Objectives: Three patients presenting with a first episode of psychosis each had a past history of social phobia. We sought to explore the literature on the co-occurrence of these disorders and investigate three hypotheses to explain this: (1) the chance co-occurrence of two illnesses with distinct aetiologies; (2) two clinical presentations reflecting different points on the same spectrum of illness; and (3) two distinct disorders representing different end points resulting from the same aetiology.

Method: A literature review of Embase, PubMed and Psych Lit was performed.

Results: We found no reports on social phobia preexisting an episode of psychosis, and prevalence studies indicate that their chance co-occurrence is extremely unlikely. Psychological explanations for co-occurrence include attributional theories, and theories related to cognitive biases and loss of self-esteem.

Conclusion: There is a phenomenological overlap between social phobia and paranoia but the two concepts should and can be distinguished. Epidemiological studies indicate that their chance occurrence as two unrelated disorders is unlikely. Most people with one of these disorders do not develop the other and hypothesis (2) is also unlikely. There is increasing speculation that anxiety, and in particular social phobic symptoms have a central role in the development of psychotic symptoms. The greatest evidence was found to support hypothesis (3).

However, it seems more likely that social phobia and psychosis, rather than representing manifestations of the same illness, instead are implicated in a complex interaction where symptoms which characterise social phobia and psychosis, have the capacity to affect, alter and possibly provoke each other. The recognition and treatment of co-occurring anxiety disorders, especially social phobia with psychosis, may have an important impact on prognosis and quality of life.

Objectives: To examine why five patients with borderline personality disorder were contributing to a high bed occupancy and high staff turnover on a general adult psychiatry inpatient unit.

Method: A retrospective audit looking at these individuals' service pattern use for the two-year period between 2001–2003 was undertaken. A new admission policy was then introduced. The policy was that admissions were agreed, where possible, at consultant level and, if deemed unavoidable, were time limited. The audit cycle was repeated for the next two year period, 2003–2005 and a third audit cycle was then performed for the period 2005–2007.

Results: Following the new admission policy, there was a 95% reduction in bed days for this group. Untoward incidents by these individuals reduced by 93% and attendance at Accident and Emergency was also significantly reduced.

Conclusions: By limiting the frequency and length of admissions there was, unsurprisingly, a reduction in adverse incidents which lead to significant problems for patients and staff alike.

Objective: This study aims to identify and review available evidence in the literature to determine the strength of association between antipsychotic medications and thromboembolism as an adverse effect.

Method: Electronic databases were searched for evidence.

Results: A total of 15 case reports, 14 case series, two observational studies and three case-control studies were found in the literature. Two case control studies found significantly increased risk of venous thromboembolism (OR 13.3 and 7.1 respectively). The risk was high for low potency antipsychotics. Studies were critically appraised to determine the strength of evidence.

Conclusion: The studies reviewed indicate a significant association between antipsychotics and venous thromboembolism. Patients using the antipsychotics and those who prescribe them should be aware of this association.

This study examined the expenditure of compensation received from legal claims by service users attending an outpatient methadone programme in Dublin. Most claims (n = 62) were as a result of road traffic accidents (74%) or personal injury (15%). There were 28 reports of claims resulting in payment of compensation totalling €912,871. Of the compensation not placed in trust (€477,871), almost 40% was spent on drugs and 8% on alcohol. Of those who reported no drug misuse at the time of the compensation being paid, seven out of 11 (64%) reported subsequently spending a significant amount on substance misuse.

The risks of receiving large amounts of money in this population are substantial and include initiation and exacerbation of substance misuse, and risk of overdose. Alternative ways of managing the payment of compensation should be considered for this vulnerable population.

Objectives: De-institutionalisation and the expansion of community services have resulted in a reduction in the number of inpatient admissions in Ireland having fallen by 31% between 1986 and 2006. However, despite this, readmissions continue to account for over 70% of all admissions. The policy document A Vision for Change identified many shortcomings in the current model of provision of mental health services, making recommendations for the future development of community-based services with emphasis on outreach components such as homecare, crisis intervention and assertive outreach approaches. These recommendations are reviewed in relation to readmissions and the impact they may have on reducing the revolving door phenomenon.

Method: Three main intervention programmes essential to the delivery of an effective community-based service outlined and recommended by A Vision for Change, along with other pertinent factors, are discussed in relation to how they might reduce readmissions in Ireland. A series of Pearson correlations between Irish inpatient admissions rates and rates of outpatient attendances and provision of community mental health services are carried out and examined to explain possible relationships between increasing/decreasing admission rates and provision/attendances at community services. International literature is reviewed to determine the effectiveness of these intervention programmes in reducing admissions and readmissions and their relevance to the Irish situation is discussed.

Conclusions: Whilst A Vision for Change goes a long way towards advocating a more person-centred, recovery oriented and integrated model of service delivery, it is apparent from the consistently high proportion of readmissions in Ireland that there are still many shortcomings in service provision. The availability of specialised community-based programmes of care is as yet relatively uncommon in Ireland and uneven in geographical distribution. A considerable improvement in their provision, quantitatively and qualitatively, is required to impact on the revolving door phenomenon. In addition a re-configuration of existing catchment populations is required if they are to be successfully introduced and expanded.

Objectives: Re-admissions to inpatient psychiatric care are now so frequent as to be designated the ‘revolving door’ phenomenon and constitute 72% of admissions to Irish inpatient psychiatric units and hospitals. It is commonly believed that treatment non-adherence with aftercare following inpatient discharge contributes to readmission. Attempts to improve adherence and reduce or shorten readmission through compulsory community treatment orders have been made in several countries including Scotland in 2005 and, from November 2008, England and Wales. Provision for conditional discharge in Ireland has already been furnished by the Criminal Law (Insanity) Act 2006 but has been compromised by the inability to impose enforcement of conditions. The paper aims to determine whether compulsory community treatment orders are effective in improving adherence and reducing re-admission and whether, in consequence, their introduction in Ireland should be considered.

Method: The legislative measures adopted to improve treatment adherence and thereby reduce re-admissions are presented. The evidence of their effectiveness is examined.

Results: Evaluation of the effectiveness of community treatment orders is limited and hindered by confounding factors. What evidence there is does not provide convincing evidence of their utility.

Conclusions: It is concluded that there is insufficient evidence to advocate their early introduction in Ireland in civil mental health legislation. Instead a wait and see policy is suggested with critical assessment of the outcome of such developments in Scotland and England and Wales. In addition further research on the characteristics of revolving door patients in Ireland and the circumstances determining their readmission is advocated. There is an anomaly in the Criminal Law (Insanity) Act 2006 which allows of conditional discharge but does not provide for its enforcement.

Objectives: We sought to determine the point prevalence of adult attention deficit/hyperactivity disorder (ADHD) in an out-patient psychiatric population.

Methods: Patients (n=243) attending five different outpatient clinics in a largely urban adult psychiatric service completed the Adult ADHD Self-Report Scale, a recently developed instrument by the World Health Organisation. Clinical and demographic data were recorded.

Results: There was a high apparent rate of adult ADHD detected (23.9%). Such patients were significantly more likely to have lower educational attainment, ADHD as children, a forensic history and the diagnosis of personality disorder as well as a higher rate of benzodiazepine use. They were no more likely to be dissatisfied with the service, nor to be heavier users of the service.

Conclusions: We report a high apparent rate of adult ADHD. Correlates of this high rate indicate individuals with less positive lifestyles than other patients. Screening for this disorder appears warranted, particularly in the light of the emergence of new non-amphetamine-based therapies.

In 1960, Thomas Szasz published The Myth of Mental Illness, arguing that mental illness was a harmful myth without a demonstrated basis in biological pathology and with the potential to damage current conceptions of human responsibility. Szasz's arguments have provoked considerable controversy over the past five decades. This paper marks the 50th anniversary of The Myth of Mental Illness by providing commentaries on its contemporary relevance from the perspectives of a range of stakeholders, including a consultant psychiatrist, psychiatric patient, professor of philosophy and mental health, a specialist registrar in psychiatry, and a lecturer in psychiatry. This paper also includes responses by Professor Thomas Szasz.

Szasz's arguments contain echoes of positivism, Cartesian dualism, and Enlightenment philosophy, and point to a genuine complexity at the heart of contemporary psychiatric taxonomy: how is ‘mental illness’ to be defined? And by whom? The basis of Szasz's doubts about the similarities between mental and physical illnesses remain apparent today, but it remains equally apparent that a failure to describe a biological basis for mental illness does not mean there is none (eg. consider the position of epilepsy, prior to the electroencephalogram). Psychiatry would probably be different today if The Myth of Mental Illness had not been written, but possibly not in the ways that Szasz might imagine: does the relentless incarceration of individuals with ‘mental illness’ in the world's prisons represent the logical culmination of Szaszian thought?

In response, Professor Szasz emphasises his views that “mental illness” differs fundamentally from physical illness, and that the principal habits the term ‘mental illness’ involves are stigmatisation, deprivation of liberty (civil commitment) and deprivation of the right to trial for alleged criminal conduct (the insanity defence). He links the incarceration of the mentally ill with the policy of de-institutionalisation (which he opposes) and states that, in his view, the only limitation his work imposes on human activities are limitations on practices which are conventionally and conveniently labelled ‘psychiatric abuses’.

Clearly, there remains a diversity of views about the merits of Szasz's arguments, but there is little diminution in his ability to provoke an argument.

Recent epidemiological trends in Irish suicide rates were examined and found to be consistent with worldwide trends. However, the time-series Irish suicide rate was not consistent with predictions made from Durkheim's classic theory of suicide. Finally, current theories of the etiology of suicide were used to derive a linear regression equation to predict the Irish suicide rate which turned out to be quite inaccurate.

The task addressed in this article is a review of the epidemiology of suicide in Ireland and, in doing so, the suicide rate in Ireland will be compared with the suicide rates of other nations of the world. Table 1 reports the suicide rate in Ireland from 1901 to 1949, Table 2 for the period 1950–2001, overall and for men and women (and parallel data for Northern Ireland are shown in Table 3). These data were compiled from Lester and Yang and from World Health Organisation publications and online (www.who.int). It should be noted that suicide was decriminalised in Ireland in 1993.

The association between bipolar affective disorder and multiple sclerosis continues to be poorly understood in view of the limited knowledge and research in this field. Here we present the case of a 43 year old female with bipolar affective disorder who later developed multiple sclerosis. The relationship between the two disorders is discussed in the light of relevant and pertinent literature. It is hypothesised that bipolar affective disorder may be the presenting manifestation of multiple sclerosis and should be considered as a differential diagnosis in patients of bipolar affective disorder with neurological symptoms.

Antipsychotic related urinary symptoms are recognised and they remain a potential treatment-limiting sideeffect of clozapine. This article reports the incidence and management of two cases of clozapine-associated incontinence in psychiatrically stable patients. Both cases occurred during treatment and appear to have a similar pathophysiology, which may be related to the atypical nature of clozapine therapy. We searched the PubMed and MEDLINE databases for articles published from 1980 to 2008 that contain the keywords 'clozapine and enuresis, ‘clozapine and incontinence,’ ‘clozapine and seizures’. We also manually searched the bibliographies of these articles for related sources, and explored the reported treatment options to this side-effect of clozapine therapy. Both patients gave an informed consent.

Catatonia is a neuro-psychiatric disorder that can occur in medical, psychiatric and drug-induced conditions but is often unrecognised. A 64 year-old woman was admitted to hospital for assessment of a significant deterioration in her ability to communicate and function normally so that she had become completely dependent on others for all activities of daily living for nearly three years. Outpatient medical and psychiatric assessments failed to clarify diagnosis. On admission to a general hospital, the neurology team initially believed she had a Parkinson's-like syndrome but after further investigation and comprehensive multidisciplinary assessment, including neuro-psychiatric review, she was diagnosed with catatonia. She was subsequently admitted to a psychiatric hospital where she received electro-convulsive therapy and changes to her psychotropic medication regimen. She responded well to treatment and within a short period of time was able to function independently again.

Absinthe is an alcoholic drink which is becoming more widely consumed after being banned for many decades. An association between absinthe use and psychiatric symptoms, ranging from impairment of concentration to marked hallucinations and seizures, has been suggested, but evidence remains unclear. Thujone, identified as a possible psychoactive ingredient, has recently been implicated in absinthe's putative neuropsychiatric effects. This report presents a case where acute suicidality emerged during absinthe consumption; possible neurobiological aetiological mechanisms and the history of absinthe use and associated adverse effects are reviewed.

Tardive dyskinesia is a neurological disorder characterised by involuntary and purposeless movements affecting any part of the body. These movements typically occur in the oro-facial area and the patient is usually unaware of them. There are inconsistent findings in the literature on the risk factors for developing tardive dyskinesia. Nevertheless, previous reports indicate that tardive dyskinesia is more common in female patients, patients with a history of alcohol and substance misuse, affective disorders, and intellectual disability. The dose, class and duration of antipsychotic nmedication may also be independent risk factors. We report on the case of a patient who developed tardive dyskinesia on a low dose of the second generation antipsychotic risperidone.

This paper examines the concept of early intervention in psychosis at primary and secondary prevention levels. Examples of early intervention service models from different countries are presented and we discuss current evidence for efficacy. We highlight the Irish experience of early intervention to date, and discuss future implementation of early intervention services in Ireland.