Adult attention-deficit hyperactivity disorder (ADHD) clinics are in their infancy in Ireland and internationally. There is an urgent need for clinical evaluation of these services. Until now, clinical outcomes have relied mainly on functional scales and/or quality of life. However, adult ADHD is a longstanding disorder with many comorbidities. Although medication for ADHD symptoms can have immediate effects, co-occurring problems may take considerably longer to remediate.

To present the psychometrics of a short outcome measure of key clinical areas including symptoms.

The ADHD Clinical Outcome Scale (ACOS), developed by the authors, is a clinician-rated scale and was administered in consecutive adults attending an ADHD clinic. A modified version was completed by the participant. A second clinician independently administered the scale in a subsample. ACOS consists of 15 items rated on a Likert scale. Two self-report scales, the Adult ADHD Quality of Life Questionnaire (AAQoL) and Weiss Functional Impairment Rating Scale (WFIRS), were also administered.

The mean age of 148 participants was 30.1 years (s.d. = 9.71), and 81 were female (54.7%). The correlation for interrater reliability was r = 0.868, and that between the participant and clinician versions was r = 0.663. The intraclass correlation coefficient for the internal consistency was 0.829, and the correlations for concurrent validity with total AAQoL and WFIRS scores were r = −0.573 and r = 0.477, respectively. Factor analysis revealed four factors: (a) attentional/organisational problems; (b) hyperactivity/impulsivity; (c) comorbidities; and (d) alcohol/drug use, self-harm and tension in relationships.

The psychometrics of the ACOS are promising, and the inclusion of typically co-occurring clinical domains makes it suitable for use as a clinician-rated outcome measure in every contact with patients attending adult ADHD clinics.

Rates of acute mental health presentations in youth were rising pre-pandemic internationally. Longitudinal studies following Covid-19 attest to ongoing deterioration in youth mental health, recognising adverse unintended consequences following public health restrictions.

This study aimed to examine whether the initial reported post-Covid-19 increase in mental health presentations persisted following the reclassification of Covid-19 to endemic status, which was accompanied by removal of most restrictions.

All referrals to paediatric liaison psychiatry (PLP) between Jan 2018–Dec 2022 in a Dublin tertiary children's hospital were included in the study. An interrupted time series analysis was conducted examining referrals with respect to different phases of Covid-19 and application of public health restrictions.

1,385 referrals to PLP were received over the 5-year study time-period. There was a significant decrease in PLP referrals immediately post Covid-19, following a significant and sustained increase as the pandemic progressed. Public health restriction phases had a unique effect on those presenting with suicidal ideation, with a significant increase in the number of referrals received. There was no effect of restrictions on other clinical profiles.

Increased referrals for youth with mental health difficulties, reported during the Covid-19 pandemic, persisted into the early endemic stage, after Covid-19 public health restriction have ceased. Potential impacts of restrictions on referrals of youth with suicidal ideation require further study. Investment in child and adolescent mental health services remain a priority, and future pandemic responses need to examine unintended consequences of any enforced public health measure.

Burnout is a consequence of chronic occupational stress. Specific work-related factors may contribute to burnout experienced by those working in mental health services (MHS), many of which have increased since the COVID-19 pandemic.

To examine personal, work- and patient-related burnout among MHS staff in Ireland during the COVID-19 pandemic, and explore the impact of work-related conditions on burnout.

We conducted a cross-sectional survey of three MHS across Ireland utilising a study-specific questionnaire, the Copenhagen Burnout Inventory and the Effort–Reward Imbalance scale.

Of 396 participants, 270 (70.6%) were female. Moderate and high personal burnout was experienced by 244 (64.1%) participants; work-related burnout by 231 (58.5%) participants and patient-related burnout by 83 (21.5%) participants. Risk factors for both personal and work-related burnout were female gender, urban service, time spent outside main responsibilities, overcommitment, high score on the Effort–Reward Imbalance scale and intention to change job. Being younger, with high workload and deterioration of personal mental health during the pandemic was associated with higher personal burnout, whereas a lack of opportunity to talk about work-related stress contributed to work-related burnout. Fewer factors were associated with patient-related burnout, namely overcommitment, working in urban services and poorer physical and mental health during the COVID-19 pandemic.

High levels of personal and work-related burnout were found among mental health workers. The weak association with COVID-19-related factors suggest levels of burnout predated the pandemic. This has implications for MHS given the recognised additional work burden created by COVID-19.

Effective doctor–patient communication is a core competency for healthcare professionals. With the pivot to online clinical education and assessment due to the COVID-19 pandemic, there was a need to explore the views of psychiatric trainees and examiners on assessment of communication skills during online high stakes postgraduate examinations.

The study was designed as descriptive qualitative research. All candidates and examiners of the September and November 2020 sitting of online Basic Specialist Training exam (a clinical Objective Structured Clinical Examination exam completed in the first 4 years of psychiatry training) were invited to participate. The respondents were interviewed by Zoom which was transcribed verbatim. Data were analyzed by NVivo20 pro and various themes and subthemes were drawn using Braun and Clarke thematic analysis.

A total of seven candidates and seven examiners were interviewed with an average duration of 30 minutes and 25 minutes, respectively. Four main themes emerged: Communication, Screen optimization, Continuation postpandemic and Overall experience. All candidates preferred to continue an online format post pandemic for practical reasons e.g., avoiding travel and overnight stay, while all examiners preferred to go back to in-person Objective Structured Clinical Examination. However, continuation of online Clinical Formulation and Management Examination was agreed by both groups.

The participants were largely satisfied with the online examination but did not consider it equal to face-to-face for picking up nonverbal cues. Overall minimal technical issues were reported. These findings may be helpful to modify current psychiatry membership examinations or similar assessments in other countries and specialties.

Research has begun to draw attention to the challenges mental health professionals faced in delivering services during the COVID-19 pandemic response. However, few studies have examined the specific experiences of consultant psychiatrists.

To examine the work-related experiences and psychosocial needs of consultant psychiatrists situated in the Republic of Ireland arising from the COVID-19 response.

We interviewed 18 consultant psychiatrists and analysed data using inductive thematic analysis.

Work-related experience of participants was characterised by increased workload associated with assumption of guardianship of physical and mental health of vulnerable patients. Unintended consequences of public health restrictions increased case complexity, limited availability of alternative supports and hindered the practice of psychiatry, including inhibiting peer support systems for psychiatrists. Participants perceived available psychological supports as generally unsuitable for their needs given their specialty. Long-standing under-resourcing, mistrust in management and high levels of burnout exacerbated the psychological burden of the COVID-19 response.

The challenges of leading mental health services were evident in the increased complexity involved in caring for vulnerable patients during the pandemic, contributing to uncertainty, loss of control and moral distress among participants. These dynamics worked synergistically with pre-existing system-level failures, eroding capacity to mount an effective response. The longer-term psychological well-being of consultant psychiatrists – as well as the pandemic preparedness of healthcare systems – is contingent on implementation of policies addressing long-standing under-investment in the services vulnerable populations rely on, not least community mental health services.

People with schizophrenia have shortened lives. This excess mortality seems to be related to physical health conditions that may be amenable to better primary and secondary prevention. Better continuity of care may enhance such interventions as well as help prevent death by self-injury.

We set out to examine the relationship between the continuity of care of patients with schizophrenia, their mortality and cause of death.

Pseudoanonymised community data from 5551 people with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index. These and demographic variables were related to death certifications of physical illness from the Office of National Statistics and mortal self-injury from clinical data. Data were analysed using generalised estimating equations.

We found no independent relationship between levels of continuity of care and overall mortality. However, lower levels of relationship continuity were significantly and independently related to death by self-injury.

We found no evidence that continuity of care is important in the prevention of physical causes of death in schizophrenia. However, there is evidence that declining relationship continuity of care has an independent effect on deaths as a result of self-injury. We suggest that there should be more attention focused on the improvement of continuity of care for these patients.

High continuity of care is prized by users of mental health services and lauded in health policy. It is especially important in long-term conditions like schizophrenia. However, it is not routinely measured, and therefore not often evaluated when service reorganisations take place. In addition, the impact of continuity of care on clinical outcomes is unclear.

We set out to examine continuity of care in people with schizophrenia, and to relate this to demographic variables and clinical outcomes.

Pseudoanonymised community data from 5552 individuals with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index (MMCI). These and demographic variables were related to clinical outcomes measured with the Health of the Nation Outcome Scales (HoNOS). Data were analysed using generalised estimating equations and multivariate marginal models.

There was a significant decline in MMCI and significant worsening of HoNOS total scores over 11 years. Higher (worse) HoNOS scores were significantly and independently related to older age, later years and both lower MMCI and more teams caring for the individual in each year. Most HoNOS scales contributed to the higher total scores.

There is evidence of declining continuity of care in this 11-year study of people with schizophrenia, and of an independent effect of this on worse clinical outcomes. We suggest that this is related to reorganisation of services.

None.

The early and effective detection of neurocognitive disorders poses a key diagnostic challenge. We examined performance on common cognitive bedside tests according to differing delirium syndromal status and clinical (motor) subtypes in hospitalized elderly medical inpatients.

A battery of nine bedside cognitive tests was performed on elderly medical inpatients with DSM-IV delirium, subsyndromal delirium (SSD), and no delirium (ND). Patients with delirium were compared according to clinical (motor) subtypes.

A total of 198 patients (mean age 79.14 ± 8.26) were assessed with full syndromal delirium (FSD: n = 110), SSD (n = 45), and ND (n = 43). Delirium status was not associated with differences in terms of gender distribution, age, or overall medication use. Dementia burden increased with greater delirium status. Overall, the ability to meaningfully engage with the tests varied from 59% for the Vigilance B test to 85% for Spatial Span Forward test and was lowest in patients with FSD, where engagement ranged from 32% for the Vigilance B test to 77% for the Spatial Span Forwards test. The ND group was distinguished from SSD group for the Months of the year backwards, Vigilance B, global VSP, Clock Drawing test, and Interlocking Pentagons test. The SSD group was distinguished from the FSD group by Vigilance A, Spatial Span Forward, and Spatial Span Backwards. Regarding differences among motor subtypes in terms of percentage engagement and performance, the No subtype group had higher ratings across all tests. Delirious patients with no subtype had significantly lower scores on the DRS-R98 than for the other three subtype categories.

Simple bedside tests of attention, vigilance, and visuospatial ability are useful in distinguishing neurocognitive disorders, including SSD from other presentations.

Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Rapid reliable identification of clinical subtypes can allow for more targeted research efforts.

We explored the concordance in attribution of motor subtypes between the Delirium Motor Subtyping Scale 4 (DMSS-4) and the original Delirium Motor Subtyping Scale (DMSS) (assessed cross-sectionally) and subtypes defined longitudinally using the Delirium Symptom Interview (DSI).

We included 113 elderly patients developing DSM-IV delirium after hip-surgery [mean age 86.9 ± 6.6 years; range 65–102; 68.1% females; 25 (22.1%) had no previous history of cognitive impairment]. Concordance for the first measurement was high for both the DMSS-4 and original DMSS (k = 0.82), and overall for the DMSS-4 and DSI (k = 0.84). The DMSS-4 also demonstrated high internal consistency (McDonald's omega = 0.90). The DSI more often allocated an assessment to “no subtype” compared to the DMSS-4 and DMSS-11, which showed higher inclusion rates for motor subtypes.

The DMSS-4 provides a rapid method of identifying motor-defined clinical subtypes of delirium and appears to be a reliable alternative to the more detailed and time-consuming original DMSS and DSI methods of subtype attribution. The DMSS-4, so far translated into three languages, can be readily applied to further studies of causation, treatment and outcome in delirium.

Delirium is a common neuropsychiatric syndrome that includes clinical subtypes identified by the Delirium Motor Subtyping Scale (DMSS). We explored the concordance between the DMSS and an abbreviated 4-item version in elderly medical inpatients.

Elderly general medical admissions (n = 145) were assessed for delirium using the Revised Delirium Rating scale (DRS-R98). Clinical subtype was assessed with the DMSS (which includes the four items included in the DMSS-4). Motor subtypes were generated for all patient assessments using both versions of the scale. The concordance of the original and abbreviated DMSS was examined.

The agreement between the DMSS and DMSS-4 was high, both at initial and subsequent assessments (κ range 0.75–0.91). Intraclass Correlation Coefficient (ICC) for all three raters for the DMSS was high (0.70) and for DMSS-4 was moderate (0.59). Analysis of the agreement between raters for individual DMSS items found higher concordance in respect of hypoactive features compared to hyperactive.

The DMSS-4 allows for rapid assessment of clinical subtype in delirium and has high concordance with the longer and well-validated DMSS, including over longitudinal assessment. There is good inter-rater reliability between medical and nursing staff. More consistent clinical subtyping can facilitate better delirium management and more focused research effort.

The recently published DSM-5 criteria for delirium may lead to different case identification and rates of delirium than previous classifications. The aims of this study are to determine how the new DSM-5 criteria compare with DSM-IV in identification of delirium in elderly medical inpatients and to investigate the agreement between different methods, using CAM, DRS-R98, DSM-IV, and DSM-5 criteria.

Prospective, observational study of elderly patients aged 70+ admitted under the acute medical teams in a regional general hospital. Each participant was assessed within 3 days of admission using the DSM-5, and DSM-IV criteria plus the DRS-R98, and CAM scales.

We assessed 200 patients [mean age 81.1±6.5; 50% female; pre-existing cognitive impairment in 63%]. The prevalence rates of delirium for each diagnostic method were: 13.0% (n = 26) for DSM-5; 19.5% (n = 39) for DSM-IV; 13.5% (n = 27) for DRS-R98 and 17.0%, (n = 34) for CAM. Using tetrachoric correlation coefficients the agreement between DSM-5 and DSM-IV was statistically significant (ρtetr = 0.64, SE = 0.1, p < 0.0001). Similar significant agreement was found between the four methods.

DSM-IV is the most inclusive diagnostic method for delirium, while DSM-5 is the most restrictive. In addition, these classification systems identify different cases of delirium. This could have clinical, financial, and research implications. However, both classification systems have significant agreement in the identification of the same concept (delirium). Clarity of diagnosis is required for classification but also further research considering the relevance in predicting outcomes can allow for more detailed evaluation of the DSM-5 criteria.

Assessment of delirium is performed with a variety of instruments, making comparisons between studies difficult. A conversion rule between commonly used instruments would aid such comparisons. The present study aimed to compare the revised Delirium Rating Scale (DRS–R98) and Memorial Delirium Assessment Scale (MDAS) in a palliative care population and derive conversion rules between the two scales.

Both instruments were employed to assess 77 consecutive patients with DSM–IV delirium, and the measures were repeated at three-day intervals. Conversion rules were derived from the data at initial assessment and tested on subsequent data.

There was substantial overall agreement between the two scales [concordance correlation coefficient (CCC) = 0.70 (CI95 = 0.60–0.78)] and between most common items (weighted κ ranging from 0.63 to 0.86). Although the two scales overlap considerably, there were some subtle differences with only modest agreement between the attention (weighted κ = 0.42) and thought process (weighted κ = 0.61) items. The conversion rule from total MDAS score to DRS–R98 severity scores demonstrated an almost perfect level of agreement (r = 0.86, CCC = 0.86; CI95 = 0.79–0.91), similar to the conversion rule from DRS–R98 to MDAS.

Overall, the derived conversion rules demonstrated promising accuracy in this palliative care population, but further testing in other populations is certainly needed.

Delirium affects all higher cortical functions supporting complex information processing consistent with widespread neural network impairment. We evaluated the relative prominence of delirium symptoms throughout episodes to assess whether impaired consciousness is selectively affecting certain brain functions at different timepoints.

Twice-weekly assessments of 100 consecutive patients with DSM-IV delirium in a palliative care unit used the Delirium Rating Scale Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD). A mixed-effects model was employed to estimate changes in severity of individual symptoms over time.

Mean age = 7 0.2 ± 10.5 years, 51% were male, and 27 had a comorbid dementia. A total of 323 assessments (range 2–9 per case) were conducted, but up to 6 are reported herein. Frequency and severity of individual DRS-R98 symptoms was very consistent over time even though the majority of patients (80%) experienced fluctuation in symptom severity over the course of hours or minutes. Over time, DRS-R98 items for attention (88–100%), sleep–wake cycle disturbance (90–100%), and any motor disturbance (87–100%), and CTD attention and vigilance were most frequently and consistently impaired. Mixed-effects regression modeling identified only very small magnitudes of change in individual symptoms over time, including the three core domains.

Attention is disproportionately impaired during the entire episode of delirium, consistent with thalamic dysfunction underlying both an impaired state of consciousness and well-known EEG slowing. All individual symptoms and three core domains remain relatively stable despite small fluctuations in symptom severity for a given day, which supports a consistent state of impaired higher cortical functions throughout an episode of delirium.

Longitudinal studies of delirium phenomenology are lacking.

We studied features that characterise subsyndromal delirium and persistent delirium over time.

Twice-weekly evaluations of 100 adults with DSM-IV delirium using the Delirium Rating Scale – Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD). The generalised estimating equation method identified symptom patterns distinguishing full syndromal from subsyndromal delirium and resolving from persistent delirium.

Participants (mean age 70.2 years (s.d. = 10.5)) underwent 323 assessments (range 2–9). Full syndromal delirium was significantly more severe than subsyndromal delirium for DRS-R98 thought process abnormalities, delusions, hallucinations, agitation, retardation, orientation, attention, and short- and long-term memory items, and CTD attention, vigilance, orientation and memory. Persistent full syndromal delirium had greater disturbance of DRS-R98 thought process abnormalities, delusions, agitation, orientation, attention, and short- and long-term memory items, and CTD attention, vigilance and orientation.

Full syndromal delirium differs from subsyndromal delirium over time by greater severity of many cognitive and non-cognitive symptoms. Persistent delirium involves increasing prominence of recognised core diagnostic features and cognitive impairment.