The Irish ‘Vision for Change’, 2006 mental health policy document proposes a framework for promoting mental health and a recovery approach to inform every level of service provision. Comprehensive assessment by the rehabilitation and recovery multidisciplinary team with active involvement of the service user is crucial in the identification of needs, goals and recovery factors. This paper outlines importance of a comprehensive assessment tool, which helps to guide the service user towards identification and achievement of their goals while encompassing the recovery ethos.

Objectives: Although there are many published reports about the human cost of schizophrenia, there are far fewer estimates of its economic cost, particularly in Ireland. The aim of this study was to provide a prevalence-based estimate of the costs associated with schizophrenia in Ireland during 2006.

Method: Using standard Cost of Illness (COI) procedures we compiled data from many sources including the Health Research Board, the Department of Health and Children and other government publications. Costs relating to health and social care, informal care, lost productivity, premature mortality and other public expenditures were included. Where national data were unavailable, we used bottom-up data from a geographically defined catchment area study and, in some instances, costs from two catchment areas were averaged. We did not measure human or intangible costs.

Results: The estimated total cost of schizophrenia was €460.6 million in 2006. The direct cost of care was €117.5 million and the burden of indirect costs was €343 million. The cost of lost productivity due to unemployment, absence from work and premature mortality was €277 million. Within indirect costs, the expenditure on informal care borne by families was €43.8 million.

Conclusions: Schizophrenia is not a very common condition but is an expensive one. This is attributable to its young age at onset, relatively low mortality rate and high severity particularly in terms of its impact on future employment. Measures to improve outcomes coupled with measures to improve employment such as supported employment strategies may impact significantly on the cost of schizophrenia. The study is limited because the national unit costs of many variables are not directly available and these Irish data are likely to be an underestimate. However, the results are comparable with a 2005 cost of illness study UK study.

Objectives: To describe the characteristics of the patient groups with severe and enduring mental illness residing in high support community residences in Dublin North East Mental Health Service and the impact of a rehabilitation and recovery service on their outcomes since the instigation of that service.

Method: Data was collected retrospectively on current and past residents from case notes and staff interviews. Data included demographics, psychiatric history and results of rehabilitation interventions. The results were compiled and analysed using descriptive statistics.

Results: Fifty patients were identified. The majority were male (62%) with a diagnosis of paranoid schizophrenia (66%).The levels of co-morbid alcohol and drug misuse were 48% and 36% respectively. Histories of verbal/physical aggression were found in 70% and noncompliance in 60%. Two thirds of patients had a past history of being detained under the Mental Treatment Act (1945). Ninety-four per cent were unemployed at admission to the residence and following rehabilitation intervention 60% were linked with vocational training programmes and 10% with community employment schemes. ‘New long-stay’ and ‘old long-stay’ patients showed a trend towards poorer outcomes, whereas patients who had previously lived in the community showed a trend towards progressing to lower levels of support.

Conclusions: Positive outcomes were achieved following active rehabilitation interventions, but there remained a cohort of patients whose needs could not be met in a supported community rehabilitation residential programme. This highlights the need to ensure that a range of rehabilitation services from inpatient to supported community placement are provided to meet the needs of patients with severe and enduring mental illness with complex needs.

Objectives: Recent advances in mental healthcare policy and service delivery have lead to the development of community care initiatives which have enabled those individuals traditionally cared for in hospital environments to be resettled successfully in community living arrangements that foster an ethos of empowerment and recovery. This study sought to identify differences between a hospital continuing care group (n = 16) and a community placement group (n = 20) in relation to quality of life, satisfaction and levels of empowerment.

Method: The study was a cross-sectional design. It follows up a cohort of individuals identified as the ‘hospital continuing care group’ (365+ consecutive days in psychiatric hospital care) by Homefirst Community Trust in Northern Ireland. A proportion of this population has been resettled into community care environments and some continue to reside in hospital. Patients both in the hospital continuing care group and the community placement group completed two standard questionnaires that covered a number of variables including empowerment, quality of life and service satisfaction.

Results: There were significant differences between the hospital continuing care and community placement groups across scores on service satisfaction, quality of life, and empowerment in the current study. Hypotheses relating to service satisfaction (z = −4.117; p < 0.01 ), quality of life (z = −3.944; p < 0.01) and empowerment (z = −4.645; p < 0.01) were supported with higher levels of each evidenced by the community placement group.

Conclusions: The results are supportive of continued resettlement from continuing care in traditional psychiatric hospitals and suggests that such resettlement increases quality of life, satisfaction with services and levels of empowerment. The limitations of the research design are empowerment. The limitations of the research design are also discussed.

Objectives: To describe the drug history and co-existing psycho-social problems among under-19 year olds accessing treatment for opiate dependency, including methadone maintenance, and examine for any gender differences.

Method: A descriptive study of under-19 years assessed at the largest drug treatment clinic in Dublin, Ireland, between October 2000 and September 2006. Data was obtained through review of case notes, assessment questionnaires and urine drug screens.

Results: Eighty-six young people were included. Their mean age was 16.8 years. Forty-six (54%) were female. Only 26 (30%) reported an intact family of origin. Twenty-three (27%) had been in care. Mean age for first use of any illicit drug was 12.4 years, and for heroin was 14.8 years. The mean age of leaving school was 14.4 years; 42 (49%) first tried heroin after leaving school. Forty-one (48%) had a history of homelessness. Forty-four (51%) had previously injected; 26 (30%) were currently injecting. Fifty-six (65%) had not been screened for blood-borne diseases; twenty-one (24%) subsequently tested positive for hepatitis C. Thirty-eight (48%) had previous convictions; 33 (38%) were facing charges. Forty-five (52%) had previously seen a psychiatrist; nine (11%) had received inpatient psychiatric treatment. Boys were more likely to leave school early, have a substance-abusing sibling, and to have a past conviction. Girls were more likely to have a partner, and have taken a deliberate overdose.

Conclusions: This study highlights the multiple and complex needs of teenagers abusing opiates. Services seeking to meet their needs will require a broad range of interventions and excellent interagency co-operation.

Objectives: To provide normative data for older national (primary) school children, broken down by age and gender, for the Children's Depression Inventory-Short version (CDI-S) and revised norms for the Children's Depression Inventory-Parent version (CDI-P) and its subscales.

Method: Forty-three randomly selected national schools took part in this study. Participants were 1,255, fifth and sixth class, Irish national school children who completed the Children's Depression Inventory Short Form (CDI-S). In total 1,018 parents completed the corresponding parent form, the Children's Depression Inventory-Parent version (CDI-P).

Results: Norms for the CDI-S and the CDI-P subscales were produced. Revised norms for the CDI-P are proposed. Results revealed no significant age or gender difference in depressive symptomatology as measured by respondent's CDI-S and total CDI-P scores. Parent's ratings of their children's depression levels (CDI-P) and children's self-reported depression levels (CDI-S) were significantly correlated. The CDI-S and CDI-P displayed good internal reliability.

Conclusion: Results indicate the utility of both the CDI-S and the CDI-P for assessing depressive symptoms in national school children in Ireland. This study confirms that national school children do display symptoms of depression. School based policies, materials and services supporting and promoting positive mental health should be developed, implemented and resourced.

Objectives: It was hypothesised that patients admitted to forensic mental health facilities are stratified along the pathway through care according to levels of need. Level of risk and psychopathology should vary with different levels of security.

Method: Seventy-five men in a forensic hospital were interviewed by three trained clinicians using the HCR-20 (Historical Clinical Risk Assessment) – clinical and risk items, The Health of the Nation Scales – Secure (HoNOS-SECURE), PANSS (Positive and Negative Syndrome Scale), GAF (Global Assessment of Functioning) and the CANFOR (Camberwell Assessment of need Forensic Version).

Results: The mean scores on a variety of clinical measures were higher in admission/high security areas and progressively lower in rehabilitation and pre-discharge areas. As patients moved through the pathways of care, they improved in a number of areas including psychiatric morbidity, risk, function, unmet needs. The following results stratified significantly; the HCR-20 summated clinical and risk (F = 9.2, df = 5, p < 0.001), the HoNOS secure (F = 18.2, df = 5, p < 0.001), PANSS (positive, general and total), GAF, staff and user unmet needs on the CANFOR.

Conclusions: The data indicate that the theoretical organisation of the units of the hospital into high, medium and low security units to form a coherent pathway through care is reflected in practice. This is a transparent route out of secure care in which restrictions are proportionate to risk and supports proportionate to need. It is unclear whether alternative models, consisting of a series of generic unstratified units for admission and discharge, all at the same level of therapeutic security, allow for the provision of treatment programmes and relational interventions appropriate to the patient's stage of recovery and rehabilitation.

Objectives: This study examines (1) what are the minimum accepted baseline investigations recommended in the literature prior to prescribing in child psychiatry and (2) whether these investigations are routinely performed.

Method: Medical literature on prescribing in child and adolescent psychiatry was reviewed, and a list of minimum baseline investigations recommended in the literature was established. A postal survey was performed to establish what current clinical practice is among child and adolescent psychiatrists. Current practice was compared with the recommendations in the literature.

Results: There are nine minimum accepted baseline investigations which are consistently recommended in the literature on child psychiatry. Six investigations are routinely performed by over 75% of respondents. However only 30% (n = 16) reported that they ‘always’ carried out eight or more of the nine recommended minimum investigations.

Conclusions: A consensus statement is necessary, providing a list of recommended investigations prior to prescribing in child and adolescent psychiatry. Continuing medical education can then highlight the importance of these investigations.

Objective: The aim of this study was to help clarify the range of acute medical problems experienced by patients on an acute psychiatric unit during a period of 28 days and nights, as encountered by psychiatric trainees, and to document any difficulties experienced by the trainee during these patient contacts.

Method: This survey was carried out prospectively over 28 days and nights in an acute psychiatric ward attached to a teaching University Hospital. Following contact with an individual patient, the trainee recorded diagnosis, intervention and any difficulties encountered.

Results: Thirty-three patient contacts were recorded (n = 33). Trainees faced a range of primary care problems 22/33 (67%), but moreover, three patients demonstrated more serious and potentially life threatening problems, leading to 11/33 (33%) patient contacts requiring urgent interventions.

Conclusions: While the debate continues as to who is best placed to provide medical healthcare for psychiatric patients, this study provides evidence that psychiatry trainees are required to draw on their previous medical and surgical experience on an almost daily basis. As psychiatrists we should consider our options on how best to manage medical problems on the acute psychiatric unit and consequently ensure confident liaison with our medical and surgical colleagues.

Objectives: The rate of suicide among young men is rising. However, young men are reluctant to use mental health services. In this study we explored young men's attitudes towards mental illness and mental health services, as well as their willingness to use these services.

Methods: Four focus groups were conducted in two Dublin schools. A total of 18 students participated in the study.

Results: Students held negative views towards mental health services, particularly in respect to psychiatric hospitals and medication. Students were not well informed about whom to contact if they had depression and were very conscious about the stigma of going to see a ‘professional’. Many students did not recognise depression as being a mental illness and could not differentiate between depression and feeling sad.

Conclusions: This study shows that a lack of knowledge and understanding about mental illness, combined with prejudice against mental health professionals and fear of stigma, are important barriers to access of mental health services for young men.

Objectives: We set out to review all admissions from the criminal justice system to the Central Mental Hospital from January 1997 to December 2003, with particular attention to patient diagnoses, offences, source of admission, length of stay, and patterns of discharge. This study was undertaken to assist with future service planning and determination of resource needs.

Methods: The service maintains a combination of electronic and handwritten records of all admissions. Information was extracted concerning all admissions from January 1, 1997 to December 30, 2003. The data was analysed using a statistical package, SPSS 11.0 for Windows.

Results: Nine hundred and eighty-six admissions of 780 individuals from the criminal justice system were recorded from January 1997 to December 2003. There has been an increase in the proportion of patients admitted suffering with severe mental illness. There has also been a significant shift in the pattern of discharges, with a higher proportion of patients leaving to return to their local hospital. The proportion of admissions returned to prison has fallen from 91.1 % in 1999 to 64.7% in 2003, while 3.3% of individuals admitted became new long-stay cases.

Conclusions: A shift in the profile of patients admitted in recent years reflects changes within the National Forensic Mental Health Service. An increased provision of regular and structured psychiatric input to the prisons has facilitated the identification of prisoners with mental illness. The shift from prison liaison to diversion from the Criminal Justice System to mental health services is however in its early stages.

Objective: The aim of this study was to determine the rates of osteopenia and osteoporosis and other general health problems in a long-stay male psychiatric unit.

Method: All 15 patients underwent a semi-structured clinical interview and a full physical examination including calculation of Body Mass Index, central obesity (abdominal circumference) and blood pressure measurement. All patients had blood sampling examining FBC, U&E, LFTs, TFTs, PSA, prolactin, lipid profile and glucose. The rates of metabolic syndrome were calculated according to the International Diabetes Federation consensus worldwide definition. Bone mineral density was determined in the lumbar vertebrae and left hip by DEXA scanning.

Results: The prevalence of osteopenia or osteoporosis was 46%, and bone mineral density was inversely correlated with serum prolactin levels (r = -0.595, p = 0.041) and chlorpromazine equivalence (r = -0.645, p = 0.017). The prevalence of obesity was 53%, while central obesity was present in 87% of patients. Metabolic Syndrome was present in 27% of patients.

Conclusions: More attention should be given to diagnosing and treating osteopenia and osteoporosis in patients on long-term antipsychotic agents and preventative measures should form part of any treatment regime in these individuals. Frequent input from dietitians should also be available for long-stay psychiatric inpatients to reduce the prevalence of obesity.

Objective: All patients who resided in state provided long-stay care in Ireland were required to pay the state for that care until 2006. In 2001 the Irish Ombudsman and Information Commissioner had highlighted the issue of the entitlement of people with medical cards to provision of free long-stay care. The Health Repayment scheme was subsequently set up in 2006 to facilitate the repayment of long-stay charges wrongly paid by patients. Issues of mental capacity arise particularly in the context of long-stay psychiatric patients applying for repayment of long-stay charges. Our aim was to devise a test suitable to assess the capacity of an individual to make an application for refund charges.

Method: There was no specific test in existence to assess the capacity of an individual to make an application for refund of charges. A suitable test was devised based on the available literature which assessed whether the person understands the ‘nature and effects’ of making a refund application. Fifty-eight long-stay patients were deemed to be entitled to apply for a refund.

Results: Staff identified 47 (80%) patients as possibly lacking the capacity to make an application. Of these, 14 patients (29.8%) were found to have capacity to make an application (mean age 58.5 years) with 33 (70.2%) found to lack capacity (mean age 73 years). Of those with capacity 50% had a diagnosis of schizophrenia/schizoaffective disorder. None had cognitive impairment of degenerative origin. Of those who lacked capacity 45.5% had a diagnosis of dementia. All of the patients with dementia who were assessed were found to lack capacity whereas 59% of those with a diagnosis of schizophrenia/schizoaffective disorder lacked capacity.

Conclusion: A substantial number of long-stay psychiatric patients may lack the capacity to make particular decisions. In this study the group who lacked capacity were an elderly group with dementia common. This process raised a dilemma about how a patient without capacity to make a refund application can then manage the money claimed on their behalf and whether guardianship safeguards are necessary.

Objective: There is a paucity of literature on the content of referral letters to psychiatric services and few relating specifically to referrals to a department of old age psychiatry. There has been a significant increase in referrals over the last five years to this service, which may reflect the ageing population and a greater awareness of the service. Our objective was to evaluate the quality and legibility of information received, clarity of reason for referral and details of pre-referral management.

Methodology: The clinical records of the first 100 referrals in 2002 to this department were analysed. The referral letters were examined for the documentation of a number of demographic variables, reason for referral, interventions to date and level of urgency.

Results: The clinical records of nine patients did not have an identifiable referral letter at the time of this analysis. Of the remaining 91 analysed, 59% were referred by their GP, 33% were inpatient liaison referrals and 8% from outpatient departments. In the majority, patients' details were given, however, only 30% included a phone number. Next-of-kin was mentioned in 29%. GP's name was included in 71% of referrals from OPD and 7% of liaison referrals. The level of urgency was stated in 19%. Whether a domiciliary or OPD visit would be more appropriate was stated in 22%. The reason for referral was clear in 75%, with 43% including some aspect of Mental State Examination, 7% had included a MMSE score, 1% mentioned level of suicide risk.

Thirty-one per cent had pre-referral investigations and 45% had pre-referral treatment documented. The letters were clearly legible in 73%.

Conclusion: The information in the referral letter in many cases was insufficient to prioritise and expedite appropriate assessment. It is planned to introduce a proforma referral form, specific to old age psychiatry, which would include the information which is required and which would, hopefully, lead to a more efficient service.

Objectives: People with schizophrenia are at increased risk of cardiovascular and endocrine disease. National guidelines recommend the physical health of people with schizophrenia be monitored by primary care, but little is known about whether such people attend primary care. We sought to examine the prevalence of cardiovascular and endocrine disease in a stable population with schizophrenia, and factors associated with attending primary care.

Method: A cross sectional survey of people with a diagnosis of schizophrenia/schizoaffective disorder was taken from a larger cohort participating in the Resource for Psychoses and Genomics in Ireland (RPGI) study. Participants were interviewed using standardised clinical assessments, and underwent anthropometric measurements, and further information was collected by medical record review and contacting the general practitioner (GP).

Results: Thirteen percent (n = 14) had established cardiovascular disease and 4.3% (n = 4) had type 2 diabetes. Risk factors for cardiovascular disease and type 2 diabetes were higher than the general population. Sixty-eight point five percent (n = 63) had attended their GP at least once in the previous year. Only 35% self reported a physical illness. Females (p = 0.03), those with both self-reported presence of physical illness (p = 0.007), and diagnosed physical illness (p = 0.001) were more likely to attend their GP. Other psychosocial, psychological and illness related variables did not predict attendance at primary care.

Conclusion: While established patients attend their GP, they had significant unidentified risk factors for cardiovascular disease and type 2 diabetes. It is likely that non-attendees at secondary care would fare worse yet.

Objective: Over recent years in England there has been widespread development of assertive outreach teams supporting patients with severe mental illness living in the community. Assertive outreach staff members are exposed to a variety of new stressors and risks. This study investigated the emotional impact on keyworkers of working with assertive outreach patients. This was considered in terms of the attitudes keyworkers hold towards patients with particular types of difficulty. The study also measured individual keyworker stress.

Methods: Keyworkers from three teams in Birmingham were surveyed regarding their attitudes towards individual patients. Questionnaires measuring attitudes and patient difficulties were derived for the purpose of the study. Strengths of attitudes were correlated against different patient difficulties. Keyworker stress was measured using the General Health Questionnaire, GHQ12.

Results: Certain patient difficulties, in particular poor engagement, psychotic symptoms and aggression were associated with feelings of failure in keyworkers whilst drug use, particularly crack cocaine use, was associated with fear of visiting patients at home. Some 41% of keyworkers met ‘caseness’ criteria on the GHQ12. Negative attitudes appeared to be independent of GHQ scores.

Conclusions: Keyworkers expressed a number of positive and negative attitudes in relation to patient difficulties. Negative attitudes did not appear to be simply a feature of keyworker stress, however it is acknowledged that the sample size was small. Keyworkers' responses suggested a sense of personal failure when their patients were unwell or poorly engaged, despite patients being selected for assertive outreach on the basis of such difficulties. Recognition of negative attitudes may help in the improvement of training and supervision of staff members.