Objective: This study aimed to examine non-attendance rates at new appointments at St James's Child Guidance Clinic.

Method: The sample consisted of all new referrals to St. James's Child Guidance Clinic in one calendar year (2004). Data was collected retrospectively from an electronic patient information system (Pinpoint), the new patient-referral logbook, referral letters, the appointment diary, and from clinical records.

Results: There were 260 new referrals to St James's Child Guidance Clinic in 2004. Out of the 260 children and adolescents granted a new appointment, 34 (13.07%) who failed to keep their appointment were identified. All patients granted an urgent appointment did attend.

Conclusions: Non-attendance rates at new assessment in St James's Child Guidance Clinic were slightly lower than those reported in other studies. The implemented evidence-based strategies to reduce non-attendance rates could explain the relatively low non-attendance rate at new assessment.

Objectives: This study examined and compared the number and pattern of referrals from neurosurgery and neurology specialist services to the inpatient liaison neuropsychiatry service in the years 2002 and 2005. We estimated the prevalence of psychiatric illness and evaluated the results of subsequent psychiatric assessment and follow-up of all patients reviewed by the neuropsychiatry service.

Methods: The medical notes of those patients referred to the neuropsychiatry team were retrospectively examined to obtain appropriate information on assessment and management of these cases.

Results: There were 544 referrals over the two years selected for study. Rates of referral to the inpatient neuropsychiatry service increased overall by 35% between 2002 and 2005. Overall, referrals from neurology comprised 85%, neurosurgery 15%. Patients with epilepsy comprised the majority of referrals (36%). A total of 378 (73%) had an acute psychiatric disorder and this group had a significantly higher rate (p = 0.01) of past psychiatric disorder (40%) than that in those with no acute mental illness (33%). Depressive episode was the most frequent acute psychiatric diagnosis (38%), followed by anxiety and organic psychiatric disorder (both 15%). Overall, 21% of patients diagnosed with acute mental illness were referred on discharge to the neuropsychiatry outpatient clinic for specialist follow up and the remainder followed-up by either local mental health teams or their GP.

Conclusions: These findings provide clear evidence that further resources should be allocated to expanding neuropsychiatry mental health services to improve detection and management of mental illness in this vulnerable patient group.

Objectives: This study aims to investigate the prevalence of neuropsychological disorders in a non-specialist clinical psychology service in adult mental health service and also to explore the existence of neuropsychological symptoms in those subjects having psychiatric disorders.

Method: The yearly data of new referrals from the psychology register and record files of the patients was collected for this purpose and subsequently analysed. The two content scales of MMPI-2, ie. HEA2 and HEA3 were administered and scored.

Results: The results indicate that neuropsychological disorders were the second major referral source during this period and a significant difference (p = 0.001) was found between the scores of HEA-2 and HEA-3, which suggest that the subjects reported more neuropsychological symptoms than symptoms of general health concern during their initial routine psychological assessment.

Conclusion: There is consistency in our findings regarding the questions raised in this study which indicates a prevalence of neuropsychological disorders in adult mental health settings. It also indicates a high rate of neurological symptoms in psychiatric patients with psychiatric disorders.

Objectives: The most recent census of psychiatric inpatients (Daly and Walsh, 2006) examined the decline of the long-stay population (both new and old long-stay) from 1963 to 2006. The aim of the present study was to identify new long-stay patients (patients in hospital between one and five years) in the 2006 psychiatric in-patient census and follow them up one year later to determine the number remaining as inpatients, ie. not having been discharged

Methods: New long-stay patients were extracted from the 2006 psychiatric inpatient census data base and were followed up one year later.

Results: Sixty-eight per cent (315/460) of new longstay patients on 31/03/06 were still resident in units and hospitals one year later on 31/03/07, the majority in psychiatric hospitals Forty-two per cent (133/315) of patients had a primary diagnosis of schizophrenia, 13% (40/315) of depressive disorder, 11% (33/315) of organic mental disorder and 8% of intellectual disability (24/315). The number of new long-stay patients discharged or who died showed a sharp decline on previous years.

Conclusions: Unless current services are improved and extended as advocated in A Vision for Change, it will be a number of years before this population leaves psychiatric hospitals and such hospitals can close because of the lack of suitable alternatives. In accordance with policy recommendations, the continuing requirement for the development of specialised rehabilitation services to cater for the broad needs of those who remain in psychiatric hospitals is of the utmost importance.

Objective: This study explored the attitudes and experiences of consultant psychiatrists regarding the Mental Health Act 2001.

Method: A postal survey was distributed to all consultant psychiatrists (n=238) in the Republic of Ireland. All specialties were included except Child and Adolescent Psychiatry.

Results: A response rate of 70% was achieved. Care of involuntarily admitted patients has improved according to 32%, but 48% found that the care of voluntary patients has deteriorated. Sixty-nine per cent of consultant psychiatrists acknowledge that involuntarily admitted patients are being changed to voluntary early to avoid a tribunal, and 21 % believe it occurs in over 40% of cases. Fourteen per cent of consultant psychiatrists have re-admitted a patient involuntarily immediately after a tribunal revoked the original Involuntary Order. Junior doctors' training by consultant psychiatrists has been reduced in 57% of placements as a result of the increased demands of the MHA 2001. Eighty-seven per cent report an increase in their on call service workload but only 23% report a sufficient increase in the number of consultants within their service. While 78% agree that patients should not be admitted involuntarily solely on the grounds that the person is suffering from a personality disorder, 58% feel that there is a risk in such patients not being involuntarily admitted in situations in which it is clinically necessary. Fifty-six per cent feel that there is a similar risk in patients with a diagnosis of substance misuse.

Conclusion: Resources required to implement the Mental Health Act 2001 have not been sufficient leading to poorer quality of service and negatively affecting NCHDs training.

Objectives: To address the relative dearth of information relating to the prevalence of psychiatric co-morbidity among attenders of community addiction facilities.

Methods: We carried out a cross-sectional study of clients attending a Dublin-based tertiary addiction centre to assess the rates of psychiatric co-morbidity, determine the demographic and clinical variables and evaluate the level of contact with allied medical care especially primary care and community psychiatric services. Information was sourced from available patient records.

Results: Forty-three per cent of the clients (n = 59), attending the service were found to have a chart diagnosis of psychiatric disorder. Only 15% of these were in contact with community psychiatric services.

Conclusions: This high rate of psychiatric co-morbidity has implications in terms of funding, training and service delivery.

Objective: To measure (a) the prevalence of problem drinking in a population of methadone-treated drug users, (b) independent associations with problem drinking, (c) the effect of hepatitis C status on drinking behaviour, (d) the knowledge of drug users of their hepatitis C status and their perception of their drinking behaviour and (e) the attitude of drug users to the effect of alcohol on hepatitis C virus (HCV) related disease.

Method: A cross sectional survey of 130 drug users in treatment at the National Drug Treatment Centre, Dublin was carried out. A questionnaire incorporated the Alcohol Use Disorders Identification Test (AUDIT), and data were collected on sociodemographics, drug use history, perceived HCV status and drinking behaviour, and attitudes to the impact of drinking on HCV related disease. Hepatitis serology and drug urine data were collected from clinical records.

Results: The prevalence of problem drinking was 41% (95% CI 33-51%). Unstable accommodation, older age, male gender and longer duration of heroin use were independent associations with being a problem drinker. There was no significant difference in the prevalence of problem drinking across HCV status. Knowledge of HCV status was accurate, however 35% of those identified as AUDIT cases failed to recognise their problem drinking.

Conclusion: HCV infection among Irish drug users is compounded by a high prevalence of problem drinking with drug users failing to modify their drinking in response. Incorrect perception of problem drinking status could be a barrier to addressing this potentially remediable risk factor.

Objectives: To investigate psychotherapy training for psychiatry trainees in N.Ireland.

Method: A detailed survey of both trainee's current experience and completion of Royal College requirements.

Results: While trainees rated experience highly in terms of enjoyment and relevance to psychiatry, we found a large proportion (94%) were failing to meet requirements for psychotherapy training, despite awareness being high (91%). Both cognitive-behavioural and psychodynamic therapy were the predominant models of therapy trainees had experience in and although most supervision was rated highly, a number of trainees had irregular or no case supervision.

Conclusions: At a time when it is becoming increasingly recognised that psychological therapies play a central role in the treatment of many psychiatric disorders, current training fails to provide a substantial experience. With such a high proportion of trainees not meeting the mandatory requirements and similar findings being replicated in other parts of the UK, serious consideration must be given to both the nature of the guidelines and the opportunities for psychotherapy training if future psychiatrists are going to be equipped to deliver a truly biopsychosocial model of care.

The phenomenon of childbirth-related post-traumatic stress disorder (PTSD) has become more widely recognised in recent years following changes in 1994 to the DSM criteria regarding how a traumatic event was defined. Emerging literature has predominately focused on prevalence rates and risk factors associated with this condition and on the use of debriefing techniques as an attempt to reduce or prevent the development of postnatal PTSD. However, little is known about the efficacy of psychological interventions that have been used to treat PTSD among postnatal women. This review summarises the limited evidence supporting the use of such treatments and discusses the significant challenges in developing and implementing psychological interventions for childbirth-related PTSD.

Objectives: Features of gambling, particularly among young people have changed over the past decade and, while there are no data from Ireland, there are suggestions from those working in the field that pathological gambling is increasing among adolescents. Relatively little is known about the effective treatment of pathological gambling in adolescents. This paper aims to review research in cognitive behavioural treatments with a view to their application in adolescents. Research among adolescence is given prominence when this is available.

Methods: The methodology comprised a literature search of Medline, Psycinfo, and EMBASE databases, using the search terms: ‘cognitive behavioural therapy’; ‘gambling; ‘psychology’; ‘epidemiology’; ‘adolescent’; ‘motivation’; ‘effectiveness’; ‘outcome’; ‘relapse’; and ‘internet’. In addition, a hand search of Clinical Psychological Reviews, Journal of Gambling Studies, Addiction, Psychology of Addictive Behaviors, and International Gambling Studies (1997-2007) was performed.

Results: A total of 23 studies comprising various cognitive and behavioural approaches were identified, all but three of them confined to adult subjects. Study methodology and quality varied greatly, with many case studies or small case series, and only three randomised control trials. None used an intention-to-treat analysis, and there was little long-term follow-up. Almost ail indicated, with more or less evidence, that cognitive behavioural strategies might be beneficial.

Conclusions: Many varieties and modifications of cognitive behavioural therapy have been applied to pathological gambling, though there are few studies of any psychological treatments for adolescent gamblers. Methodological problems surround much of the research. Notwithstanding these reservations cognitive behavioural approaches seem to offer promise in managing this serious problem.

“People with mental health problems are particularly vulnerable to social exclusion” – Vision for Change.

People with mental health problems are very vulnerable. However those with mental health problems who have additional social problems are even more vulnerable.

Currently psychiatric services in Ireland are provided on a ‘catchment area’ basis, with a consultant psychiatrist leading a multi-disciplinary team providing a service to the population of a defined geographical area. These services comprise both outpatient and inpatient care, and there is significant regional variation in terms of both bed availability and multidisciplinary team staffing. Sub-specialities, with the exception of child psychiatry and psychiatry of old age, are often unavailable, particularly outside Dublin. In such cases, some additional duties (eg. liaison, rehabilitation, perinatal) are assumed by the local general adult services.

However, the overall distribution of services is uneven. Instead of services being concentrated upon those areas of greatest need, the opposite is often the case, with the most deprived areas having the least services in terms of acute beds and community mental health teams per thousand people. These areas also have less psychological services and specialist services despite increased levels of mental illness.

Within this vulnerable population there are a number of sub-groups who are even further marginalised, and for whom there are significant barriers both at point of contact with services and with accessing appropriate follow up services. These include the homeless, the ever-increasing cohort of migrants to this country, those in prison and children and adolescents. Stigma and discrimination are the greatest barriers to social inclusion, quality of life and recovery for people with mental illness.

Insight is an elusive concept in psychiatry with a long history of divergent definitions and methods of measurements. Although insight was previously presumed to be a binary construct that an individual could possess or lack, there is an emerging consensus that insight is a multi-dimensional construct consisting of a spectrum of phenomena. Over recent years there has been increasing interest in the topic of insight, especially in relation to psychotic disorders where insight is frequently diminished. In this educational review we will discuss the history associated with the construct of insight, current theories in relation to insight, the association of insight with clinical symptoms and prognosis with particular reference to psychosis, the various methods of measuring insight, the aetiology of insight and present deficiencies in our understanding of insight.

Objectives: We aimed to further our understanding of the concept of recovery by analysing comments made in small group discussions that occurred on a planning Away Day held by a community mental health team along-side service users and carers, which had recovery as its theme. The purpose of this was to reshape the structure and workings of the team.

Method: Five small groups, of approximately 10 individuals each, comprised of service-users, carers, representatives from voluntary organisations and mental health professionals were asked to discuss three questions related to Recovery.

Results: The commentary reflected previous qualitative research on the philosophy of recovery. Issues that were raised included defining wellness as independent to illness, constructive risk taking, the importance of social factors, medication issues and the importance of self-management and optimism. The comments subsequently went on to shape community mental health team service delivery.

Conclusion: Discussion and reflection between mental health professionals, service users and carers can lead to a change in attitude and practice in a well-resourced, fully multi-disciplinary community mental health team, within which both the biological and non-biological aspects of mental illness are accepted. The result has been an introduction of service changes which have helped develop a team that is more accessible and increasingly collaborative.

This paper examines mental capacity legislation in Ireland and its implications for medical treatment decisions for people whose capacities are believed to be impaired. It draws on inferences from case laws and legislations in other jurisdictions and concludes that there is an urgent need for the enactment of appropriate mental capacity legislation in Ireland.

Status epilepticus (SE), both convulsive and nonconvulsive, is a rare adverse effect of electroconvulsive therapy (ECT). This case report describes SE post-ECT associated with central nervous system (CNS) metastatic melanoma and reviews pertinent literature. The authors recommend that when CNS pathology is suspected, pre-ECT neurology consultation, neuroimaging, and EEG all may be indicated. This is especially important for patients with histories of primary cancers, such as melanoma, that metastasise to the brain.

This paper provides an overview of the major studies of bipolar affective disorder (BAD) and borderline personality disorder (BPD), and assesses whether the disorders might be better understood as variants of the same basic disorder. There is a shortage of research that delineates the features of both disorders within their representative samples. As a consequence the symptomatic overlap of the disorders, detected by categorical assessment instruments, is often misconstrued as an indication of the disorders' high rates of comorbidity (up to 81%).

In paying particular attention to features of both disorders, eg. affective instability and impulsivity, the paper provides evidence that BPD attenuates bipolar disorder along the spectrum of affective disorders, from non-classical bipolar presentation through to severe BAD with borderline features. The paper cites clinical, research and pharmacologic support of the contention that BPD, rather than representing a distinct disorder, is merely an attenuation of Axis I disorders, most especially bipolar affective disorder. Borderline personality is evident across the bipolar spectrum and exacerbates symptomatology and leads to poorer recovery prognosis.

Clozapine, the drug of choice for treatment resistant schizophrenia, has a range of serious cardiac side-effects. This paper describes a fatal case of myocarditis in a 48 year old man four weeks after starting clozapine. In particular, this case illustrates how incipient the disorder can be and the need for a high level of suspicion. Difficulties in diagnosing clozapine induced myocarditis and ways to minimise its risk are also discussed.