Objective: To measure the level of commitment by mental health care professionals within the Eastern Health Board to the concept of community mental health.

Methods: An adapted version of the Baker-Schulberg Community Mental Health Ideology Scale was administered to a random sample of professionals (psychologists, psychiatrists, psychiatric nurses, community psychiatric nurses, social workers and occupational therapists).

Results: Psychiatrists within this study had the lowest scores indicating the least level of commitment, and were also found to focus upon extrinsic issues, such as economic barriers, as possible obstacles to the development of a community mental health service in Ireland.

Conclusion: Policy and decision making committees need to address the balance of the mental health care professionals represented on those committees.

Three cases of schizophrenia (DSM-III-R) (l), whilst responding to treatment, exhibit a group of symptoms which had the essential features of “flashbacks”, as described in relation to psychedelic drugs, though there was no evidence of psychedelic drug misuse. Symptoms were characterised by memory flashes of the original psychotic experience, followed immediately by very brief re-experiencing of earlier symptoms, including visual perceptual changes in clear consciousness and full insight. Symptoms were less clear, less severe, but more distressing, than the original episodes. Symptoms were triggered by stress/anxiety, and relieved by an anxiolytic. The association of flashbacks with schizophrenia is discussed.

First admissions for schizophrenia to inpatient psychiatric services in Ireland are declining. The reason for this decline has been debated and it has been proposed that it could be attributable to either a decline in incidence or to policy changes or to both.

Objectives: This study examines the trends in first admission numbers for schizophrenia in Ireland and the influence of gender and marital status on age at first admission over the time period 1971-2004.

Method: Data were derived from the National Psychiatric Inpatient Recording System (NPIRS) for the years 1971-2004 inclusive. All first admissions with a diagnosis of schizophrenia during these years were included in the analysis.

Results: The results showed a significant decline in the number of first admissions with the number of first admissions for males exceeding those for females. The average age of first admission was higher for females than males (p < 0.001). The average age of first admission showed a decline for males (p < 0.001), but not for females. Marital status was a stronger predictor of age of admission than gender (p < 0.001). Never married persons had a lower age of first admission than those married and the delaying effect of marriage on age at first admission was evident in males and females (p < 0.001).

Conclusions: An examination of first admission hospital data confirm male disadvantage in schizophrenia. The study highlighted a number of areas for future research which include examining gender differences in more refined diagnostic sub groups of schizophrenia and the monitoring of first contacts with community-based mental health services.

Bipolar disorder can emerge in the context of organic brain pathology. In the case presented, long-standing hydrocephalus was diagnosed in a man with relatively late-onset bipolar illness who presented initially with somewhat atypical, treatment-resistant depressive symptoms. Hypomania, followed by a rapid-cycling bipolar course, subsequently developed. This report reviews the association between bipolar disorder and hydrocephalus, and examines possible neurobiological mechanisms implicated in both conditions.

Objective: To quantify the perceived discrepancies between the medication that GPs believed their patients were taking and that which was recorded on admission to acute psychiatric wards.

Methods: A prospective survey of 107 consecutive admissions to a Swansea psychiatric hospital was carried out.

Results: In 62% of patients studied, there was at least one discrepancy each and in 33%, the discrepancies were considered potentially clinically significant.

Conclusions: The study showed a significant number of potentially serious discrepancies in medication at the GP-Hospital interface and highlighted the need for improved communication between GPs and their psychiatric colleagues. The possible reasons for the discrepancies and the implications for communication between primary and secondary care for psychiatric patients are explored.

Therapeutic drug monitoring of tricyclic antidepressants is a controversial issue. A case is reported in which a patient with recurrent depression developed asymptomatic tricyclic toxicity while on trimipramine, a tricyclic antidepressant, and diltiazem, a calcium channel blocker. A metabolic interaction involving cytochrome P450 3A (CYP3A) is postulated. It is suggested that routine therapeutic drug monitoring of tricyclic levels should be an essential part of the management of depression.

A service based on the principle that the comprehensive mental health needs of a community can be more efficiently met by supporting the existing primary care services has been developed in the North Aylesbury Vale, Buckinghamshire, England. The Buckingham Project is a home-based mental health service and caters for a rapidly expanding rural community of approximately thirty five thousand people between the ages of 16 and 65 years. Professional support is provided to the services and care already provided by primary health care teams, social agencies and above all, by families. Specially trained nurses work as specialists within the primary care teams in the area. Initial consultation is provided on the day of referral, often in the patient's home. Cost effective management approaches are employed throughout. The emphasis is on early detection of major mental illness and immediate intensive treatment using cognitive/behavioural treatment methods, and targeted low dose medication where necessary. The approach differs from the traditional hospital-based specialist services.

Objectives: The aims of the audit were to monitor the activities of the liaison clinic over a 12 month period, to establish the number of attenders and non-attenders and to evaluate whether the service was meeting the needs of patients with perinatal disorders.

Method: The Coombe Women's Hospital is one of three maternity hospitals in Dublin and had 6,452 deliveries and 5,273 inpatient gynaecological procedures performed in 1994. The charts of all the patients who were given an appointment for the psychiatric clinic between January 1 and December 31, 1994 were reviewed.

Results: Fifty-six patients attended the clinic over the 12 month period, 38(68%) of whom were new referrals to the service. Twenty-two patients were antenatal, 20 were postnatal and 14 patients were attending the gynaecology department. Seventeen patients (30%) who were referred to the clinic failed to attend for their first appointment. Forty-one (73%) patients had sufficient symptomatology to make an ICD-10 diagnosis. Medication was prescribed for 58% of those who attended. Four patients were referred to their catchment area service for inpatient care: six patients were referred to their catchment area service for further outpatient care as they had psychiatric illnesses which predated their pregnancies.

Conclusions: The number of patients referred to the liaison service with postnatal depression is remarkably less than that anticipated and there is a high rate of defaulting among first attenders. Various recommendations are made to improve the effectiveness of the service.

What is probably one of the most exciting potential advances in psychiatry is occurring slowly, possibly too slowly and has gone unnoticed by many. I am talking about ‘Chaos theory’, which is a mathematical concept that has influenced the study of such diverse subjects as the weather, evolution and the electroencephalogram. Is it our lack of mathematical training that makes us so fearful? This may be so, but we can still understand chaos theory without having to learn large mathematical formulae.

Chaos theory is about dynamic non-linear systems that are orderly at first, but may become completely disorganised over time. That is initial conditions that are alike in the beginning, may have markedly different outcomes over time. An analogy commonly drawn from weather studies is the butterfly effect. This draws on the premise of initial conditions which is a butterfly fluttering its wings in Tokyo can lead over time and distance to a storm for example over New York. In other words a small perturbation in a non-linear system can lead to great variations in outcome. The chaos theory is about how phenomena can vary between different kinds of states around what is called a ‘strange attractor’ and obtain from this a semblance of order out of what initially can be perceived as disorder.

In this way chaos differs from random behaviour and causal systems. Eventual outcome in a random system is not determined by initial conditions. The eventual outcome in a causal system has a linear relationship with its initial conditions. In other words a small change in initial conditions will lead to a small change in the eventual outcome. But in Chaos theory a small change in the initial conditions can lead to major changes in the eventual outcome. These changes become exponential over time.

The original example of a chaotic system was developed by Lorenz. In his early work on weather systems he found using computer simulations that started with similar, but slightly different initial data, orbits would stay close to each other for a while but would eventually diverged in a manner that turned out to be exponential over time. His model was deterministic, that is the orbits were unique in the sense that there was only one orbit passing through a given point of the space in which the orbit lay. The three variables he was measuring were convective air circulation in relation to vertical and horizontal temperature variations.

A 54 year old woman presenting to the psychiatric services with persecutory delusions, complex visual hallucinations and fluctuating levels of consciousness was discovered to have a meningioma occupying the cerebellopontine angle. The psychiatric symptomatology of cerebellopontine angle lesions is reviewed and the pathogenic mechanisms are explored in the light of the symptomatology observed.

Objectives: Second opinion is a medical opinion provided by a second physician/ medical expert after first receiving an opinion by another physician/ medical expert. Little is known about the provision of second opinion in Child and Adolescent Mental Health Services (CAMHS). This study describes the second opinion service provided by the Child and Adolescent Mental Health Services (CAMHS) in the South Wales region.

Methods: We undertook a survey of a second opinion service in Child and Adolescent Mental Health Services (CAMHS). We also assessed whether the recommendations made by the second opinion clinic were implemented by the referrers.

Results: The diagnoses were not changed in 68% of the cases but alternative treatments were suggested. In 90% of the cases the treatment recommended by the clinic was implemented and nearly 70% of the patients showed improvement with the recommended treatment.

Conclusion: A second opinion service can provide valuable support and expertise to CAMHS and the referred families.

A case of chronic disulfiram (Antabuse) toxicity is described, in the context of a literature review, apparently the first such description from Ireland. The rare combination of encephalopathy with peripheral neuropathy occurred in this case, along with other probably related features. These included a fluctuating clinical course, cerebellar ataxia, grand mal seizures, impotence and a delay in improvement on discontinuing disulfiram. It is likely that symptoms of anxiety and depression in this man were also in part induced by disulfiram toxicity, but interpretation of events is complicated by developing arteriosclerosis. The difficulties in distinguishing toxic effects of disulfiram from complications of chronic alcoholism are emphasized, with resulting delay in recognizing disulfiram toxicity.