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To describe an enforced but gentle transition from prescribed intravenous methadone to oral methadone in 14 opiate-dependent patients. We examined their case notes looking for ease of transition, evidence of illicit drug use before and during the 6 months following transition and progress 3 years later.
Eight patients immediately stopped injecting, the remainder used intravenous heroin in addition to prescribed oral methadone for some months. There were no serious adverse events. Three years later, four patients had ceased opiate use altogether and six were maintained on oral methadone (five of these without illicit use). Two patients were prescribed oral methadone by their general practitioner and one was no longer in treatment.
We show that it is possible to alter the formulation of prescribed methadone without deterioration in clinical stability or losing patients from treatment. This is an important conclusion as it is presumed that one of the aims of treatment with intravenous methadone is to move patients away from injectable to oral use. Offering patients a transition period of 6 months and a choice of the process of transition may be helpful.
We undertook a retrospective case-note review of three cohorts of mental health admissions to determine the extent to which patient and service characteristics changed between 1988 and 1998. Changes in clinical admission thresholds were investigated by a psychiatrists' review of handwritten medical admission assessments.
Patients admitted in 1998 were demographically less stable and clinically more complex than those admitted 10 years earlier. Clinical admission thresholds remained consistent.
Our findings suggest that the perceived increase in pressure on psychiatric services over this period was a response to a change in population need. This study highlights important questions about the clinical decision-making process leading to use of alternatives to admission and the appropriateness of acute admissions.
The National Institute for Clinical Excellence (NICE) has issued guidance regarding the treatment of Alzheimer's disease. A postal survey of old age psychiatrists, geriatricians and neurologists was conducted to establish working practice pre-NICE and investigate expectations about the effect of this guidance.
The overall response rate was 26.3%. Old age psychiatrists prescribe the majority of drugs for the treatment of Alzheimer's disease. There was variation in the annual expenditure on such treatment. The main reason for non-prescription was a lack of funding. Over 80% of doctors thought that patients with mild disease should now be targeted for treatment.
In order to implement the guidance it will be necessary to address the issue of funding and have clear role allocation between local services.
We observed a pattern of combining depot antipsychotic medication with the newer ‘atypical’ antipsychotics in forensic patients. We aimed to determine the prevalence and rationale for such ‘combination therapy’.
The medical records of forensic patients in 3 forensic hospitals in New South Wales, Australia, were reviewed and the responsible psychiatrists asked to explain the rationale for treatment of those patients on combination therapy.
Twenty-two per cent of the forensic patient population were receiving combination therapy. The reasons given for combination therapy were the presence of treatment-resistant illness, to ensure adherence to at least part of the treatment and to assist transfer to lower security units.
Such a high prevalence of a practice that is discouraged and without theoretical justification is a cause for concern. It appeared to reflect the practical difficulties of managing forensic patients.
Between 1998 and 2000, a surprisingly high number of positive results was noticed in our regional medium secure unit when testing for D-lysergic acid diethylamide (LSD). This led to an investigation of possible factors involved. It was felt that the testing protocol, particularly the use of a single, non-isotopic homogeneous immunoassay without routine further confirmatory testing, was largely to blame for what seemed to be a high incidence of false positives. On two different occasions, samples from each patient were sent, on the same day, to two different laboratories. At the first laboratory, only one test method was used and at the second one test plus two confirmatory tests were carried out.
Out of a total of 23 patients tested on two separate occasions, the first laboratory gave three positive results the first time and three positive results the second, while the second laboratory gave only one positive result on the second occasion that samples were sent and none on the first. This reinforces the belief that, without adequate confirmatory analysis, many psychiatric and non-psychiatric prescribed drugs can give false positives.
Positive LSD results should be confirmed by at least one, preferably chromatographic, alternative method. A protocol for testing and reporting LSD in psychiatric patients should be considered in order to minimise the risk of obtaining false-positive results which have negative clinical, legal and psychological repercussions.
Sir James Crichton-Browne (1840–1938) held a uniquely distinguished position in the British psychiatry of his time. Unburdened by false modesty, he called himself ‘the doyen of British medical psychology’ and, in the narrow sense, he was indeed its most senior practitioner. At the time of his death, he could reflect on almost half a century's service as Lord Chancellor's Visitor and a similar span as a Fellow of the Royal Society.
To devise a protocol, reflecting best practice, for obtaining second opinions in child and adolescent psychiatry through discussion with consultants in child and adolescent psychiatry within the Yorkshire region at their quarterly meetings.
The major pressure for second opinions falls upon the Academic Unit of Child and Adolescent Mental Health and on the in-patient units. Other consultants who are considered to have specialist expertise in certain areas may also receive referrals for second opinions. Both consultants requesting and offering second opinions considered a protocol for obtaining them would be helpful to their practice.
An agreed protocol between consultants in child and adolescent psychiatry within a region ensures that young people with complex problems have access to second opinions on their diagnosis and management by consultants who can be recommended to referrers by other consultants. The network of consultants ensures such opinions are not requested excessively and that ‘rogue’ opinions without therapeutic follow-up are avoided.
In order to establish whether there is consistency in the management of sexual assault allegations in a psychiatric in-patient unit, and to assess quality of data recording, a manual search of 177 case notes included in an audit project, carried out between October 1997 and May 1999 was carried out. Each recorded allegation was noted on a standard form.
There was little consistency between cases, and data recording was patchy.
There is no accurate method of recording or monitoring alleged sexual assault in the trust studied. In spite of a policy document, these cases are dealt with ad hoc.
The outpouring of praise for the life and work of this remarkable man, who died this year, has been so fulsome that one might reasonably believe that the catalogue of his virtues had been exhausted. I would venture to suggest that two seemingly disparate virtues have been omitted or underplayed. I refer to his musicianship and his compassion. May I describe one occasion when these two virtues co-existed?
There is a shortage of doctors in the UK, particularly in psychiatry and pathology. Little is known about prospective medical students' career intentions or attitudes. This study aimed to report on the career intentions and attitudes to psychiatry of 819 attenders at a sixth-form conference for prospective medical students.
A much higher proportion of students expressed favourable attitudes to psychiatry as a career than might have been expected. The most popular career was paediatrics and the least popular was genitourinary medicine.
Medical schools need to be proactive in providing information, career advice and positive role models. This may counteract negative propaganda and encourage career choice in tune with students' earlier feelings and patients' needs.