Objective: This study is designed to evaluate a hospital based integrated service for the comprehensive delivery of care and treatment to patients with schizophrenia, on epidemeological, cost effectiveness, and quality of life parameters. Methods: All patients with an ICD9 diagnosis of schizophrenia who received services from the St. Lomans Catchment area during a 2 year period were evaluated for service utilization during a subsequent 2 year period. Data was collected on basic demographics for the epidemiological aspects of the study, and for all aspects of services utilized, eg. day hospital attendance, inpatient bed useage, time spent with psychiatrist, community nurse visit or clinic visit. Costs for all services were calculated using disaggregate cost data. Quality of life of the patients was assessed through the Lehman quality of life questionnaire administered to every third identified patient. Results: 572 schizophrenic patients were identified from the case register and case records search. An analysis of the data indicated no difference in age of first contact with services on rural/urban or male/female comparisons contrasting with previously reported findings. Males tend to utilize proportionately more services in both rural and urban settings. Inpatient hospitalizations contributed the most to per patient costs and a small group of patients, comprising less than 5% of the total population, consumed 10% of the total costs consumed by all diagnostic groups and 30% of the costs of all schizophrenics. Non-hospitalized patients experienced the highest quality of life ratings. Conclusions: Hospital based community services to schizophrenics can be run cost-effectively. There remains a small subgroup of schizophrenic patients who are hard to place or treat in the community and they consume a disporportionate amount of the hospital's costs. Services that attempt to establish patients in the community can do so cost effectively provided there are hospital inpatient beds available as a back up. The benefits of this type of comprehensive service delivery to the schizophrenic population served are demonstrated.

Objective: To compare the perceived accuracy of diagnostic information derived from psychiatric patients and a range of other informants using a schedule for assessing personality disorders (Personality Assessment Schedule). Method: The Personality Assessment Schedule includes a rating of reliability of the information obtained from whatever source. A record was made of these reliability scores in 405 patients with psychiatric disorder; 146 with both subjects and other informants and 259 with the informant only, and analysed using non-parametric statistics. Results: There was significant variation in the distribution of scores among the four psychiatrists who rated 232 of the interviews with informants, suggesting that inter-individual differences are paramount in deciding who is a reliable informant. Nevertheless, the views of other informants when they were spouses or cohabitees were judged to be more accurate than those of other relatives or acquaintances. No differences were found in the perceived reliability of data from subjects and informants when both were interviewed separately. Conclusions: Subjects and informants are judged to be equally reliable in giving assessments of personality status but the informants who have the closest relationship to subjects, spouses and cohabitees, are judged superior to informants of more distant immediate relationship in the accuracy of their information about personality status.

Objective: To determine the influence of the legal system on new attenders at an alcohol treatment unit. Method: One hundred and forty seven new patient referrals to an alcohol unit were examined prospectively over a four month period. Data were obtained by standard psychiatric interview, drinking history inventory, Severity of Alcohol Dependence Questionnaire and a detailed questionnaire of present and past legal involvement. Subjects were then followed up and the numbers remaining in treatment after the first visit and after one month ascertained. Results: Both legally referred and non-legally referred groups had significant past legal involvement while those attending under legal pressure were found to be as severely addicted as other referral types and to have no greater drop out rate from treatment. Conclusion: It is suggested that legally pressured attenders should be accepted into treatment as readily as other referral types and that greater liaison between the criminal justice system and alcohol treatment units is required.

Objective: The aims of this study were to assess the procedures for involuntary admission to both public and private psychiatric hospitals as determined by the Mental Treatment Act, 1945 which is one of the oldest pieces of mental health legislation in the EC. Method: Over a prospective five month period all involuntary admissions to both a public and a private hospital in Dublin were studied. Social-demographic data and clinical features of 54 involuntary admissions were recorded and analysed. Results: 11.2% of public admissions were involuntary as were 3.4% of admissions to the private hospital. The most common diagnoses were schizophrenia and mania. 74.1% of the patients had been previously admitted. 81.5% of the patients were detained in hospital for less than three months although they were committed for a potential six months. There was no formal method of decertification. Conclusions: There appears to be little need nowadays for differentiating between legislation for public and private patients. The duration of the initial reception order should be reduced from six months to a period of forty-eight hours for initial assessment and treatment. If necessary this could be extended to three months. Formal methods for decertification are required. Mental health legislation in Ireland needs to be modernised.

Objective: This study investigated the frequency of abnormal Dexamethasone Suppression Test (DST) in a randomly selected group of mentally handicapped subjects. Method: Forty three subjects living in the community were selected and assessed on a variety of clinical rating scales including Hamilton Rating Scale for Depression (HDS) and Wessex Case Register Form (WCRF). DST was conducted on all the patients and the findings correlated with demographic and clinical variables. Groups defined by DST status were also compared using t-test. In subjects who showed an abnormal response, clinical assessments and DST was repeated after 3 months. Results: Only 7 of 43 subjects showed an abnormal response which did not correlate with either the severity of affective symptoms or the presence or absence of behavioural difficulties. Six of the 7 DST positive subjects were either severely or profoundly impaired on DSM-III criteria indicating that the underlying brain pathology may be pathogenetically important. This was supported by the observation that abnormal DST response was enduring at follow up. Conclusions: The findings suggest that DST may be of little value as a diagnostic tool in the mentally handicapped.

Objectives: To describe existing Scottish psychiatric emergency services, particularly the staffing levels and supervision of junior staff, to assess the level of recording of the urgency of referrals to such services and to determine the approximate rates of emergency presentations. Method: A postal questionnaire was sent to all 29 Scottish psychiatric hospitals, addressed to the physician superintendent or the consultant in charge of emergency services. Twenty-six were returned and further details on these and the other three services were clarified by telephone contact with medical records and medical staff. Description of services, number of presentations, staffing levels and degree of supervision were recorded. Rates of referral were estimated for Health Board populations. Results: Services varied from hospital based walk-in clinics through to community orientated domicillary assessment services. Emergency presentations are usually seen by junior staff in a psychiatric hospital outpatient department, a psychiatric ward or at an accident and emergency department. Out of hours supervision is typically by telephone advice from a consultant. Rates of emergency presentations based on collected and estimated figures were highest in urban areas. Conclusions: Scottish psychiatric emergency services are disparate in nature but all provide a 24 hour service. There is a lack of reliably collected data on the urgency of referrals but estimates suggest that there is a greater need for emergency psychiatric care in the large urban areas. Working definitions are proposed to assist in the classification of the urgency of referrals.

Objective: To survey suicides occurring in Waterford City and County in 1990, to calculate a suicide rate for the region and to examine a series of drownings which occurred during the study period. Method: A catchment area study was carried out with information being collected from coroner's reports, police records, postmortem reports and other sources. Cases were defined by clinical criteria. Results: 13 males and 1 female were considered to have died by suicide, giving an estimated suicide rate of 15 per 100,000. Demographic characteristics and prevalence of psychiatric morbidity conformed broadly to national trends. Conclusion: Structuring a study to deal with suicides within a particular catchment area allows ready access to detailed information from local sources and yields information of special interest and significance to the psychiatric services of the area. Study of a series of drownings in young adult males in 1990 which had aroused much local concern illustrates the difficulties in categorising deaths accurately by this method.

Objective: Anxiety management techniques may all be expected to produce immediate therapeutic effect; more information is required on long term outcome after contact with the therapist ceases. The study is an independently monitored enquiry into the outcome of a brief technique, Anxiety Control Training. Following eight ten-minute instructional sessions with the therapist, assessments were made by a person who had not been involved with the treatment. Medication was withheld throughout the whole period of the study and ‘booster’ sessions were not given in order that an estimate may be made of the degree of subsequent improvement which may be attributed to the patient's own resources and continued practice of the technique. Method: The study was conducted on a sample of patients referred to an anxiety management service suffering from a phobic disorder. Assessments of the severity of the phobia and of generalized anxiety were made at commencement of treatment, at the end of the eight sessions and thereafter at three month and nine month intervals. Follow up assessment of all patients included in the sample was achieved. Results: At inception into the treatment phase seven of the 22 patients suffered from a moderate to severe degree of generalized anxiety in addition to phobia. As expected a significant (p<0.001) degree of improvement in phobic severity occurred during the period of therapy. Following termination of therapy further significant (p<0.01) improvement occurred up to the final assessment. The number of patients suffering from generalized anxiety was too small to allow confident conclusion but the results suggest improvement in generalized as well as phobic anxiety. Conclusions: The instructional sessions of the ACT procedure provide skill in mastery over anxiety. The subject may continue to use this skill without further aid from the therapist; with regular practice of the technique progressive improvement is likely to occur.

Two individuals, a father and son with idiopathic intestinal pseudo-obstruction (IIPO), a familial visceral neuropathy, and major depressive illness are presented. In both the bowel symptoms preceded the onset of the depressive illness – the bowel symptoms presenting in mid-adolescence and the depressive illness presenting in middle age. Both patients required numerous laparotomies and both were treated with a series of ECTs. Both developed vitamin B12 deficiency anaemia and other evidence of malabsorption. At post-mortem both patients showed evidence of distension of the small bowel with volvulus. An extensive pedigree of both conditions overlapping in two inter-related families now extending to the fourth generation with 28 children under the age of 30 is described. Pending further investigation and genetic studies we postulate a possible common neurotransmitter pathology and recommend further neurochemical and histopathological studies of the myenteric plexus in IIPO. Furthermore, the genetic locus of familial IIPO might provide a genetic marker for some forms of primary affective disorder.

Three children who experienced hallucinations in two single-parent families are described. The children's symptoms subsided when the families were treated using a family therapy approach. This report highlights the need for mental health professionals to be aware of the possible response of children to parental psychopathology.

The occurrence of neuroleptic malignant syndrome in two sisters is described. The possibility of there being any genetic predisposition to develop the syndrome is raised.

Objective -To examine the safety and efficacy of alprazolam as an outpatient detoxification agent. Mehtod - Two-year, prospective, uncontrolled study of detoxification from alcohol employing alprazolam in a North Wicklow day centre. The HAD scale was used to measure emotional change. Results -Detoxification was completed in 26 cases. Adverse effects were mild or absent. Significant changes were recorded in both HAD scale scores. Client and staff satisfaction ratings were both high. Conclusions - Alprazolam is a safe and effective detoxification agent in outpatients. The HAD scale provided an objective measure of changes in anxiety and depression in this group of alcoholics. The treated population were older and more often employed than were alcoholics treated in the parent psychiatric hospital.

Objective: To determine the level of engagement as defined by return for out-patient appointment in patients referred for alcohol counselling in a general hospital. Method: The hospital was offered a service with counselling within 24 hours for patients who were identified by ward staff as having alcohol related problems. Referred patients were interviewed on the ward by a nurse who specialised in alcohol counselling. Follow-up appointments were offered. Results: 60% of those given counselling returned for further counselling as out-patients. 83% of women counselled were engaged compared with 42% of men (p<0.05). The mean SADD (a measure of alcohol dependency) score was 23.9 in those subjects who were engaged and 18.6 in those not engaged (p<0.05), indicating greater dependency in the former group. Conclusions: Although these patients had not actively sought help with their drinking 60% returned for counselling as out-patients. Women and those with high levels of alcohol dependency were more likely to seek further counselling.

Objective: Psychiatric units in general hospitals are becoming a key feature of Irish psychiatric practice. This is in accordance with national policy as laid down in “Planning for the Future” in 1984. To date these units have not been the subject of much research. This paper presents baseline data, gives some clinical impressions of how these units are operating, and discusses the implications of these findings. Method: Questionnaires were sent to the medical directors of all 12 psychiatric units in general hospitals in Ireland. In addition, statistical data was collected from the Health Research Board and from the Mental Health Services Section of the Department of Health. Results: All the questionnaires were returned and the results showed that these units were operating in a largely self sufficient way with little usage of local psychiatric hospitals. Outside Dublin 35% of all Health Board admissions are now going to such units, a figure comparable to England and Wales. There was little evidence of patient selectivity as units seemed to be treating the full range of psychiatric disorders. Conclusion: The picture given of general hospital units in Ireland is, in the main, very encouraging. The main problems encountered were the management of disturbed patients and the heavy demands of liaison psychiatry and these two areas would need to be further researched.