Objectives: Initial examination of data held by the Mental Health Commission indicated a number of patients having repeated involuntary readmissions (defined as patients having three or more involuntary episodes in a calendar year). The Commission sought more empirical analysis of the data relating to these patients, to determine if there were any trends or commonality regarding their demographic characteristics, length of episode, and diagnoses.

Methods: From 1 November 2006 the Mental Health Commission has been notified of all involuntary admissions in Ireland under the Mental Health Act (2001). From this national database information on patients who have had three or more involuntary admissions per year was analysed.

Results: In the period studied there has been an overall reduction in the number of voluntary and involuntary admissions to Irish psychiatric hospitals and units. However, the use of involuntary admission remains constant at around 10% of all admissions. Seven percent (n=569) of involuntary admission orders in this four year period relate to two percent (n=121) of all involuntary patients. Patients who have experienced repeated involuntary admissions are predominantly male (59%), often have a diagnosis of schizophrenia, or schizotypal and delusional disorders (57%), or mania (20%), are in the age band 22-64 (80%) and more often live in rural counties.

Conclusions: Potential appears to exist to significantly reduce the number of involuntary admissions by focusing on the care given to patients who are repeatedly re-admitted. More analysis is needed of voluntary and involuntary re-admissions if inpatient facilities are to be effectively configured.

Objectives: Psychotherapeutic skills are essential to practice psychiatry effectively, but previous surveys of trainees in Ireland show that they have not been getting adequate training in psychotherapy. This survey of college tutors was carried out to coincide with the establishment of the College of Psychiatry of Ireland which is introducing new psychotherapy training requirements. The survey aims to ascertain if trainees had fulfilled the Royal College of Psychiatrists' psychotherapy training requirements, models of psychotherapy available and the availability of psychotherapy qualifications amongst consultants and senior registrars.

Methods: A questionnaire was posted to all registered tutors in the Republic of Ireland.

Results: The postal questionnaire was sent to the 62 registered college tutors in the 13 training schemes. There is one tutor in each training hospital. The response rate was 79%. Our survey reveals that no psychotherapy training was available according to 16.3% of tutors. Only 22.5% of tutors were aware of trainees who had met college training requirements in the previous two years. 79.8% of tutors reported that there were consultants and senior registrars with qualifications in psychotherapy who could offer training if time and resources permitted.

Conclusions: Current training requirements are not being fulfilled. There are consultants and senior registrars who have psychotherapy qualifications to provide psychotherapy training but there are inadequate resources and time to formalise training. It is unlikely that the implementation of training requirements by the new college will be realisable without a review of training delivery.

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: Care planning is a multidisciplinary process used to develop an individualised recovery plan for each service user. The success of this process will depend on the extent to which members of mental health teams can work with one another, with service users, and with other service providers in developing a coordinated plan that meets service user needs across multiple domains.

Aims: This paper examined the teamworking challenges that Community Mental Health Teams (CMHTs) face during the care planning process and how such challenges may be managed.

Method: A narrative review of published articles and policy documents relevant to teamworking and recovery-focused care planning within mental health teams.

Findings: Teamworking challenges include the provision of integrated rather than fragmented care, the empowerment of the service user, and development of a distributed model of leadership, responsibility and decision making.

Conclusions: CMHTs face a range of substantial but manageable challenges in attempting to implement recovery-focused care planning. Recommendations include the need to integrate recovery-orientated skills and values into professional training, the need for greater multidisciplinary training opportunities, and the need to evaluate CMHTs based on recovery-orientated criteria.

Objective: The aim of this exploratory study was to investigate the extent of suicide ideation, psychological maladjustment and views of mental health service support in a sample of secondary school pupils.

Method: A cross-sectional survey was conducted on a purposive sample of participants (n=93) recruited from a secondary school located in the south east of Ireland. Participants completed a Background Information Questionnaire (BIQ); the Suicide Ideation Questionnaire (SIQ); and the Reynolds Adolescence Adjustment Screening Inventory (RAASI).

Results: Approximately ten percent of participants displayed high levels of suicide ideation whilst one third reported having previously had suicidal thoughts; one quarter reported psychological adjustment difficulties, although these varied by age and sex. Participants' drug use and their levels of parental closeness were both individual factors that significantly predicted both suicide ideation and psychological adjustment. Females reported higher levels of parental closeness than males. Forty percent of respondents rated mental health support services as insufficient to meet their needs.

Conclusion: The findings raise serious concerns about the extent of suicidal thoughts amongst young people in Ireland; they also highlight a potentially important role for parents in this regard. Further research should ascertain national prevalence rates whilst appropriate school-based mental health education/promotion and support services should also be implemented.

To determine if a consultation/liaison mental health clinic in primary care as proposed for Vision for Change, The Primary Care Strategy and the Department of Health is an efficient model of delivering mental health care in Ireland.

Methods: The pattern of service use and the clinical characteristics of new patients attending a pilot consultation/liaison clinic in a local primary care centre were studied.

Results: During the first 16 months of this clinic 1.2% of patients did not attend the initial assessment in the liaison clinic versus 29.75% in the regular Outpatients Department (OPD). Less than one in five (17.1%) required a follow-up review with the clinician in the consultation/liaison clinic compared to almost all patients first seen in OPD secondary care (96.6%). A small minority of patients (6.1%) needed referral to secondary care due to the complexity of their presentation.

Conclusions: A consultation/liaison mental health clinic in primary care results in an efficient use of manpower resources due to the low Did Not Attend (DNA) rates and low proportion of formal referrals to secondary care. As patients seem to favour this type of setting, over traditional outpatient departments, a move towards consultation/liaison clinics in the primary care team should be considered.

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.

Corticosteroids are commonly used in the treatment of a variety of medical conditions in children and adolescents. However, adverse psychiatric side effects can occur which pose challenges in treatment of medical conditions. This case highlights some of these challenges, in particular the treatment of steroid-induced psychiatric complications in Acute Lymphocytic Leukaemia (ALL). It also accentuates the importance of awareness among pediatricians of the potential adverse psychiatric effects when prescribing corticosteroids in this age group. Families need to be advised accordingly to ensure early recognition and treatment.

Objective: To review the role of handwriting analysis in psychiatry.

Method: Case-report and review of key papers.

Results: M, a 27-year-old man, presented with incoherent speech, palilalia, logoclonia, incongruous affect, paranoid delusions and auditory hallucinations. M was diagnosed with schizophrenia and cannabis misuse, complicated by speech and language difficulties. M spent long periods writing on pieces of paper; towards the start of his admission, his writing was unintelligible but became more intelligible as his psychosis resolved. M's handwriting demonstrates clinical features of psychosis (e.g. clang associations) and graphological abnormalities associated with schizophrenia in the literature (rigidity in letter-formation, mechanical expressions, and tendency toward over-use of straight lines).

Conclusion: Analysis of handwriting is likely to play a limited role in psychiatric diagnosis but may prove useful in monitoring clinical improvement in certain patients.

One of the most important questions facing psychiatry today concerns its relationship to the emerging international service user movement. I believe that this movement presents not only the greatest challenge to psychiatry, but also the greatest opportunity. As it becomes more organised and influential this movement is starting to play a major role in shaping the sort of questions that are being asked about mental health services and their priorities. Yet there is limited reflection in our profession about how we, as doctors, might engage positively with it. It seems that while we are comfortable working with individuals and organisations who accept the medical framing of mental problems, we are less willing to contemplate working with critical service users. These are people who reject the medical model because they feel harmed by a system that describes their problems using the language of psychopathology. If we are serious about having an inclusive debate on mental health we will have to overcome this impasse. We need to entertain the idea that people who reject the medical framing of their problems are nevertheless legitimate stakeholders. It is time that we learned how to talk to them and to listen to their ideas. The user movement, with its substantial critical component, is not going to go away.

One of the most important elements of the relationship between psychiatric services and the people who use them is the reality of psychiatric power. Many critical service users accept that legally sanctioned interventions may be necessary when individuals lose capacity to care for themselves and perhaps put themselves or others at risk. However they do not accept the fact that the Mental Health Act in Ireland gives sole authority to doctors to take decisions on such interventions without any obligation to consult other interested parties.

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.