Objectives: To investigate whether placebo effects may vary in strength, depending on appearance of the medication.

Method: Polish subjects were randomly given different kinds of pills and told that the medicine was produced abroad or in Poland and that it was cheap or very expensive. Measures of different forms of well-being were taken directly after the ‘therapy’.

Results: Subjective ratings were higher for subjects who received big white or small red medicine compared to subjects who received small white or big red pills. The results are discussed in the light of the subject's previous experience with drugs of different kinds.

Conclusion: It was shown that placebo effects do vary in strength, depending on the appearance of the pill.

Abnormalities of circadian rhythms in depressed patients have been noted, including decreased amplitude, distorted waveform, day-to-day instability, and unusual 48 hour periods. Consistent electroencephalographic sleep recording in these patients show a shortened rapid eye movement latency and slow-wave sleep (stages 3 and 4), resulting in an increase in rapid eye movement sleep. This phenomenon appears to be a dependable, measurable marker for diagnosing primary depression. Total sleep deprivation appears to significantly improve mood in a high percentage of depressed patients. Current pharmacological research suggests that drug treatment such as lithium would not affect the intra sleep cycles of the REM stagebut would shift the phase backward and lithium would also shift the phase of circadian rhythm of the daytime sleepiness backward. This paper highlights some of the new approaches for investigating the molecular substrate for the control of circadian rhythmicity and sleep in man and critically examines the hypothesis of the alteration of this mechanism in psychopathology, particularly depression. What is known of the endogenous clock mechanism is discussed with known molecular circadian mechanisms with a view towards understanding how circadian information is transmitted to the rest of the central nervous system and how it is affected in depression.

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.

Objectives: This study set out to explore if there were measurable personality characteristics specific to parents of people with autism.

Method: Parents of 12 people with a DSM-III-R diagnosis of autism presented for the study. Each of the people with autism were matched where possible with a counterpart without autism but with a lifelong disability on parameters of age, sex and IQ level. Parents of the ‘autism’ and ‘non-autism’ groups were then interviewed in detail using four personality assessment instruments. Scores were tabulated for both mothers and fathers in each group and intergroup comparisons were made.

Results: No significant personality profile difference was identifiable between the two parental groups.

Conclusions: Personality traits specific to parents of people with autism are not identifiable in this study thus casting doubt on the validity of personality phenotypes as measurable heritability factors in autism.

Objectives: To outline the limitations of traditional studies of outcome in schizophrenia and to review the findings arising from ‘first episode’ psychosis studies.

Method: An extensive literature search was performed and relevant papers were examined and analysed.

Results: Current knowledge regarding outcome predictors in schizophrenia has primarily been derived from a series of ‘consecutive admission’ and ‘long-term follow-back’ studies. However, methodological considerations may limit the generalisability of these studies' findings. The prospective evaluation of first episode cohorts has advanced our knowledge regarding the relative importance of premorbid and intercurrent factors in determining outcome in schizophrenia.

Conclusions: To date, the ‘first episode’ strategy has highlighted some potentially clinically modifiable outcome predictors. These findings may open the way for targeted introduction of measures aimed at preventing poor outcomes in schizophrenia.

Objectives: We aimed to identify which illness related topics were of most interest to chronic psychiatric patients in our catchment area service, and to obtain a baseline measure of the amount of knowledge which patients with schizophrenia had about their illness.

Method: Patients attending for a minimum of one year were recruited from the outpatient clinic and day centre. Participants completed three instruments: a brief questionnaire which asked about the details of their diagnosis and drug treatment regimen, the ‘Educational Needs Questionnaire’ (ENQ), and a modified form of the ‘Understanding Schizophrenia Scale’ (USS).

Results: Forty-seven patients with a chronic psychotic illness participated in the study. Despite having attended the service for an average of 14 years, the majority of patients were unable to correctly identify their diagnosis. Most patients were able to name the drugs which they had been prescribed; but were not able to describe the dosage of these drugs. According to the ENQ results, patients expressed most interest in learning about general aspects of their illness, such as ‘how to cope with stress’, and less in how to manage specific illness related symptoms. Similarly, schizophrenia patients were found to know more about general aspects of their illness, such as rehabilitation and non-medical aspects of treatment, than about medication.

Conclusion: Chronic psychiatric patients, especially those with schizophrenia, have very limited knowledge of their illness and its treatment. The focus of psychoeducation should be extended from insight and compliance to include broader ‘quality of life’ issues which appear to be of more concern to patients themselves. Patient participation in psychoeducation can thus be improved by including topics identified by such instruments as the ENQ. It is encouraging that cognitive deficits and negative symptomatology do not seem to prevent long-term psychiatric patients from benefiting from such inputs.

Objectives: Continuing deinstitutionalisation has led to growing concern about the availability and accessibility of services for people with learning disabilities transferring to community living. This study was undertaken in order to assess the configuration of services in terms of availability and uptake for people with learning disabilities who have left long-stay hospital care and to identify gaps or barriers to service provision within the unique integrated health and social services structure in Northern Ireland.

Method: The ‘keyworkers’ of 195 people – most of whom were aged 40-59 years with a diagnosis of moderate intellectual impairment – were interviewed by a researcher one year after discharge using the Service Interview.

Results: While a wide range of generic and specialist services was available, ‘packages’ of care consisted largely of public sector services (eg. GPs, chiropodists and social workers) and relied, to some extent, on the type of community accommodation. Although services appeared well co-ordinated in terms of care reviews and keyworker arrangements, 40% of people required more one-to-one support particularly in areas related to integration. However, services were perceived by care staff to be satisfactory

Conclusions: The development of community care has been slower in Northern Ireland than elsewhere and a large proportion of resources remain tied up in hospital care. However, existing community-based services appear to be addressing individual needs. Some former patients, though, may have been subject to transinstitutionalisation in the sense that their choice of accommodation was restricted mainly to large private sector homes and work and daytime opportunities were insufficient to facilitate integration. Service planners and providers need to give further consideration to the likely effects of different forms of rehabilitation, reprovision and resettlement and to be aware that the pattern of service provision is likely to be different for the more dependent cohorts of people who leave hospital in the future.

The failure to recognise the pervasive developmental disorders/autism spectrum disorders is probably not uncommon in adult psychiatry. Indeed some of the treatment-resistant chronic mental illnesses are due to the failure to make this diagnosis and apply more appropriate treatment.

Patients with PDD/ASD cause considerable diagnostic difficulties in both inpatient and outpatient adolescent and adult psychiatry. Clinical experience suggests that patients with PDD/ASD in adulthood have been misdiagnosed as having schizophrenia resulting in inappropriate treatment. Mesibov and Handlan state that the diagnostic situation is complicated because the characteristics of autism are less pronounced in older clients. It is critical that an accurate diagnosis is given because of the specific treatment implications. In the past decade there have been considerable developments in our understanding of autism. The importance of bringing the developmental viewpoint into adult psychiatry is now highly relevant. Unfamiliar diagnostic categories now have to be considered by adolescent and adult psychiatrists. Grounds for the deletion of adult psychiatric disorders, eg. simple schizophrenia from ICD102 may exist. Instead PDD/ASD disorder may need to be considered.

As the purpose of diagnosis is to ensure appropriate client management, it is essential that diagnostic criteria are continually reviewed in view of clinical observation and research developments. In this paper, diagnostic categories causing confusion are outlined, and that these are variants of the core deficit of autism is suggested. The major PDD/ASD diagnoses in adolescence and adulthood are listed below.

Two of the following are required for the diagnosis of autism:

This year we celebrate the 60th anniversary of the death of that famous cat artist, Louis Wain. It is therefore appropriate to reflect briefly on his life, his art, and in particular the rather controversial nature of his mental illness.

Louis Wain was born in London in 1860, the eldest child of William, a textile traveller, and Felicia, a designer of carpets. Louis had five younger sisters. As a child he was regarded as physically weak, not starting school until the age of 10 where his academic performance was indifferent, and from which he played truant frequently. In 1877 he went to the West London School of Art, qualifying in 1880. His first job was that of an art teacher, but he needed to supplement his income from this job by doing freelance illustrations for magazines. Eventually he gave up art teaching and became a full-time illustrator, working initially with the Illustrated Sporting and Dramatic News.

In 1884 he married Emily Richardson, a governess in the Wain household and 10 years his senior. Their happy marriage ended two years later when Emily died of breast cancer. During her illness a stray black and white kitten joined the Wain household. The kitten was named Peter and he was a great comfort to Emily in her terminal illness. While Louis sat frequently by his wife's sick bed he began drawing Peter from every possible angle. This was the first time he showed any interest in drawing cats, as prior to that he had been a general illustrator.

Objectives: To examine the operation of a deliberate self-harm service at a large general hospital with reference to standards outlined by the Royal College of Psychiatrists. To examine the characteristics of referrals and to make recommendations for improvements to the service.

Method: Data on referral and assessment characteristics were collected for 96 consecutive referrals over a three month period.

Results: The services achieved the college standards in relation to the time period for assessments. Most referrals were made routinely at a predictable time but assessments were conducted on an ad hoc basis. Only a minority of those referred had a mental illness or complex problems. A significant number of patients were discharged from the A&E department without a psychiatric assessment. Assessors underemphasised the role of previous deliberate self-harm and/or the presence of mental illness in forming a judgment on the risk of suicide. After-care arrangements were predominantly medical (general practitioners or psychiatrists) with little multidisciplinary input.

Conclusions: The deliberate self-harm service at the hospital could be improved by the establishment of a self-harm services planning group to oversee the delivery of the service throughout the hospital and address the deficits identified. Given the number of referrals seen within the service and the fact that deliberate self-harm is only one element of a comprehensive liaison service, consideration should be given to the establishment of a separate multi-disciplinary liaison team. Once again importance is drawn to the need for all assessors to be aware of the risk factors in relation to the future risk of suicide rather than placing undue emphasis on whether the most recent attempt was planned or impulsive in nature.

Lead encephalopathy is a relatively rare medical condition. It can present with multiple seizures, delirium, blindness, aphasia and dementia. Usually it is due to environmental exposure. This paper describes a case of delayed diagnosis of lead encephalopathy secondary to petrol sniffing which responded to chelating agents therapy. A high index of suspicion must be maintained to diagnose this treatable cause of encephalopathy.

A case of schizophrenia with vampiric delusions is described. The relevant classical and contemporary literature is reviewed, both in relation to clinical vampirism and the relationship between vampirism and schizophrenia. In patients with vampiric delusions, the possibility of future vampiric behaviour should be considered, and appropriate treatment initiated.

A case of abnormal bereavement is described in a man with borderline learning disability and Asperger's syndrome. Bereavement issues and concurrent assessment of psychiatric illness in people with pervasive developmental disorders are discussed. Particular reference is made to relevant psychopathology and possible underlying psychodynamic mechanisms.

Objective: Depot antipsychotic medication is often prescribed as maintenance treatment for patients with bipolar affective disorder. In this study we examined the case notes of 14 patients with bipolar disorder who had been prescribed depot antipsychotics. Our aim was to establish the effectiveness of depot medication in this group.

Method: We calculated the total number of hospital admissions, length of hospital stay, and total number of affective episodes for each patient from the onset of their illness to the time of the study. The frequency of affective episodes and hospital admission were compared during periods on or off depot medication.

Results: Treatment with depot antipsychotics was associated with a significant decrease in the number of hospital admissions, overall affective episodes and manic episodes in particular.

Conclusions: Prophylactic treatment with depot antipsychotics may be useful for certain patients with bipolar disorder, in particular those patients who experience frequent manic episodes. Further proof of the efficacy of depot antipsychotics in the prophylaxis of bipolar affective disorder requires the completion of a double-blind prospective trial.

The case of a 32 year old man with moderate intellectual disability, severe behavioural problems and psychotic symptoms is described. Having tried various traditional antipsychotics he was commenced on clozapine with a marked improvement in symptoms. Clozapine is a useful drug for the treatment of schizophrenia in the intellectually disabled who are refractory to the conventional antipsychotics. It improves aggressive and self-injurious behaviour which may be in addition to its antipsychotic effect.

A patient presenting with psychogenic paralysis then Ganser syndrome is described. Formulation is made in terms of unresolved grief manifesting as shifting dissociative symptoms. Treatment and the patient's resistance to it are discussed. The nosological status of Ganser syndrome 100 years on is reviewed and the role hysteria as a causative mechanism endorsed.

Objectives: Parents often present practising clinicians who see children with chronic fatigue syndrome with printouts from the internet. These are then brought into the discussion about the management and aetiology of this debilitating condition. We set out to systematically study the information on the internet on this subject and to explore the diversity of advice in relation to current research knowledge.

Method: Systematic search by means of the internet browser Netscape Navigator and search engines AltaVista and Yahoo! Advice about levels of rest, exercise, medication, psychological interventions and suggestions about return to school is critically compared with current research evidence.

Results: Thirteen websites were accessed. All have some treatment advice. Six offer conflicting advice about levels of rest, with two suggesting large amounts of rest, two suggesting some rest and two suggesting graded exercise. Nine suggest medications (with a wide variety of pharmacological activities) despite the lack of research evidence showing a significant contribution from medication. Four suggest psychological treatments but some advise that it is unnecessary despite the established evidence in chronic fatigue (and other chronic illnesses) that appropriate psychological treatments are helpful. There are a wide variety of differing diets recommended.

Conclusions: Few websites provide useful management advice. Advice offered is often in conflict. Some of the advice is either contrary to current research evidence or not supported by it. This raises concerns about inaccurate information reaching families who have a child with chronic fatigue syndrome, with potentially damaging consequences. This suggests a need for a debate about the availability and validation of health related information on the internet.