Objectives: The commonest psychiatric presentation in most emergency departments (EDs) is deliberate self-harm. However, there are other significant categories of psychiatric presentation which include alcohol and substance misuse, acute psychosis and mood disorder. In addition to the NICE Guidelines for deliberate self-harm, there are good practice guidelines available for the management of other psychiatric attendances to the ED. The aim of this study was to identify the psychiatric attendances other than deliberate self-harm to Beaumont Hospital ED over a 12-month period with the objective of studying the rates and characteristics of attendances and to investigate whether good practice guidelines were met.

Method: From a total of 657 psychiatric attendances other than deliberate self-harm which were recorded, data was collected on demographics, provision of a psychosocial assessment and adherence to good practice guidelines.

Results: Alcohol (38%) was the most common reason for presentation. Of the total number of attendees, only 44% received a psychosocial assessment compared to 59% of attendees who had presented following deliberate self-harm during the same 12-month period.

Conclusions: The attendees who did not receive a psychosocial assessment represent a vulnerable group in which the levels of psychosocial assessment need to be improved in order to meet good practice guidelines standards of care.

Objective: To retrospectively examine the case-notes of all children and adolescents admitted with deliberate self-harm (DSH) or suicidal ideation during the study period 1993-2003. The study aimed to identify underlying reasons why children and adolescents engage in DSH, and to identify common psychiatric, psychosocial and familial factors which may predispose or contribute to an individual's engagement in such behaviour.

Method: All children presenting to the hospital with DSH or suicidal ideation were identified and data collected from their case notes. A study specific questionnaire was designed to collect demographic details, details on clinical presentation, past attempts, comorbid psychiatry disorders, family history and family circumstances. Information was also recorded on hospital stay and discharge planning.

Results: During the 11-year period, 231 children presented with suicidal ideation or behaviour. The mean age was 12.85 with an age range from 6-17 years, with a female:male ratio of 2.5:1. Overdose was the most common method (81.2%) and paracetamol most commonly the drug of choice. More than half of the group (55.7%) expressed a wish to die. More than half (51.8%) had expressed suicidal ideation in the past, 31% had made a previous attempt, and 11.7% had been previously admitted. Of the children 8% presented with suicidal behaviour more than once over the study period. There was a family history of completed suicide in 6.6%.

Conclusion: Deliberate self-harm in young people is a significant public health problem in Ireland. During the period of this study, rates have continued to increase. There is an urgent need for national bodies such as the National Suicide Review Group to extend their focus to include those under age 18 and for services to be developed that might reduce DSH behaviours. More research is needed in the area of childhood suicidal behaviour.

Objectives: The Mental Health Act (MHA) 2001 provides the legislative structure in Ireland for the involuntary admission and treatment, including with ECT, of patients suffering from mental disorders. A recent Seanad Bill proposed removing the option of administering ECT to involuntary patients who do not provide informed consent. This controversial issue has stimulated extensive media and stakeholder debate. In this study we explored the attitudes of consultant psychiatrists towards prescribing ECT for involuntary patients.

Methods: We compiled a current list of consultant psychiatrists attached to approved centres nationwide. We sent a study specific questionnaire to consultants of all adult psychiatry specialties.

Results: From the 249 individualised anonymous questionnaires posted, 164 (66%) were returned and analysed. When clinically indicated for involuntary patients willing to consent to ECT treatment, 159 (97%) consultants stated that they would and three (2%) would not prescribe ECT. For involuntary patients who lack capacity and are unable to consent, 157 (96%) consultant psychiatrists stated that they would and six (4%) that they would not prescribe ECT. For involuntary patients who have capacity to consent but are unwilling to do so, 52 (32%) consultant psychiatrists stated they would and 104 (63%) would not prescribe ECT.

Conclusions: The overwhelming majority of consultant psychiatrists would prescribe ECT for involuntary patients who are unable to consent to this treatment. Divergent attitudes emerged for treating patients who are unwilling to consent, with most consultant psychiatrists stating they would not prescribe ECT for this patient group.

Objective: Substance misuse complicates an individual's management in adult Mental Health services. This study aimed to examine both the overall prevalence of substance misuse in those admitted to the psychiatric unit and additionally those admitted with a primary diagnosis and comorbid substance misuse. The study focuses on the associated diagnoses and demographics in 100 consecutive admissions to an acute psychiatric unit in an Irish university hospital.

Method: Clinical notes were reviewed independently by two members (one being a doctor), of the multi-professional research team within four days of their admission. Substance misuse proximal to the/at the time of admission (reflecting the current usage) was noted.

Results: The combined prevalence of mental illness and substance misuse was 47% (CI 37-57%). Twenty two out of 100 (22%, CI 14-32%) were admitted primarily for the management of substance misuse and dependence (plus psychosocial reasons). Twenty-five of the patients admitted with a primary psychiatric illness (25%, CI 17-31%) were discovered to have comorbid substance misuse. At risk groups were found to be males and aged under 45 years.

Conclusion: Our study demonstrates the importance of screening and identification for substance misuse in psychiatric inpatient units; and consequently, the need for individual case management, additional development of dual diagnosis services and accurate patient data reporting to facilitate forward service-planning.

Objective: The aim of this study was to determine the prevalence of metabolic syndrome and obesity as defined by Body Mass Index (BMI) in a long-stay psychiatric unit where all care is provided by the psychiatric team.

Method: All residents in this long-stay unit were screened. Their BMI was calculated. Waist circumference and blood investigations were done. Ward records were used to determine those who had been previously diagnosed with hypertension and diabetes. The ATP 111 criteria were used to determine the prevalence of metabolic syndrome.

Results: We found a prevalence of 33% for BMI obesity and a prevalence of 66% for metabolic syndrome. These are higher than those of the general Irish middle aged population and the accepted estimate of a general psychiatric population. It is also higher than that of a previous published study on an Irish long-stay psychiatric ward population.

Conclusion: There is high prevalence of BMI obesity and metabolic syndrome in long-stay psychiatric residents. This has the potential to impact significantly on physical morbidity and mortality. People with severe and enduring mental illness should have access to primary care and other health services on the same basis as any other citizen.

Objectives: This audit is supported by regulations within the Mental Health Act 2001. It is in response to the Mental Health Commission Strategic Priority Number One, Quality Framework, 2002-2008 which aims to promote high standards of physical examination in the care of long-stay residents of psychiatric facilities. It is based on improved awareness of adverse effects of mental illness or its treatment on physical health. This awareness informs better practice.

Method: Physical examination proforma and case notes of all long-stay residents in wards in Carlow and Kilkenny were assessed over a six month period to examine the quality of physical examination. Following departmental meetings and literature review, standards of care as recommended by the Royal College of Psychiatrists in Occasional Paper 67 and Irish statutory documents were agreed to be the appropriate benchmark.

Results: Areas of strength were the examination of ‘routine’ systems (> 92%), ie. cardiovascular, respiratory, alimentary, central nervous, genitourinary and the frequency of clinical review by treating psychiatric team. Areas needing improvement were eye (8%) and ear (3%) examinations, measurements of weight (58%), height (1.6%), body mass index (1.6%), waist circumference (0%), investigating for prostatic specific antigen (50%), discussion of results of physical examination and investigations with the residents (both 0%) and referral to BreastCheck (36%).

Conclusion: A new physical examination form has been created for long-stay residents to correct these deficiencies and a new departmental policy document setting out a standard of practice consistent with recommended practice and general statutory requirements has been put into place.

Objectives: This audit aimed to: identify the level of allergy documentation in admission notes, case notes and medication charts in the Department of Psychiatry, Portlaoise; establish the degree of compliance to the gold standard guidelines; highlight areas requiring further improvement and make realistic recommendations to ensure better compliance with the stipulated guidelines on allergy documentation; and re-audit after six months.

Methods: Gold standard guidelines on allergy documentation were obtained from various sources. Audit was performed over three days during which data was collected from the allergy section of medication charts, current case notes and original admission notes in both acute and long-stay wards. Recommendations were made and some were adopted, changes to practice were implemented for six months; at which time re-audit was performed.

Results: The initial audit revealed that: the allergy section was completed in 25% of medication charts; only 12% of current case notes had any documentation of allergy status; an for the original admission notes, the allergy section was documented in 65% of notes. Based on these results, a formal initial assessment proforma with a designated allergy section was introduced and a renewed awareness of the importance of the documentation of allergy status was actively promoted amongst non consultant hospital doctors (NCHDs). Six months later, re-audit showed that: in the medication charts there was a significant improvement in the level of compliance with documentation of allergy status (allergy or NKDA) in the allergy section up from 25% to 58.1%; in the current case notes, there was only marginal improvement in the level of compliance on the front of case notes from 12-19.1%; and in the original admission notes, there was also considerable improvement in the level of compliance with documentation of allergy status up from 65% to 80.9%.

Conclusion: This audit improved the level of documentation of allergy sections in the relevant areas and therefore helped in preventing avoidable and potentially fatal allergic reactions. It will also help save money for the Health Service Executive by reducing compensation costs filed by patients.

Impaired cognition is a core feature of schizophrenia (SZ) that precedes, accompanies, and often outlasts a patient's clinical symptoms. The success of new generation antipsychotics, as well as their failure to ameliorate the persistent disabilities associated with the disorder are well documented. Consequently, a number of psychosocial and cognitive interventions have been developed to address specific aspects of disability not adequately alleviated by medication.

Among these, interventions adapted from the acquired brain literature that target cognitively based disability (cognitive remediation therapy; CRT) have received significant empirical support both for ameliorating specific deficits in memory, attention and executive function, and improving real world outcome. CRT strategies have focused either on providing drill-based training aimed at increasing capacity or providing behavioural strategies for compensating for cognitive deficits, or a mixture of both. Nonetheless, these interventions have varied widely and several questions remain.

This review provides a brief overview of cognitive remediation therapies in psychosis, discusses evidence for its success, and outlines a number of questions that remain about its implementation. Given the current unavailability of cognitive remediation as part of standard care in Irish mental health services, we conclude by describing one such intervention developed within our clinical research group and the questions we hope to address in making this programme more widely available to Irish patients.

Bipolar disorder can emerge in the context of organic brain pathology. In the case presented, long-standing hydrocephalus was diagnosed in a man with relatively late-onset bipolar illness who presented initially with somewhat atypical, treatment-resistant depressive symptoms. Hypomania, followed by a rapid-cycling bipolar course, subsequently developed. This report reviews the association between bipolar disorder and hydrocephalus, and examines possible neurobiological mechanisms implicated in both conditions.

Diogenes syndrome or senile squalor syndrome has been described in the psychiatric literature with an associated mental illness in between one half and two thirds of the cases cited. The occurrence of the syndrome in the absence of a psychiatric disorder has received much attention with many hypotheses proposed. We present the case of a 72-year-old man living for many years in domestic squalor whose presentation, neuropsychological profile and history suggest an underlying autistic spectrum disorder. We are not aware of any similar case in an older adult reported in the medical literature. The co-occurrence of these two conditions is an intriguing one as certain key features of autistic spectrum disorder may predispose to Diogenes syndrome.

The use of antidepressants in bipolar illness remains controversial. This controversy continues to be fuelled by short-term studies that inconsistently report efficacy or no benefit. However, long-term studies have been consistently unfavourable, suggesting that understanding the long-term course of the illness in the setting of antidepressant treatment is important. This is an extraordinary case in which prospectively collected daily mood ratings were available in a type I bipolar individual who had experienced minimal medication changes over a 21-year period was reviewed. Data regarding the number of euthymic days in the setting of antidepressant use and after antidepressant discontinuation were collected.

Induction of cycling and increase in the number of depressed days occurred after five years of continuous serotonergic antidepressant administration. Discontinuation of antidepressants after 11 years of continuous use was associated with only a partial improvement which had a delayed onset. Cycling and increase in depression was noted after years of continuous use of serotonergic antidepressant treatment. Antidepressant-associated destabilisation may occur after long-term exposure and may be associated with prolonged worsening even after antidepressant discontinuation.

We report on the case of a middle aged lady who was referred by her GP with what appeared to be a case of first episode psychosis. Following assessment and investigation an underlying cerebellar tumour was identified. Our aim is to draw attention to the ongoing debates regarding the possible role of the cerebellum in psychosis and cognition and on neuroimaging as a diagnostic modality in cases of first episode psychosis.

Depression will be the second leading contributor to the global burden of disease by 2020. In Ireland, in 2009, 6061 people were hospitalised with depressive disorders. This represents a significant economic and social burden. There is growing awareness of the difficulty in treating depression with medications alone. The likelihood that a patient will achieve remission with the first antidepressant tried is around 30%, and the rates are similar for the second antidepressant tried. This falls to around 15% after three trials. Many patients are exposed to pharmacotherapy for extended periods of time with little beneficial effect, but often with side-effects. Patients are therefore in great need of clear information with regard to their chance of success. Clinicians are in need of clear guidance on prescribing strategies which have proven efficacy. However, this guidance often discusses treatment strategies based on varying levels of evidence. Guiding bodies may approach the problem from varying perspectives. The UK National Institute for Health and Clinical Excellence (NICE) has a clear government mandate with regard to provision of not only effective but cost-effective treatments. The British Association of Psychopharmacology (BAP) is an independent body of interested researchers and therefore may discuss prescribing options from the point of view of tertiary care institutions, and university centres. The South London and Maudsley NHS Foundation Trust publish the popular Maudsley guidelines. These are perhaps more pragmatic in nature, but include very low levels of evidence, including case series.

The American Psychiatric Association (APA) is an independent member association which also publishes guidelines. These are published in the American Journal of Psychiatry and the latest guidelines were published in October 2010.

All these bodies attempt to weigh their advice according to the level of evidence available and aim to provide clinical guidance in difficult situations. The burden on guiding organisations is to provide some direction and clarity in areas that are often unclear or controversial. Clinical guidelines are one method of providing support and guidance to busy clinicians. However, this clinician-centered approach has limitations. The onus is on the authors of the guidance to provide ever-more treatment options. This may mean that conclusions about the efficacy of medications is overstated or the limitations of the literature not fully explored in explanatory notes.