Anorexia Nervosa (AN) has the highest rates of morbidity and mortality of any psychiatric disorder. Psychiatrists in Ireland have reported difficulties in managing patients with AN, particularly those with severe levels of illness. This paper explores these management difficulties, including the financial and organisational impediments to service provision, and the legal and ethical dilemmas involved in dealing with those patients who refuse treatment.

Aims: To identify and describe the context and factors involved in the opioid lapse process following discharge from an Irish inpatient opioid detoxification treatment programme.

Design, participants, setting: Prospective follow-up study of consecutive detoxified opioid dependent patients treated in a specialist inpatient drug dependency unit.

Measurements: The Maudsley Addiction Profile and a structured interview were administered to 109 patients, 18–36 months after discharge.

Findings: Of 109 people interviewed at follow-up, 102 (94%) reported at least one episode of opioid use after leaving the residential treatment programme. Eighty eight patients (86% of the lapsers) identified more than one major factor contributing to their recidivism. The median number of factors identified as having a major role in the lapse was four. The most frequently reported major contributors to lapse were low mood (62%), difficulties with craving (62%), ease of access to heroin (48%) and missing the support of the treatment centre (43%).

Conclusions: Early lapse was common following inpatient treatment of opioid dependence. Lapse tended to result from a number of common, identifiable, high-risk situations, feelings and cognitions which may assist clinicians and patients develop lapse prevention strategies to anticipate and interrupt this process.

Aims: To identify the sociodemographic, clinical and service delivery risk factors for suicide in psychiatric patients in a limited geographic area.

Method: A retrospective case study of 35 patients who died as a result of suicide between January 2006 and December 2008.

Results: Male gender, unemployment, living alone, basic education and significant life events were identified as sociodemographic factors. A history of previous psychiatric admission, previous suicide attempt, suffering from depression, co-morbidity of another psychiatric disorder (mainly stress-related symptoms and alcoholism), and contacting the services prior to suicide were found as typical clinical factors. Hanging was the most common method of suicide in both men and women. Most men died in spring and summer, while the majority of females died in autumn.

Clinical implications: As in similar studies, mental disorders could be identified as the strongest risk factor for suicide. Almost 70% of suicides were conducted by people suffering from a mental disorder. Treating mental disorders and identifying certain sociodemographic and clinical characteristics of people suffering from mental disorders and addressing them is the key in suicide prevention strategies.

Aim: To evaluate patients' satisfaction with a psychiatric day hospital in the West Galway Catchments area.

Study design: This is a cross-sectional study. Methods: This study was undertaken by using a 33-items questionnaire for 44 patients who attended the day hospital. SPSS version-12 was used for collecting and applying tests to the data, Fisher's exact test was used to analyse the data as sample size is small and P<0.05 was considered statistically significant. Results are also presented in the form of descriptive analysis including percentages and frequencies.

Results: Only 37 out of the 44 patients returned the questionnaires. Among the participants were 61% (n=22) male and 38% (n=15) female. The patients were mostly satisfied with the services available at the day hospital, except the waiting period for a first appointment. There was no significant (P=0.11) gender difference in terms of patients' satisfaction with the day hospital service. The age group, 45 years and above, were less satisfied (P=0.02) with the availability of a comfortable room for counselling, as compared to the younger age group. The patients did not like to tell others that they were attending the day hospital. The results were comparable with previous published patient satisfaction surveys using the same questionnaire by the Health Research Board, except that the patients in the present survey were more satisfied with the waiting area and availability of counselling.

Conclusions: Patients are mostly satisfied with the West Galway day hospital services.

The older patients (45 years and above) are not satisfied with the counselling room, and therefore further investigations are needed to ascertain their requirements for a counselling room. Patients are more satisfied with the waiting area and availability of counselling compared to the findings of other similar studies conducted in Ireland. Resources are needed to be allocated to the day hospital services.

Objective: This study was conducted to gauge the attitude of fifth year medical students to psychiatry as a potential career choice and to determine if an eight-week clinical attachment had any impact on this.

Methods: We surveyed a cohort of fifth year medical students from Trinity College Dublin. A purpose designed, self-completed questionnaire was used to establish a number of variables and was given to students on the first and last day of their attachment in psychiatry. Participation was optional and responses were confidential. Questionnaires were distributed following an explanation of the purpose of the study.

Results: The survey was applied to 118 fifth year medical students. The most significant finding of the study was the increase in number of students choosing psychiatry (17%) as a possible career upon completion of the attachment as compared to before (4%). The majority of the students considered psychiatry as a mainstream specialty with little change in this perception pre and post attachment. Almost all of the students believed that a psychiatry posting would improve their communication skills when dealing with patients.

Approximately half of students chose medical subspecialties as career choice prior to their psychiatry posting but this declined afterwards. There was a small increase in the number of students wanting to become GPs and those who were undecided about their potential career choice.

With regards to deterrents to doing psychiatry, the principal one was the belief that psychiatry was too depressing and stressful. Lack of interest, adverse career prospects and financial considerations featured in a minority of student answers.

Conclusions: The findings of this study suggest that psychiatry remains less attractive to students as a career compared to some other specialities but a clinical attachment may be an important means of raising interest in psychiatry as a career.

Objective: Alcoholism ultimately leads to impairment of memory and other cognitive functions. This can interfere with treatment, if cognitively impaired alcohol-dependent individuals have difficulties recalling and implementing skills acquired during therapy. We investigate if alcohol-dependent individuals without clinically apparent withdrawal symptoms may still be impaired in higher-order cognitive functions.

Methods: Thirty-four alcohol-dependent patients and 20 matched healthy controls were tested with the Verbal Learning and Memory Test which includes seven measurement points. The test comprises free recall, free recall after distraction and after 30 minute delay, and a word recognition task. Testing was performed between day seven and day 10 after the beginning of abstinence, when clinical withdrawal symptoms had ceased.

Results: Compared to healthy controls, alcohol-dependent patients performed worse in free recall after delay, but not in word recognition. Healthy controls showed a more linear progression of improvement in verbal memory performance. Overall, alcohol-dependent individuals showed reduced verbal learning efficiency. The extent of impaired recall after distraction was positively associated (one-tailed test) with history of delirium (r=0.34, p=0.04), seizures (r=0.46, p=0.01), and years since diagnosis for alcohol dependency (r=0.39, p=0.01).

Conclusions: Our results provide evidence that unmedicated alcohol-dependent patients without obvious withdrawal symptoms had impaired verbal recall, but normal recognition performance, at seven to 10 days after onset of abstinence. This deficit may deteriorate treatment outcomes due to poorer implementation of skills newly-learned during this time period.

Objective: This study explores unrecognised symptoms related to post-traumatic stress disorder (PTSD) in individuals with a range of psychiatric disorders in the absence of traumatic events. We also examine the association between PTSD symptoms, social interaction with peers and therapeutic alliance with mental health professionals.

Method: A purposive sample of 120 adults consecutively referred to the psychology department from September 2008 to September 2010 was included in this study. We used the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) to ascertain the presence of PTSD symptoms, social interaction levels and treatment alliance with health professionals.

Results: Individuals previously undiagnosed with PTSD, referred without any noted traumatic event had high levels of symptoms related to PTSD, as measured by the PK scale of the MMPI-2. The PK scale was significantly correlated with several MMPI-2 clinical scales, the Social Introversion Scale (Si) and the Treatment Alliance Scale (TRT) (p < 0.001).

Conclusion: This study demonstrated the presence of symptoms related to PTSD in individuals with a range of psychiatric disorders despite the absence of reported trauma. The presence of symptoms related to PTSD may be associated with an indirect negative impact on social contacts and a poorer therapeutic alliance with mental health professionals. Investigating symptoms of PTSD during a psychological assessment even when trauma is not the presenting complaint is merited in most cases.

Objectives: To examine the Laois/Offaly Child and Adolescent Mental Health Services (CAMHS), focusing on new referrals and trends in the service.

Methods: Data was collected over a one-year period from July 1, 2008 to June 30, 2009 using the computer system MAISY (Medical Audit Information System) and through chart reviews. A Client Satisfaction Survey was administered to both parents and children.

Results: The Laois/Offaly CAMHS team provides service to a total population of around 140,000, of which around 32,000 are less than 16 years old. In this one-year period, 303 referrals were received with 167 offered an assessment, of which 150 availed of an appointment. Forty-six percent were offered appointments within one week of receiving the referral with 87% being assessed within one month. A further 41 were assessed from a previous waiting list, compiled prior to the actual study period, thus resulting in a total of 191 assessments.

Thirty referrals required assessment only. Behavioural/Emotional difficulties and Attention Deficit Hyperactivity Disorder (ADHD) were the most common reason for referral. During this time the ADHD waiting list was suspended due to staff constraints. Seventy-six percent were diagnosed with an Axis I disorder with 34% given medication treatment. Of the return appointments over the year, eight percent of patients did not attend (DNA). Both parents and children reported being satisfied with the service, according to the Client Satisfaction Survey.

Conclusions: The Laois/Offaly team services a catchment area of approximately three times the number recommended by A Vision for Change, with a staff equivalent less than the number recommended for one whole team. The team was able to provide a rapid service for assessment of new referrals, with the ADHD waiting list suspended. Axis I pathology was often diagnosed among those assessed (around 75%), with about one-third being treated with medication. Follow-up appointments achieved a high attrition rate, with only around eight percent not attending. Patient satisfaction with the service rated high by both parents and children.

Background and aims: This paper describes the context in which the Vron, a six-bedded 24-hour nursed care unit, has developed its role from a fast track rehabilitation unit, to work explicitly within an early intervention service. The study aimed to evaluate the work of the Vron by examining the change in CANSAS, HoNOS and EM scores between admission to and discharge from the unit.

Results: Approximately half of the admissions to Vron were from acute psychiatric wards. Most patients were discharged to their own tenancy or supported accommodation. There was a significant reduction in mean HoNOS score and increase in mean EM score during admission. Mean staff and patient-rated unmet needs reduced in the course of admission. In the course of admission, approximately half of the patients developed occupational roles.

Discussion and conclusions: The findings of this service evaluation must be interpreted with caution in view of the methodological limitations, in particular the lack of a comparator service intervention. However, it is suggested that units of this type may have a useful role in the rehabilitation of patients with complex severe mental illness, particularly if deployed at an early stage in an individual's illness, to prevent development of disability. The Vron focuses on a number of specific clinical and social areas which align with typical strategies in early intervention.

Objectives: To assess the knowledge of basic psychiatric trainees in Ireland of the Clinical Indemnity Scheme (CIS) and to ascertain how many basic specialist trainees in psychiatry had obtained additional medical indemnity cover and reasons for obtaining additional cover.

Method: A structured questionnaire was distributed by post to 300 basic specialist trainees in psychiatric training schemes in Ireland. The questionnaire enquired about demographic details and examined the level of trainees' knowledge of the clinical indemnity scheme. Results were compiled and analysed using descriptive statistics and SPSS version 14.

Results: The response rate was 49%. The bulk of respondents were male (65.5%), aged between 30-35 years of age (44.6%). The majority of the respondents were aware of the CIS, with approximately half of the respondents having acquired additional medical indemnity cover. The level of awareness of the CIS was proportionately more amongst male respondents (69.1%), compared with females (58.5%). However, more females (61.5%) had additional medical indemnity cover compared with males (45.5%). Irish national trainees were more aware (72.9%) and had additional medical indemnity (80%), compared with non-Irish national trainees of whom approximately 61% were aware of the CIS and only 40% had an additional cover. The level of knowledge regarding details of what the CIS provided coverage for was quite poor. Respondents who had obtained additional indemnity were unsure what cover their additional indemnity provided. Only 10 respondents had been involved in medico-legal cases and of these, five had medical indemnity at the time of the case, stating that the legal advice and support was helpful.

Conclusion: Our survey has highlighted that a considerable number of basic specialist trainees in psychiatry in Ireland had no detailed knowledge of what the CIS indemnifies them for and what situations were not covered by the scheme. Additionally, it revealed a clear split in favour of Irish national trainees in comparison to non-Irish national trainees in terms of awareness of the CIS and the procurement of additional medical indemnity. There needs to be an educational drive to provide more information to psychiatric trainees regarding the CIS and other medical insurance schemes. Furthermore, it would be important to examine factors that influence trainees in obtaining/not obtaining additional cover.

Objectives: We present our experience of an annual research symposium for psychiatric trainees in Scotland. This paper aimed to consider trainees' involvement in research by examining firstly rates of publication and secondly the views of trainees.

Methods: A list of all presentations to the Senior Trainees' Annual Research Symposium (STARS) meetings 2007-2009 was compiled and a detailed search made of major research databases. A questionnaire survey examined the views of attendees at the 2009 meeting.

Results: Fifty percent of presented work achieved publication. Feedback from symposia attendees was almost universally positive.

Conclusions: At a time of debate on the value of research sessions as part of higher training and a recent reduction in time allocated to research in the UK, we report on a thriving annual meeting. Research symposia for higher trainees were valued by participants and may be one useful means of encouraging trainee research.

Montelukast (a leukotriene receptor antagonist) is a commonly prescribed medication used in the management of asthma in both children and adults. It has been associated with a possible increased risk of various neuropsychiatric events in post-marketing analyses of clinical trial data and surveillance studies. When establishing a link between a medication and side effects, it is usual to establish and enquire whether there is a chronological relationship between the commencement of the medication and the onset of the symptoms.

We report a case where a number of unusual neuropsychiatric events were reported several years after commencement of montelukast in a young boy who may have a genetic predisposition and a likely psychological trigger. There was complete resolution of these symptoms upon the withdrawal of montelukast.

Background: Use of benzodiazepines and Z-drugs in the elderly is associated with adverse outcomes such as increased risk of falls and fractures and cognitive impairment. We aimed to assess the prescribing practice of benzodiazepine and Z-drugs in those aged over 65 years in a general hospital against evidence based standards and to examine the effects of multidisciplinary feedback, as well as determine the prevalence of usage.

Methods: All case-notes and medication charts of patients over the age of sixty five on surgical and medical wards in Sligo General Hospital (SGH) were retrieved and analysed over a two-day period in 2008. Data was collected in relation to benzodiazepine and Z-drug prescribing. We followed up on this initial data collection by screening discharge summaries at six weeks to assess benzodiazepine and Z-drug prescribing on discharge. Audit results were disseminated together with consensus guidelines on the prescribing of these medications in older adult population to all general practitioners in County Sligo. Educational sessions were held for both doctors and nurses in SGH. The audit cycle was completed by a re-audit of benzodiazepine and Z-drug prescribing six months from original study using identical methods.

Results: We found a high prevalence of benzodiazepine and Z-drug use in original audit, 54% (38/70) of the group audited. The prevalence fell to 46% (32/70) at the re-audit post intervention. This result was not statistically significant. The percentage of patients commenced on benzodiazepine and Z-drugs prior to admission fell from 36% (25/70) at the initial audit to 23% (16/70) at the re-audit.

Conclusion: Prescribing practices were not in keeping with consensus guidelines as highlighted by this relatively basic audit cycle. Multidisciplinary feedback and letters to GPs resulted in some reduction in the number of patients prescribed benzodiazepines and Z-drugs. Ongoing educational strategies aimed at relevant health care workers with regular audit of medication use within the general hospital setting is pertinent to further improve prescribing practice.

Psychiatry, more than most medical specialties, must engage with undergraduate medical education to prevent the further marginalisation of mental health within medicine. There is an urgency to the need for psychiatrists and educationalists to communicate, and for psychiatrists to be aware of developments in educational theory. The idea of ‘threshold concepts’ is currently widely discussed by educationalists. Threshold concepts are described as areas of knowledge without which the learner cannot progress, and which, when grasped, lead to a transformation in the learner's perspective and understanding. Threshold concepts have been criticised on conceptual grounds, and there is a lack of clarity as to how to identify them empirically. While they may represent a fruitful approach to the task of engaging medical students in psychiatry teaching, it is suggested that further development of the idea is required before it could be usefully applied. However empirical studies in other disciplines suggest that there may be associated benefits to the teaching of the discipline from trying to identify threshold knowledge.