Objective: This study reviewed all inpatient admissions in a community oriented old age psychiatry service with the aim of assessing the appropriateness of admission criteria, obtaining a profile of those admitted, and providing information about service utilisation.

Method: A retrospective chart review of all first inpatient admissions from 1989-1993 was carried out. Information concerning sociodemographic and clinical variables, and outcome measures in terms of discharge destination, was obtained.

Results: There were 205 first admissions in the study period. There were 37 patients (18%) admitted on an involuntary basis. One per cent of admissions were not assessed at home prior to admission. Six patients had no formal psychiatric disorder, of the remainder 53% had an organic, and 47% a functional psychiatric disorder. Of those admitted 68% were discharged to their original destination. Patients with dementia were more likely to be discharged to nursing homes. Other discharge destinations were also used.

Conclusions: The policy of initial domiciliary assessment of all referrals prior to admission is feasible in the majority of cases. Defined admission criteria clarify reasons for admission, and ensures appropriate use of beds. The range of discharge destinations highlights the need for maintaining close ongoing links with other service providers.

Objective: To examine the treatment of and outcome for elderly patients presenting with depressive symptoms.

Method: 100 consecutive elderly patients presenting to an old age psychiatric service with depressed mood were studied, 51 met DSM-III-R criteria for major depression and 49 met criteria for a range of other diagnoses. Demographic details, psychiatric history and clinical examination including Hamilton Depression Rating Scale, Mini-Mental State Examination and Cumulative Illness Rating Scale scores were recorded at first presentation. Treatment of index episode was recorded and outcome assessed at time of follow up (mean of 19.1 ± 9.1 months later).

Results: 57% of the major depressives and 41% of the other diagnoses had a good outcome. Within the other diagnoses group 30% of the comorbid anxiety/depression patients and none of the patients with dysthymia or personality disorder had a good outcome. In the major depression group there was no clear association between outcome and any clinical or demographic measure. Within the other diagnoses group a good outcome was significantly associated with being younger, having had more psychiatric admissions and being less likely to require benzodiazepine treatment (p < 0.05). The two groups received similar treatment except that the other diagnoses group were more likely to have had psychotherapy and the major depressed patients to have had ECT (trend) than the major depressed group.

Conclusions: The outcome for patients with major depression is similar to that found in previous studies. Patients with depressive syndromes associated with dysthymia, personality disorder, or comorbid anxiety/depression respond poorly to conventional treatments of depression.

Objective: The repeated, self-inflicted, non-accidental injury known as Self Injurious Behaviour (SIB) is a cause of severe stress to carers and a challenge to multi-disciplinary teams working with people with a mental handicap. A need for Irish data on this problem was answered by collecting a representative cohort and following its members up to record the prevalence of SIB.

Method: The group studied included all people with an IQ of less than 50 (that is those in the moderate, profound and severe range of intellectual ability) whose place of origin was within the geographical borders of a single community care area. Following a preliminary tracing process, each person was followed up for one calendar month using a specifically prepared format to record daily occurrence of SIB.

Results: The group resulting from the tracing process consisted of 429 people (= 0.4% of the total population), 62 (=14 %) of this group exhibited SIB, during the time of the study. Of the demographic variables studied SIB was found to be related to IQ. Of those who self-injured those who showed multiple topographies and those who showed the greatest frequency of SIB were more likely to be found in the population who lived in a residential facility.

Conclusions: SIB is related to IQ but in a non-linear way suggesting that factors other than IQ militate against more severely handicapped people displaying this behaviour. SIB is not caused by living in a residential centre however our results suggest that living in a residential facility is the result of displaying SIB. This study suggests that implications for future treatment approaches and service provision for those exhibiting SIB in Ireland can be made with reference to research from other countries.

Objectives: To examine the process and outcome of use of clozapine in patients with mental handicap, with particular reference to selection of patients, response to treatment, adverse effects and withdrawal from treatment.

Methods: The case notes and medication charts of all patients commenced on clozapine between January 1991 and December 1994 were examined.

Results: Seventeen patients had been commenced on clozapine, the majority in the mild and moderate range of handicap. Fifteen had ICD-9 diagnosis of schizophrenia and all were refractory to conventional neuroleptics. Improvement was marked in 47% and substantial in 76%, with a mean daily dose of 453.8(sd = 238.5)mg and a range of 200mg-900mg. Reduction of aggressive behaviour was an important indicator of improvement. Five patients were withdrawn but only one related to side effects. Four patients had a past history of epilepsy and six others either developed seizures or EEG changes on treatment.

Conclusion: Clozapine use has been associated with considerable benefit in patients with mild and moderate handicap wh o have schizophrenia. In this population aggression responded well but a high prevalence of drug-induced epilepsy was evident.

Objectives: To assess the experience and attitudes of trainees towards a range of aspects of their training in Psychiatry.

Objectives: The aims of this study were to review the outcome of those long-stay patients two years after identification and to compare those discharged with those remaining in hospital in order to identify factors which might contribute to their continuing stay.

Methods: All the new long-stay patients who were more than one year and less than six years on 1st March 1992 were included in the study. Their current placement. Legal status and demographic and clinical details were recorded. Findings: Sixtynine percent of the original cohort remained in hospital, 9% had died, and 22 % had been discharged, mainly to highly staffed accommodation. Approximately half of those remaining in hospital were considered suitable for community placement. Those remaining in hospital were older, had longer durations of illness and were more likely to be dangerous than those discharged.

Conclusions: Despite continuing developments in community services a considerable number of new long-stay patients still remain in hospital and the proportion of those compulsorily detained remains unchanged.

Objectives: Rapid cycling mood disorder is an important clinical phenomenon. The concept of rapid cycling has evolved since it was first described in 1974. The purpose of this review is to summarise current diagnostic criteria, postulated risk factors and suggested management strategies.

Method: A Medline and Psych-Lit computerised literature search was supplemented by tracing back through the references from existing review work.

Results: Over 80 papers were identified which discussed diagnosis and management of rapid cycling.

Conclusions: DSM-IV provides a useful but narrow definition of rapid cycling. Standard treatment of affective disorder may exacerbate rapid cycling. If a rapid cycling course develops, discontinuation of antidepressants and use of mood stabilisers is recommended.

Objective: The objective of this article is to review the use of the opiate antagonist naltrexone as an alternative to opiate agonist maintenance in the treatment of opiate addiction.

Method: An extensive literature search, via Medline, Biosis, Psycinfo and other databases was carried out.

Results: Naltrexone has been used in the treatment of opiate addicts in a variety of settings. A number of methods of induction onto naltrexone of recently abstinent addicts have been used in different settings. Naltrexone has had a wide range of outcome success with different populations and associated treatment regimes.

Conclusions: The benefits of naltrexone can be compared with alternatives such as methadone maintenance and therapeutic communities. Naltrexone can be made more effective in the general population of opiate addicts with the use of adjunctive therapies.

A 48 year old housewife, admitted with a diagnosis of major depressive episode suddenly developed Ganser syndrome during the course of her illness. This resulted in spontaneous resolution of symptoms of depression. The resolution of intrapsychic conflict as a result of development of Ganser syndrome which led to sudden remission of major depressive episode is discussed.

We report the case of a patient with schizophrenia who has suffered severe side effects with many different antipsychotics. She is poorly compliant with treatment probably because of her experiences with medication. We determined her genotype at the CYP2D6 gene that codes for an enzyme principally involved in the metabolism of many antipsychotics. She was homozygous for the ‘B’ mutation, the most frequent of several known mutations. She therefore has no functioning CYP2D6 enzyme in common with 5%-10% of the population. This may explain why she is sensitive to quite moderate doses of antipsychotic medication, and more rational prescribing may lead to fewer side effects and increased compliance.