We describe a case of primary progressive aphasia (PPA) in a 62 year old right handed Irish woman who had progressive speech and language difficulty over a period of six years. She continued to work for a remarkable length of time and lived independently managing all her activities of daily living. The case posed a diagnostic challenge because initial presentation was suggestive of a conversion disorder. She also displayed signs and symptoms which overlapped with a fronto-temporal dementia and possibly early Alzheimer's disease. In our discussion, we explore the possible reasons for this overlap and the implication for psychiatrists. The need for adequate and sensitive investigations and a multi-disciplinary approach cannot be overemphasised as PPA cases are easily missed depending on the stage at which the patient presents.

William Sealy Gosset [1876-1937] was a brewer in Arthur Guinness and Co. Dublin from 1899 to 1935 when he moved to London. In 1907, writing under the nom de plume Student he published his paper on “the probable error of a mean” which was later developed by R A Fisher into Student's test of significance now in everyday use in biology and industry.

Objective: The assessment of the personality status of Adolf Hitler using a structured interview schedule, the Personality Assessment Schedule, with two informants, one a psychiatrist with an interest in psychohistory and the other a historian with special knowledge of the Third Reich and Weimar Republic. Method: The Personality Assessment Schedule was given in two forms to the two informants at different times; on each occasion Hitler was assessed as he was in 1937. Results: There was considerable discrepancy between the ratings of the two informants, the historian recording less-personality disturbance in all areas of function, although correlations between the two sets of ratings were relatively high (R1 0.5-0.6), with rater bias accounting for the differences in severity. Both informants regarded Hitler as having a dissocial personality disorder (using the new ICD-10 criteria), but the psychiatrist's rating also scored the diagnosis of paranoid and histrionic personality disorders. Conclusions: Interview schedules which use informants to assess personality disorder can be of value in examining the personality status of historical figures.

Objectives: The aim of this survey was to assess current structures for provision of consultation/liaison services to older people in the Republic of Ireland, and to ascertain the proportion of referrals to psychiatry of old age arising from consultation/liaison referrals.

Methods: A postal questionnaire was sent to the 19 public sector, old age psychiatry services, operating in 2005. Information was obtained from 15 of these 19 services regarding the referrals they received in 2005.

Findings: Consultation/liaison referrals make up 36% of total referrals to psychiatry of old age services. Two of 14 services had ring-fenced resources for consultation/liaison work. Three of 14 consultants described their service as having a significant liaison component. Location of the service and the criteria for accepting a referral are associated with the proportion of referrals that are consultation/liaison.

Conclusions: Consultation/liaison referrals make up a significant proportion of referrals. To provide an effective consultation/liaison service ring-fenced resources are required. Despite this recent long term strategies for national service development have neglected this area.

The impact of prenatal alcohol exposure is far reaching and transgenerational but is largely under diagnosed. This has been a major public health concern but remains an area that has lacked attention with regards service development and research in Ireland. There is a need for mental health professionals to have a good working knowledge of the range of deficits associated with prenatal alcohol exposure. Knowledge of these deficits will facilitate identification of affected children for early diagnosis and intervention. This paper reviews available literature on this topic using broad search criteria. The aim of this article is to create greater awareness among professionals working with children in Ireland considering the high rates of alcohol consumption and the fact that most cases of FASD present with chronic undiagnosed mental health problems.

In Ireland, traditionally, most public Adult Mental Health Services (AMHSs) had a small cohort of service users with eating disorders (EDs) in their service. However, over the last 5 years, the National Clinical Programmes have been encouraging Mental Health Services to develop ED programmes in each catchment area. This has culminated in a model of care for EDs for children and adults. It appears that in relation to AMHSs, meaningful inclusion of families/significant other(s) in ED programmes is somewhat inconsistent. This paper will discuss the possible impact of excluding or minimising family/significant other(s)’ inclusion. It will also outline a suggested approach of including families/significant other(s) in a meaningful way in an out-patient ED programme.

Objective: Community organisations provide care for psychiatric patients at multiple levels. With increasing emphasis on joint planning and purchasing of care it is important to ascertain the views of such organisations towards statutory organisations and services the latter provide.

Method: All community organisations working within one inner city catchment area in London were approached in order to obtain their views and experiences on the mental health services provided by the secondary care services. This was a postal survey and non-responders were contacted by personal calls.

Results: Sixty organisations out of a total of 100 in the database responded. More than half had experiences of statutory services and these were generally negative. The services provided were perceived as being rigid and inflexible. A large majority of the organisations wished services to be more flexible as well as provide more training for voluntary organisations.

Conclusion: The survey suggests that the perceptions of the statutory services and co-working with voluntary organisations can succeed only if the two groups work together closely to make good quality community care possible.

Residency training in psychiatry in America is an option which has been little explored by Irish psychiatric trainees, although one which is readily available to them. This article attempts to illustrate this option by providing a brief outline of residency training, and by comparing this with psychiatric training in Ireland or the UK.

A case of post traumatic rapid cycling unipolar mania is described in an individual with no apparent genetic predisposition to an affective disorder. A head injury is proposed as being causative. It is suggested that head injury should be included as a cause of rapid cycling affective disorder.

Objective: The objective of the present study was to examine the use of medication in an elderly psychiatric inpatient population.

Method: This was a retrospective survey of medication prescribed to the total elderly inpatient population of a single psychiatric hospital. Data collected included basic sociodemographic information, length of stay, number of admissions, frequency of psychiatric disturbance, diagnosis and medication prescribed.

Results: A total of 340 cases were studied, 229 (67%) were female, 324 (95%) had been inpatients for more than one year, 111 (33%) suffered from dementia, while the remainder were in the functional category. In 57% more than one psychotropic drug was used. Over half (56%) of those with dementia were on neuroleptic medication.

Conclusion: Psychotropic polypharmacy was found in this population of elderly patients. Management issues emphasised include the risk of polypharmacy in this age group, the need for staff education, an active pharmacy committee and alternative methods of managing behavioural disturbance in elderly patients in particular those with dementia.

Objectives: To describe the drug history and co-existing psycho-social problems among under-19 year olds accessing treatment for opiate dependency, including methadone maintenance, and examine for any gender differences.

Method: A descriptive study of under-19 years assessed at the largest drug treatment clinic in Dublin, Ireland, between October 2000 and September 2006. Data was obtained through review of case notes, assessment questionnaires and urine drug screens.

Results: Eighty-six young people were included. Their mean age was 16.8 years. Forty-six (54%) were female. Only 26 (30%) reported an intact family of origin. Twenty-three (27%) had been in care. Mean age for first use of any illicit drug was 12.4 years, and for heroin was 14.8 years. The mean age of leaving school was 14.4 years; 42 (49%) first tried heroin after leaving school. Forty-one (48%) had a history of homelessness. Forty-four (51%) had previously injected; 26 (30%) were currently injecting. Fifty-six (65%) had not been screened for blood-borne diseases; twenty-one (24%) subsequently tested positive for hepatitis C. Thirty-eight (48%) had previous convictions; 33 (38%) were facing charges. Forty-five (52%) had previously seen a psychiatrist; nine (11%) had received inpatient psychiatric treatment. Boys were more likely to leave school early, have a substance-abusing sibling, and to have a past conviction. Girls were more likely to have a partner, and have taken a deliberate overdose.

Conclusions: This study highlights the multiple and complex needs of teenagers abusing opiates. Services seeking to meet their needs will require a broad range of interventions and excellent interagency co-operation.

Objective: To investigate assertions that Celts have higher rates of alcoholism and mental illness than non-Celts.

Method: The records of 3,000 admissions to Northwick Park Hospital Psychiatric Unit, Harrow (a North West London suburban middle class borough research hospital with a strictly defined catchment area – the London Borough of Harrow: population 200,000), from June 1987 for three years under the clinical care of four consultant psychiatrists, were examined.

Results: There were 683 with non-Celtic names and 175 with Celtic names (16.7%) (data on 10 patients incomplete). 306 (35%) of non-Celts and 88 (50%) of Celts were aged under 40 years. Alcohol dependence (ICD 303) was significantly commoner (p<0.001) among the Celts (35.3%) than among the non-Celts (12.9%). There were highly significant excesses (p<0.001) of native-born Celts with ICD 303 (54%) compared with non-Celts 12.9% or with Celts born outside Celtdom (23%). Patients with Norman names tended to follow the Celts in these respects. There were no differences with respect to the prevalence of psychosis or other ICD categories among Celts and non-Celts.

Conclusion: Doctors should be aware of the high prevalence of alcoholic dependence among people with Celtic names, whether these were born in Celtic countries or not, entertain a high index of diagnostic suspicion and take preventative measures accordingly. However, we found no excess of other categories of psychiatric disorder among Celts as compared with non-Celts. Patients with Norman-derived names seemed to follow the Celts in these respects.

Objectives: To validate the hospital anxiety and depression scale (HAD) in an outpatient alcohol treatment centre.

Methods: Forty three patients referred to an alcohol outpatient treatment centre completed the HAD which was validated against the external criteria of the Montgomery-Asberg Depression Rating Scale and the Clinical Anxiety Scale.

Results: The HAD performed well operating at a cut-off of 7/8 for the depression scale and for the anxiety scale of the HAD the optimal cut-off value was 10/11.

Conclusion: The HAD is acceptable to patients and its use in alcohol treatment clinics is recommended as a screening instrument for anxiety and depression which can easily be administered by non-psychiatrists.

Objective: All patients who resided in state provided long-stay care in Ireland were required to pay the state for that care until 2006. In 2001 the Irish Ombudsman and Information Commissioner had highlighted the issue of the entitlement of people with medical cards to provision of free long-stay care. The Health Repayment scheme was subsequently set up in 2006 to facilitate the repayment of long-stay charges wrongly paid by patients. Issues of mental capacity arise particularly in the context of long-stay psychiatric patients applying for repayment of long-stay charges. Our aim was to devise a test suitable to assess the capacity of an individual to make an application for refund charges.

Method: There was no specific test in existence to assess the capacity of an individual to make an application for refund of charges. A suitable test was devised based on the available literature which assessed whether the person understands the ‘nature and effects’ of making a refund application. Fifty-eight long-stay patients were deemed to be entitled to apply for a refund.

Results: Staff identified 47 (80%) patients as possibly lacking the capacity to make an application. Of these, 14 patients (29.8%) were found to have capacity to make an application (mean age 58.5 years) with 33 (70.2%) found to lack capacity (mean age 73 years). Of those with capacity 50% had a diagnosis of schizophrenia/schizoaffective disorder. None had cognitive impairment of degenerative origin. Of those who lacked capacity 45.5% had a diagnosis of dementia. All of the patients with dementia who were assessed were found to lack capacity whereas 59% of those with a diagnosis of schizophrenia/schizoaffective disorder lacked capacity.

Conclusion: A substantial number of long-stay psychiatric patients may lack the capacity to make particular decisions. In this study the group who lacked capacity were an elderly group with dementia common. This process raised a dilemma about how a patient without capacity to make a refund application can then manage the money claimed on their behalf and whether guardianship safeguards are necessary.

Objectives: De-institutionalisation and the expansion of community services have resulted in a reduction in the number of inpatient admissions in Ireland having fallen by 31% between 1986 and 2006. However, despite this, readmissions continue to account for over 70% of all admissions. The policy document A Vision for Change identified many shortcomings in the current model of provision of mental health services, making recommendations for the future development of community-based services with emphasis on outreach components such as homecare, crisis intervention and assertive outreach approaches. These recommendations are reviewed in relation to readmissions and the impact they may have on reducing the revolving door phenomenon.

Method: Three main intervention programmes essential to the delivery of an effective community-based service outlined and recommended by A Vision for Change, along with other pertinent factors, are discussed in relation to how they might reduce readmissions in Ireland. A series of Pearson correlations between Irish inpatient admissions rates and rates of outpatient attendances and provision of community mental health services are carried out and examined to explain possible relationships between increasing/decreasing admission rates and provision/attendances at community services. International literature is reviewed to determine the effectiveness of these intervention programmes in reducing admissions and readmissions and their relevance to the Irish situation is discussed.

Conclusions: Whilst A Vision for Change goes a long way towards advocating a more person-centred, recovery oriented and integrated model of service delivery, it is apparent from the consistently high proportion of readmissions in Ireland that there are still many shortcomings in service provision. The availability of specialised community-based programmes of care is as yet relatively uncommon in Ireland and uneven in geographical distribution. A considerable improvement in their provision, quantitatively and qualitatively, is required to impact on the revolving door phenomenon. In addition a re-configuration of existing catchment populations is required if they are to be successfully introduced and expanded.