The clinical and demographic features of 100 bipolar disorder patients, who were categorised into bipolar I, bipolar II, unipolar mania and rapid cycling groups, and who were further classified on the basis of the sequence of occurrence of the manic and depressive episodes within each cycle, are compared. Bipolar I (including unipolar manic) patients, 77% of whom had a sequence of moods where mania preceded depression (Mania-Depression – normothymic Interval: M.D.I.) constituted 69% of the total sample. Six per cent were classified as bipolar II and 25% has a rapid cycling disorder. Patients who had an M.D.I. sequence of moods, whether rapid or non-rapid cycling, had a younger age of onset, a higher male:female ratio and a stronger family history of bipolar disorder than patients whose depression preceded mania (D.M.I.). Unipolar manic patients, 12% of the sample, had a comparable age of onset, a greater family history of bipolarity and more frequent hospitalisations than the bipolar I-M.D.I. group. Rapid cycling patients had a lower mean serum thyroxine concentration than the non-rapid cycling bipolar disorder patients. This study supports the rationale for distinguishing bipolar patients with an M.D.I, sequence from those with a D.M.I, pattern and rapid cyclers from non-rapid cyclers.

The treatment outcome of 100 bipolar disorder patients (B.P.) was examined retrospectively to determine whether bipolar subtypes had a differential prophylactic response to lithium, carbamazepine, neuroleptics and antidepressant drugs when these treatments were given in a predetermined sequence. Sixty-eight per cent of 53 B.P.-I patients with a mania-depression-normothymic-interval (M.D.I.) sequence of mood changes had a good response to lithium, and all but one of the remainder responded with the addition of carbamazepine or an antidepressant. While only 17% of 12 unipolar manic patients achieved prophylaxis with lithium and a further 17% when carbamazepine was added, the other 66% remained normothymic when a neuroleptic was prescribed with lithium. Of the seven rapid cycling patients where depression preceded mania, 28% had a good prophylactic effect with lithium, a further 28% when a tricyclic antidepressant was added and 14% with lithium and carbamazepine. None of the 18 rapid cycling M.D.I. group had a good response to lithium, but 39% stabilised when carbamazepine was added to lithium. Twenty-eight per cent of this group failed completely to respond to any of the treatments used. Neuroleptics increased the severity and duration of depressive phases for all subtypes except the unipolar mania group.

A one year cohort of referrals (n=178) to a primary care based psychiatric clinic in a large Health Centre is described. Fears that such a clinic might detract from treatment provided for psychotic patients seemed unfounded. Waiting time for assessment was short and patients were more likely to attend than at hospital based clinics. Admission rates were considerably reduced. Contact between patients and their general practitioner seems to continue at a high level even during psychiatric intervention but half of the “frequent attender” group cease contact. The pattern of attendance on follow-up suggests that many patients may receive unnecessarily long out-patient care.

The evidence to date suggests that such clinics provide a useful service but other aspects of quality of care require evaluation.

Objective: This study is designed to evaluate a hospital based integrated service for the comprehensive delivery of care and treatment to patients with schizophrenia, on epidemeological, cost effectiveness, and quality of life parameters. Methods: All patients with an ICD9 diagnosis of schizophrenia who received services from the St. Lomans Catchment area during a 2 year period were evaluated for service utilization during a subsequent 2 year period. Data was collected on basic demographics for the epidemiological aspects of the study, and for all aspects of services utilized, eg. day hospital attendance, inpatient bed useage, time spent with psychiatrist, community nurse visit or clinic visit. Costs for all services were calculated using disaggregate cost data. Quality of life of the patients was assessed through the Lehman quality of life questionnaire administered to every third identified patient. Results: 572 schizophrenic patients were identified from the case register and case records search. An analysis of the data indicated no difference in age of first contact with services on rural/urban or male/female comparisons contrasting with previously reported findings. Males tend to utilize proportionately more services in both rural and urban settings. Inpatient hospitalizations contributed the most to per patient costs and a small group of patients, comprising less than 5% of the total population, consumed 10% of the total costs consumed by all diagnostic groups and 30% of the costs of all schizophrenics. Non-hospitalized patients experienced the highest quality of life ratings. Conclusions: Hospital based community services to schizophrenics can be run cost-effectively. There remains a small subgroup of schizophrenic patients who are hard to place or treat in the community and they consume a disporportionate amount of the hospital's costs. Services that attempt to establish patients in the community can do so cost effectively provided there are hospital inpatient beds available as a back up. The benefits of this type of comprehensive service delivery to the schizophrenic population served are demonstrated.

Objective: To compare the perceived accuracy of diagnostic information derived from psychiatric patients and a range of other informants using a schedule for assessing personality disorders (Personality Assessment Schedule). Method: The Personality Assessment Schedule includes a rating of reliability of the information obtained from whatever source. A record was made of these reliability scores in 405 patients with psychiatric disorder; 146 with both subjects and other informants and 259 with the informant only, and analysed using non-parametric statistics. Results: There was significant variation in the distribution of scores among the four psychiatrists who rated 232 of the interviews with informants, suggesting that inter-individual differences are paramount in deciding who is a reliable informant. Nevertheless, the views of other informants when they were spouses or cohabitees were judged to be more accurate than those of other relatives or acquaintances. No differences were found in the perceived reliability of data from subjects and informants when both were interviewed separately. Conclusions: Subjects and informants are judged to be equally reliable in giving assessments of personality status but the informants who have the closest relationship to subjects, spouses and cohabitees, are judged superior to informants of more distant immediate relationship in the accuracy of their information about personality status.

The concept of the child psychiatric unit is considered. The character, capacities and activities of one unit are described and some features of the admissions over its first 21 years are discussed in relation to the findings of other studies. Among the factors considered are the patients' presenting diagnoses, their sex, their physical health and their length of stay in the Unit. Some possible future directions for the Unit are discussed, and the pattern of work over the two decades covered by the study is related to current and future requirements. It is suggested that for several categories of disorder, a child psychiatric unit offers unique advantages in both assessment and treatment.

Forty seven patients with idiopathic Parkinson's disease (PD) were assessed to ascertain the presence or absence of emotionalism. Thirty eight per cent of the sample reported being more tearful since the onset of PD than previously. Five patients (10.6%) were found to exhibit emotionalism according to specified criteria. Emotionalism in PD is not solely associated with lowered mood or global cognitive impairment.

Objective: To determine the influence of the legal system on new attenders at an alcohol treatment unit. Method: One hundred and forty seven new patient referrals to an alcohol unit were examined prospectively over a four month period. Data were obtained by standard psychiatric interview, drinking history inventory, Severity of Alcohol Dependence Questionnaire and a detailed questionnaire of present and past legal involvement. Subjects were then followed up and the numbers remaining in treatment after the first visit and after one month ascertained. Results: Both legally referred and non-legally referred groups had significant past legal involvement while those attending under legal pressure were found to be as severely addicted as other referral types and to have no greater drop out rate from treatment. Conclusion: It is suggested that legally pressured attenders should be accepted into treatment as readily as other referral types and that greater liaison between the criminal justice system and alcohol treatment units is required.

Objective: The aims of this study were to assess the procedures for involuntary admission to both public and private psychiatric hospitals as determined by the Mental Treatment Act, 1945 which is one of the oldest pieces of mental health legislation in the EC. Method: Over a prospective five month period all involuntary admissions to both a public and a private hospital in Dublin were studied. Social-demographic data and clinical features of 54 involuntary admissions were recorded and analysed. Results: 11.2% of public admissions were involuntary as were 3.4% of admissions to the private hospital. The most common diagnoses were schizophrenia and mania. 74.1% of the patients had been previously admitted. 81.5% of the patients were detained in hospital for less than three months although they were committed for a potential six months. There was no formal method of decertification. Conclusions: There appears to be little need nowadays for differentiating between legislation for public and private patients. The duration of the initial reception order should be reduced from six months to a period of forty-eight hours for initial assessment and treatment. If necessary this could be extended to three months. Formal methods for decertification are required. Mental health legislation in Ireland needs to be modernised.

Between 1975 and 1985 there was a significant increase in the total number of admissions for mania and schizophrenia and a significant decrease for personality disorder to the Royal Edinburgh Hospital. All admissions for 1975 and 1985 in these three groups were subsequently examined retrospectively. The number of first admissions for personality disorder dropped significantly and the number of readmissions for mania increased significantly. Patients with schizophrenia and personality disorder had shorter admissions and a shorter relapse-free interval in 1985 but the overall effect of these changes was to reduce the total number of bed days used by these groups. For mania there was no change in admission length but significant shortening of the relapse-free interval leading to a substantial increase in total bed days used. There was no evidence that a change of diagnostic practice had occurred or that patients admitted with mania in 1985 were less ill. Although there were changes in referral and after-care arrangements, these were not specific to mania. Further work should specifically address the issue of aftercare arrangements and their influence on prognosis in mania, and the resource implications of the continuing rise in admissions.

Objective: This study investigated the frequency of abnormal Dexamethasone Suppression Test (DST) in a randomly selected group of mentally handicapped subjects. Method: Forty three subjects living in the community were selected and assessed on a variety of clinical rating scales including Hamilton Rating Scale for Depression (HDS) and Wessex Case Register Form (WCRF). DST was conducted on all the patients and the findings correlated with demographic and clinical variables. Groups defined by DST status were also compared using t-test. In subjects who showed an abnormal response, clinical assessments and DST was repeated after 3 months. Results: Only 7 of 43 subjects showed an abnormal response which did not correlate with either the severity of affective symptoms or the presence or absence of behavioural difficulties. Six of the 7 DST positive subjects were either severely or profoundly impaired on DSM-III criteria indicating that the underlying brain pathology may be pathogenetically important. This was supported by the observation that abnormal DST response was enduring at follow up. Conclusions: The findings suggest that DST may be of little value as a diagnostic tool in the mentally handicapped.

Objectives: To describe existing Scottish psychiatric emergency services, particularly the staffing levels and supervision of junior staff, to assess the level of recording of the urgency of referrals to such services and to determine the approximate rates of emergency presentations. Method: A postal questionnaire was sent to all 29 Scottish psychiatric hospitals, addressed to the physician superintendent or the consultant in charge of emergency services. Twenty-six were returned and further details on these and the other three services were clarified by telephone contact with medical records and medical staff. Description of services, number of presentations, staffing levels and degree of supervision were recorded. Rates of referral were estimated for Health Board populations. Results: Services varied from hospital based walk-in clinics through to community orientated domicillary assessment services. Emergency presentations are usually seen by junior staff in a psychiatric hospital outpatient department, a psychiatric ward or at an accident and emergency department. Out of hours supervision is typically by telephone advice from a consultant. Rates of emergency presentations based on collected and estimated figures were highest in urban areas. Conclusions: Scottish psychiatric emergency services are disparate in nature but all provide a 24 hour service. There is a lack of reliably collected data on the urgency of referrals but estimates suggest that there is a greater need for emergency psychiatric care in the large urban areas. Working definitions are proposed to assist in the classification of the urgency of referrals.

Records of the war service disability claims for Australian Vietnam veterans in Tasmania (n = 751) were analysed to establish patterns of interrelationships between categories of disability. The predicted relationship between psychiatric disability and stress related skin disabilities was strongly supported and relationships between psychiatric and other medical disabilities were found. An exploratory principal components analysis produced three independent components which accounted for 21.2 percent of total variance. Component 1 was interpreted as a general military service component and components 2 and 3 were labelled as stress components. The most likely interpretation of the two stress components was that they reflect differences in profiles of records for disability claims depending on the time when the disability presented. The relevance of the findings is discussed.

Objective: Diogenes syndrome or the senile squalor syndrome is characterised by gross self neglect, domestic squalor and social withdrawal. Two series of such patients have been described in Britain. This paper examines the frequency and characteristics of the syndrome in an Irish urban population and discusses the management issues involved. Method: Detailed demographic, social, medical and psychiatric data was collected on all patients fulfilling the criteria for Diogenes syndrome who were referred to the North Dublin Old Age Psychiatry Service over a two year period 1989-1990. Results: Twenty nine cases (5% of all referrals) were identified giving an incidence rate of 0.5% per annum. Most were single or widowed (83%), and living alone (72%). 79% were known to the public health nurse and 59% had at least one medical problem. The commonest reason for referral was self-neglect. Thirteen suffered from senile dementia, three had schizophrenia, three were alcohol dependent and 10 had no psychiatric diagnosis. Subsequently, 12 patients remained at home, 12 moved into residential care and five died. Conclusion: The patients in this Irish series resemble those in the two British series. Management issues emphasised are the need to consider each patient as an individual and to balance risk with the right to self-determination. The role of care teams for the elderly in overall management is discussed.

Objective: To survey suicides occurring in Waterford City and County in 1990, to calculate a suicide rate for the region and to examine a series of drownings which occurred during the study period. Method: A catchment area study was carried out with information being collected from coroner's reports, police records, postmortem reports and other sources. Cases were defined by clinical criteria. Results: 13 males and 1 female were considered to have died by suicide, giving an estimated suicide rate of 15 per 100,000. Demographic characteristics and prevalence of psychiatric morbidity conformed broadly to national trends. Conclusion: Structuring a study to deal with suicides within a particular catchment area allows ready access to detailed information from local sources and yields information of special interest and significance to the psychiatric services of the area. Study of a series of drownings in young adult males in 1990 which had aroused much local concern illustrates the difficulties in categorising deaths accurately by this method.