The adverse effects of marijuana are well documented, as well as its positive therapeutic uses. Cannabis has traditionally been associated with an antiemetic action following acute ingestion and synthetic cannabinoids have an established use as antiemetics for chemotherapy induced nausea. However, there has been limited recognition of chronic cannabis use as a cause of cyclic vomiting syndrome. Cannabinoid hyperemesis was first identified by Allen er al in 2004. Compulsive bathing was also described as part of the clinical picture. This same syndrome has been confirmed a number of times in the medical literature in the interim. The condition has, to our knowledge, never been reported, in a psychiatric patient.

We describe a young African male presenting to an Irish psychiatric service with first episode psychosis with an acute onset, no prodromal features and early and complete remission. Migrant and ethnic minority groups may differ in their clinical presentation, course and outcome of psychosis compared with the Caucasian population. This has implications for assessment and treatment of ethnic minority patients in an Irish context given the recent migration into a previously homogeneous population.

Background. The high risk of suicide in bipolar disorder is well recognized, but may have been overestimated. There is conflicting evidence about deaths from other causes and little known about risk factors for suicide. We aimed to estimate suicide and mortality rates in a cohort of bipolar patients and to identify risk factors for suicide.

Method. All patients who presented for the first time with a DSM-IV diagnosis of bipolar I disorder in a defined area of southeast London over a 35-year period (1965–1999) were identified. Mortality rates were compared with those of the 1991 England and Wales population, indirectly standardized for age and gender. Univariate and multivariate analyses were used to test potential risk factors for suicide.

Results. Of the 239 patients in the cohort, 235 (98·3%) were traced. Forty-two died during the 4422 person-years of follow-up, eight from suicide. The standardized mortality ratio (SMR) for suicide was 9·77 [95% confidence interval (CI) 4·22–19·24], which, although significantly elevated compared to the general population, represented a lower case fatality than expected from previous literature. Deaths from all other causes were not excessive for the age groups studied in this cohort. Alcohol abuse [hazard ratio (HR) 6·81, 95% CI 1·69–27·36, p=0·007] and deterioration from pre-morbid level of functioning up to a year after onset (HR 5·20, 95% CI 1·24–21·89, p=0·024) were associated with increased risk of suicide.

Conclusions. Suicide is significantly increased in unselected bipolar patients but actual case fatality is not as high as previously claimed. A history of alcohol abuse and deterioration in function predict suicide in bipolar disorder.

Objectives: Treatment resistant depression (TRD), commonly encountered in clinical practice, leads to socioeconomic disability and therapeutic pessimism. This paper reviews evidence for pharmacological approaches used in TRD.

Method: Electronic literature searches were performed using Medline and Psychlit using broad search terms relating to TRD.

Results: Agents that potentiate both serotonin and noradrenaline may allow more patients to achieve full remission. Attention must be paid to dose titration and length of treatment courses in TRD. Augmentation with lithium and switching within antidepressant class or between classes can often improve symptoms but efficacy of other augmentation approaches remains uncertain. Antidepressant combinations and addition of atypical antipsychotics can be useful but combinations of predominantly serotonergic antidepressants should be avoided. Electroconvulsive therapy retains an important role in TRD but pharmacological treatments need to be continued concomitantly.

Conclusions: Good improvement is seen in TRD after vigorous antidepressant treatment but most patients continue to have lower grade symptomatology.

Koro is characterised as a perception that one's genital organs are shrinking and will eventually recede into the abdomen. It was initially described in South East Asia as a culture bound syndrome but this syndrome has recently been recognised in a non-culture bound context A case is described of a depressed Eastern European asylum seeker with koro like symptoms. All symptoms resolved completely with fluoxetine treatment The relevant literature to the case is reviewed, in relation to onset, symptoms and treatment of this rare syndrome. In addition comparison is made with previous reports of the non-culture bound variant.

Objectives: To assess social and educational status, trauma experienced, diagnosis and treatment of asylum seekers, who presented to psychiatrists in St James's hospital Dublin over a two-year period.

Method: All files of asylum seekers assessed by psychiatrists in St James's hospital over a two-year period were scrutinised. Using a pro-forma, data was obtained about social and educational status, language skills, trauma suffered, diagnosis, treatment and follow-up. Demographic data was obtained from the Department of Justice, the Irish refugee centre and various social welfare offices.

Results: Over a two-year period 31 asylum seekers were in contact with this service. Most originated from Africa. Overall subjects were well educated but socially isolated with poor language skills. Many had been imprisoned or tortured, or had relatives or friends tortured or killed prior to migration. Almost one third met criteria for PTSD and greater than a third met criteria for major depression. The majority of subjects received pharmacological treatment, but few were offered psychological treatments. Most had no prior psychiatric diagnosis and dropped out of treatment at an early stage.

Conclusions: Large numbers of asylum seekers are currently residing in Dublin and may need specialised psychological support and treatment. They have been exposed to significant levels of pre-migratory trauma, often have poor language skills and drop out of treatment quickly which may indicate dissatisfaction with existing treatment approaches. There is an urgent need for increased funding for the psychological needs of this vulnerable group, for the provision of trained interpreters, specialised psychotherapy and assessment of their needs.

A patient presenting with co-existent Capgras and deClerambault's syndromes, with a history of morbid jealousy is described. This combination of syndromes has not previously been described. The relevant literature to this case is reviewed, in relation to the onset of these syndromes, aetiology and treatment. Abnormalities in pathways involving recognition of familiar faces have been implicated in a number of similar cases.

Two cases of fathers who committed suicide following the revelation that they had sexually abused their own or other children, are described. The importance of being alert to the possibility of suicide and suicidal acts by family members following a disclosure, is emphasised. Improved liaison and co-ordination between agencies working with these families may enable vulnerable cases to be more readily identified and consequently offered appropriate support and treatment.

The revelation that the father in a family has sexually abused his own or other children often precipitates a crisis within the family. The distress suffered by the children themselves and by their mothers is well documented. (Browne and Finkelhor, Hildebrand and Forbes). Goodwin reported suicide attempts in 11 of 201 families, in which sexual abuse had been confirmed. Eight of the attempts were made by daughter-victims. In three of the five cases of mothers who attempted suicide, the abuse was intrafamilial. The impact on father perpetrators, previously a less well researched field, has been receiving more attention of late. Maisch, in a sample of 63 fathers convicted of incest reported that two fathers subsequently committed suicide. Wild has reported on six cases of suicide and three of attempted suicide by perpetrators following disclosure of child sexual abuse. The Cleveland Inquiry Report mentions one father, charged with several sex offences, who committed suicide while awaiting trial. A recent letter to The Guardian newspaper (18th February 1989) by 11 local paediatricians in that area suggests that there are now two such cases of suicide committed by alleged perpetrators.