A 57-year-old man with chronic obstructive pulmonary disease (COPD), obstructive sleep apnoea (OSA) and no prior psychiatric history presented repeatedly over 6 months with mental and behavioural changes. Laboratory tests, chest X-ray and sleep study diagnosed an infective exacerbation of COPD, type II respiratory failure and OSA. Differential diagnoses included delirium, primary mania in bipolar affective disorder or organic pathology causing secondary mania. Oxygen, steroids, bronchodilators, antibiotics and non-invasive ventilation were administered to treat his infection and respiratory failure. However, blood gas analysis showed persistent hypoxia and hypercarbia, aggravating his ongoing mental state disturbance that required security supervision and sedation with antipsychotics and benzodiazepines. Sudden onset of classic manic symptoms and multiple presentations suggested secondary mania, driven by chronic hypoxia in end-stage COPD and OSA. The challenge was establishing a balance between mental state control and treatment of physical illness.

Objective: Significant controversy continues to exist in the empirical literature regarding the diagnosis and treatment of mitral valve prolapse (MVP). In addition, there is also inconsistency in the correlation of anxiety disorders as co-existing with MVP, as well as cause and effect issues in terms of the role of the autonomic nervous system, MVP and panic attacks. Recent studies suggest that the co-morbidity of an anxiety disorder and clinical depression appears to increase the likelihood of MVP in predisposed patients. The objective of this review was to examine, clarify, and further define the medical and psychiatric aspects of MVP.

Methods: A literature review was conducted on empirical studies and reviews examining MVP.

Results: It was found that although MVP is highly correlated with psychiatric disorders, the lack of adequate control groups and clear criteria for a diagnosis of MVP in most empirical studies examining these associations make it difficult to determine the relationship between MVP and psychiatric disorders.

Conclusions: Suggestions for further research in the areas of depression and personality characteristics are offered. It is also suggested that the use of control groups from populations with cardiac disorders and a better definition of MVP will clarify many of the problems in empirical studies aiming to determine the relationship between MVP and psychiatric disorders.

Clozapine (Clozaril-Sandoz) is an atypical anti-psychotic drug used for the treatment of resistant schizophrenia. We describe the first fatal outcome as a consequence of neutropenia in the British Isles attributed to the use of clozapine. This death occurred despite proper monitoring by the Clozaril Patient Monitoring Service (CPMS) and full clinical vigilance.

The suicide rate for county Kerry in 1988 was determined by clinical means using postmortem records as a starting point. Sixteen deaths due to suicide were thus identified (eight males and eight females). The official figure for the year is 19 (13 males and six females). Four of the clinically determined suicides did not appear in the official figures. Combining information from both sources gives a figure of 23 suicide deaths, a rate of 18.58 per 100,000. The authors conclude that there are continuing deficiencies in suicide recording practices.

This is a case report on a 57-year-old lady who presented to the Psychiatry Department of Tallaght Hospital after being referred by Neurology Department. She was initially attending Neurology Department for idiopathic Parkinson’s disease which was later refuted as there was no objective evidence of response to treatment. She attended the A&E department with altered consciousness and headache, but her computed tomography of the brain was normal, and was diagnosed with migraine. But it was noted that she was reporting paranoia and auditory hallucinations, and her family had noticed marked change in her accent. On assessment in psychiatric outpatient she was noted to have psychotic symptoms. She reported these symptoms to be ongoing for the last 4 years, but have worsened to an extent that she was extremely distressed by them. She had acquired a Scottish accent. The change in accent coincided with worsening of her psychotic symptoms. Based on her assessment she was diagnosed with schizophrenia and was commenced on olanzapine. Not only her psychotic symptoms resolved but also her accent reverted to native form.

Objectives: To determine to what extent official suicide rates in counties Kildare and Mayo underestimate the rates as clinically determined, and to examine and compare the association between the sociodemographic characteristics of the two Irish counties and trends in the suicide rates.

Method: Populations for the two counties for the years 1988-1994 were calculated. Official suicide mortality data was obtained from the Central Statistics Office. Following examination of the coroners' files for both counties the number of suicides was estimated using clinical criteria.

Results: Neither county showed a significant change in suicide mortality over time from 1988-1994. Suicide was underestimated in official mortality data for each county. There were significant differences in the choice of method of suicide with an excess of drowning in Mayo and of shooting in Kildare. Mayo suicides were more likely to be single and unemployed.

Conclusions: Much local research is needed before implementing suicide prevention programmes due to the many demographic differences and differences in traditions and choice of method of suicide that exist between counties.

A patient in a medium secure psychiatric unit with a 19-year history of treatment-resistant schizophrenia and violence whose mental illness only responded to clozapine, was noted to have a sustained tachycardia. Echocardiography revealed mild biventricular cardiomyopathy. The patient was not significantly affected by this. Initial recommendation from Cardiology was to consider discontinuation of clozapine. It was decided, however, that the risk of worsening psychosis and resultant violence outweighed the risk of the patient’s relatively mild cardiomyopathy. The patient was commenced on ramipril, and later bisoprolol. The patient no longer requires treatment in a medium secure unit and has remained on clozapine with follow-up from cardiology.

Objectives: To review recent use of psychosurgery in Britain and Ireland; to outline the indications and contraindications; and to summarise the Irish experience of psychosurgery.

Method: The Geoffrey Knight National Unit for Affective Disorders (GKU), now based at the Maudsley Hospital has performed the largest number of psychosurgical operations in the last 30 years. This paper reviews criteria for referral and outcome of stereotactic subcaudate tractotomy at the GKU. The twenty-one referrals from Ireland to the Unit, resulting in eight operations over the fifteen year period 1981-1995, are considered separately.

Results: The efficacy of stereotactic subcaudate tractotomy is of the order of 30-60% and there is a low incidence of long-term adverse effects. The outcome of the eight Irish patients who underwent psychosurgery compare favourably with the overall outcome figures for the Unit.

Conclusions: Stereotactic subcaudate tractotomy remains a treatment of last resort in the rare cases of severely treatment-resistant affective disorders and obsessive compulsive disorders.

An audit of Consultant Psychiatrists' views on and uses of antidepressant drugs is reported. At present senior prescribers largely opt for the older tricyclic antidepressants despite a knowledge of their shortcomings. MAOIs are less popular and newer drugs are viewed cautiously and apprehensively. Lofepramine is largely viewed as an alternative to dothiepin and amitriptyline. Non-drug strategies in the management of depression consist largely of support, environmental manipulation and electroconvulsive therapy. The relatively novel treatment, cognitive therapy, has a strong minority following.

The first case in which lithium toxicity and leucocytosis with hypomania appear to have been induced by the selective serotonin reuptake blocking antidepressant, fluoxetine, is described. The possible pathophysiology of this interaction is discussed.

The Coronavirus Disease 2019 (COVID-19) has accounted for more than 25 000 cases in Ireland with approximately 28% of the clusters in nursing homes as of June 2020. The older population is the most vulnerable to serious complications from this illness and over 90% of deaths due to COVID-19 to date have been in patients over the age of 65. Continuing to provide routine care within nursing homes in these challenging times is an essential part of ensuring that presentations to hospitals for non-essential reasons are minimized. In this article, we describe a project being undertaken by a rural Psychiatry of Old Age Service in the northwest of Ireland. We aim to provide ordinary care in extraordinary times by using mobile tablets within the nursing homes and long-stay facilities in our region for remote video consultations during the COVID-19 crisis.

Autism spectrum disorder (ASD) is frequently identified in children but is often unrecognised in adults. ASD is characterised by difficulties in social interaction, communication and restricted interests, but other presentations are common, especially in adults. This report describes a 34-year-old man with a history of multiple psychiatric diagnoses including generalised anxiety disorder, major depressive disorder and panic disorder. He was diagnosed with ASD in his early 30s and engaged in a targeted treatment plan, including rationalisation of medications, supportive therapy and occupational therapy, which successfully facilitated discharge from mental health services. This case illustrates the atypical presentation of ASD in adults, which is diagnostically challenging. Such cases often present to community mental health services and may be misdiagnosed as treatment resistant cases of depressive, anxiety or personality disorders. Accurate diagnosis and targeted management is more likely to yield a successful outcome.

Objective: In recent years a number of articles have highlighted deficiencies in drinking histories taken by junior doctors. This study examines whether standards have improved as a result. It also examines for the first time: 1. the quality of drinking histories taken from patients following parasuicide; and 2. the quality of illicit drug usage histories.

Method: An audit of case notes was undertaken of 114 patients admitted to a district hospital's acute psychiatric wards or assessed following overdose. Two periods were considered; one preceding many of the articles, and the second four years later.

Results: There was an overall improvement from 58% of histories in 1988 having no mention of alcohol usage to 25% in 1992. (X2MH=10.57, p<0.01). There was, however, insufficient improvement of quantitative histories to reach statistical significance. Histories taken as part of an overdose assessment were not significantly different from those taken for inpatient admission. In 1992, 27% of patients had any illicit drug usage history recorded which represented a statistically significant improvement (X2MH=5.91, p<0.02) compared with four years earlier.

Conclusions: Although improvements have been noted, alcohol and drug histories remain inadequate.