were not identified as having an alcohol use disorder.

Overall, 36% of the subjects screened positive for either an alcohol use disorder and/or for binge drinking using the AUDIT.

Male gender and under 65s were risk factors for both alcohol use disorders and binge drinking.

Conclusions: The high point-prevalences of alcohol use disorders and binge drinking in hospital inpatients in particular are a cause for concern as they may have illness complicated by or secondary to undiagnosed alcohol excess. As this population is an easily accessible group for screening, and clinical and economic evidence supports intervention, we recommend screening all acute hospital admissions for alcohol use disorders and binge drinking, followed by appropriate management.

Background: Most children who have Asperger's Syndrome (AS) are not identified until early school age, when social difficulties with other children become evident. Consequently, primary school teachers have an important role to play both in the recognition and management of the condition.

Objectives: Our study sought to examine the perception of primary school teachers regarding the recognition and management of AS.

Methods: A structured questionnaire on the recognition and management of AS was circulated to all 90 primary school principals in the Fingal County of Dublin for them to copy and distribute to teachers in their schools for completion. Self-addressed envelopes were provided to each principal for the return of completed questionnaires.

Results: Three hundred and forty-three completed questionnaires were returned by 54 out of the 90 school principals. Fifty-eight per cent of respondents reported that they had ever taught a child with the condition and 49% reported that recognition and management of emotional and behavioural disorders was covered in their undergraduate training. Some 78.4% said that they would recognise the symptoms of AS in a child, with those who had training on the recognition and management of emotional and behavioural disorders being more likely to report that they would recognise such symptoms while 71.1% said children with AS should be taught in mainstream classes. However, 77.3% did not think mainstream schools are presently adequately resourced to cater for children with AS. Some 96.2% said they would like to receive in-service training from the Child and Adolescent Mental Health Services on the detection and management of children with AS.

Conclusion: There is a need for formal in-service training for all primary school teachers in the recognition and management of children with Pervasive Developmental Disorders (PDD). The recognition and management of children with PDD should also be included in the curriculum of all undergraduate teacher training institutions in Ireland.

Objectives: To examine the mental health status of homeless children and their families living in a supported temporary housing project.

Method: The assessment measures used: (i) the 28-item General Health Questionnaire (GHQ); (ii) the Child Behaviour Checklist (CBCL); and (iii) the Parenting Stress Index (PSI). The population studied consisted of 14 families and 31 children. Children aged two to 16 years were eligible for the study. Most of the families (12/14) assessed were single parent (mother only) family units.

Results: The General Health Questionnaire was completed by the 14 mothers and two fathers. Of the mothers 28% (4/14) indicated the presence of psychiatric ‘caseness’. The Child Behaviour Checklist (CBCL) was completed on 31 children by the mothers. More than a third of the children (12/31) had a Total Problem Score above the ‘clinical’ threshold, indicating the presence of mental health problems of sufficient severity to merit referral for treatment. Of the children 45% (14/31) manifested externalising problems in the ‘deviant’ range, while 29% of the children (9/31) manifested internalising problems in the ‘clinical’ range. In all, when the CBCL scores were examined within each family, 78% (11/14) had at least one child with a CBCL dimension of clinical significance. The Parenting Stress Index was completed by each mother. Of the mothers 70% (10/14) obtained scores in the critical range. They reported feeling incompetent in their parenting role, being dominated by their children's needs and feeling social isolated from their relatives and peers. Their scores also indicated poor self-esteem and significant depressive symptoms. Of note the peak score was the lack of emotional and active support from the other parent.

Conclusion: This study revealed a high level of stress and clinical morbidity in this group of homeless mothers and their children and the need to provide appropriate mental health supports and services for them.

Depression will be the second leading contributor to the global burden of disease by 2020. In Ireland, in 2009, 6061 people were hospitalised with depressive disorders. This represents a significant economic and social burden. There is growing awareness of the difficulty in treating depression with medications alone. The likelihood that a patient will achieve remission with the first antidepressant tried is around 30%, and the rates are similar for the second antidepressant tried. This falls to around 15% after three trials. Many patients are exposed to pharmacotherapy for extended periods of time with little beneficial effect, but often with side-effects. Patients are therefore in great need of clear information with regard to their chance of success. Clinicians are in need of clear guidance on prescribing strategies which have proven efficacy. However, this guidance often discusses treatment strategies based on varying levels of evidence. Guiding bodies may approach the problem from varying perspectives. The UK National Institute for Health and Clinical Excellence (NICE) has a clear government mandate with regard to provision of not only effective but cost-effective treatments. The British Association of Psychopharmacology (BAP) is an independent body of interested researchers and therefore may discuss prescribing options from the point of view of tertiary care institutions, and university centres. The South London and Maudsley NHS Foundation Trust publish the popular Maudsley guidelines. These are perhaps more pragmatic in nature, but include very low levels of evidence, including case series.

The American Psychiatric Association (APA) is an independent member association which also publishes guidelines. These are published in the American Journal of Psychiatry and the latest guidelines were published in October 2010.

All these bodies attempt to weigh their advice according to the level of evidence available and aim to provide clinical guidance in difficult situations. The burden on guiding organisations is to provide some direction and clarity in areas that are often unclear or controversial. Clinical guidelines are one method of providing support and guidance to busy clinicians. However, this clinician-centered approach has limitations. The onus is on the authors of the guidance to provide ever-more treatment options. This may mean that conclusions about the efficacy of medications is overstated or the limitations of the literature not fully explored in explanatory notes.

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

Welcome to the first module in our Continuing Professional Development Section (CPD). CPD is now a key element in the clinical activity of all health professionals and a cornerstone of good clinical governance throughout mental health services. This section of the Irish Journal of Psychological Medicine will provide CPD modules dedicated to key topics in mental health care. In order to assist learning and self-assessment, multiple choice questions will be provided at the end of each module.

This module and its multiple choice questions are available online on the website of the Irish Journal of Psychological Medicine (www.ijpm.org). The CPD policy of the College of Psychiatry of Ireland indicates that psychiatrists who participate in suitable online learning which fits the criteria for CPD may claim CPD points under the Personal CPD category (up to a maximum of 5 points per year).

We are confident that this CPD Section of the Irish Journal of Psychological Medicine will prove to be a valuable resource for consultant psychiatrists, psychiatric trainees and all journal readers. We welcome feedback from readers and, especially, any suggestions for topics to be covered in future CPD modules. Suggestions should be emailed to: [email protected]

Objectives: This study examined and compared the number and pattern of referrals from neurosurgery and neurology specialist services to the inpatient liaison neuropsychiatry service in the years 2002 and 2005. We estimated the prevalence of psychiatric illness and evaluated the results of subsequent psychiatric assessment and follow-up of all patients reviewed by the neuropsychiatry service.

Methods: The medical notes of those patients referred to the neuropsychiatry team were retrospectively examined to obtain appropriate information on assessment and management of these cases.

Results: There were 544 referrals over the two years selected for study. Rates of referral to the inpatient neuropsychiatry service increased overall by 35% between 2002 and 2005. Overall, referrals from neurology comprised 85%, neurosurgery 15%. Patients with epilepsy comprised the majority of referrals (36%). A total of 378 (73%) had an acute psychiatric disorder and this group had a significantly higher rate (p = 0.01) of past psychiatric disorder (40%) than that in those with no acute mental illness (33%). Depressive episode was the most frequent acute psychiatric diagnosis (38%), followed by anxiety and organic psychiatric disorder (both 15%). Overall, 21% of patients diagnosed with acute mental illness were referred on discharge to the neuropsychiatry outpatient clinic for specialist follow up and the remainder followed-up by either local mental health teams or their GP.

Conclusions: These findings provide clear evidence that further resources should be allocated to expanding neuropsychiatry mental health services to improve detection and management of mental illness in this vulnerable patient group.

Objectives: We aimed to further our understanding of the concept of recovery by analysing comments made in small group discussions that occurred on a planning Away Day held by a community mental health team along-side service users and carers, which had recovery as its theme. The purpose of this was to reshape the structure and workings of the team.

Method: Five small groups, of approximately 10 individuals each, comprised of service-users, carers, representatives from voluntary organisations and mental health professionals were asked to discuss three questions related to Recovery.

Results: The commentary reflected previous qualitative research on the philosophy of recovery. Issues that were raised included defining wellness as independent to illness, constructive risk taking, the importance of social factors, medication issues and the importance of self-management and optimism. The comments subsequently went on to shape community mental health team service delivery.

Conclusion: Discussion and reflection between mental health professionals, service users and carers can lead to a change in attitude and practice in a well-resourced, fully multi-disciplinary community mental health team, within which both the biological and non-biological aspects of mental illness are accepted. The result has been an introduction of service changes which have helped develop a team that is more accessible and increasingly collaborative.