Objectives: This study assessed patients' views of a methadone programme in a Dublin general practice including the degree to which the patients were ‘involved in decisions about their treatment’.

Method: All patients receiving methadone were asked to participate. A face to face questionnaire, with open and closed questions, was administered. Interviews lasted approximately 30 minutes. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using a thematic approach.

Results: Forty one (87%) of the 47 patients attending the general practice methadone service were interviewed. Of the 39 patients who had used heroin on admission, 69% had stopped and 31% reduced heroin use since starting methadone treatment. A total of 71% reported that the doctor either always involved (59%) or sometimes involved (12%) them in decisions about their treatment. Involvement was interpreted as ‘being listened to’ or ‘having a say’ in deciding methadone dose. Surprisingly those who reported that they were not involved in treatment decisions were more likely to have stopped heroin use (10/11). A significant majority of patients (81%) expressed the desire to stop taking methadone.

Conclusion: Most patients receiving methadone in general practice were listened to and had a say in deciding their methadone dose but did not have an opportunity to engage in more structured or contractual forms of involvement in treatment such as written care plans. In line with a patient centred approach, treatment providers should set their sights beyond the safe delivery of methadone, to provide a service which is centred on patient goals, expectations and choice.

Objectives: The objective of this study was to ascertain the topics patients and mental health professionals thought should be covered in a psychoeducation programme at a day hospital.

Methods: Patients at the psychiatric day hospital and mental health professionals were invited to complete the study questionnaire. Replies from 101 participants were analysed.

Results: The patients and mental health professionals generally agreed regarding the topics to be covered in the eight-week psychoeducation programme. Patients tended to score ‘suicide’ as more important than did the mental health professionals.

Conclusions: Patients in a day hospital setting and mental health professionals share similar concerns about what information needs to be imparted about the patients' illnesses. However, suicide is seen by patients as a more important topic in such a setting.

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.

There is an established ethical and legal duty upon psychiatrists to obtain informed consent before treating a patient, although some exceptions do apply under Mental Health Legislation. The required standard for informed consent has been the subject of important case law in Ireland and other common law jurisdictions and this has caused some uncertainty for clinicians. The standard of informed consent can be viewed from the point of view of what the medical profession thinks is appropriate, or alternatively from the position of what a patient would reasonably expect to be told. These contrasting approaches are discussed in detail. A recent decision of the Irish Supreme Court establishes the ‘patient-centred’ standard for informed consent as the relevant standard in Irish law. The current legal position on informed consent is discussed in relation to common clinical scenarios in psychiatric practice.

Objective: We describe use and effects of head shop powders among opiate dependant polydrug users and recreational drug users. These powders contain cathinones and were sold as bath salts or plant food via the internet or in head shops.

Method: As this is a relatively new phenomenon, a qualitative approach using three data sources, in-depth interviews, a focus group (containing 10 opiate users) and a head shop website containing 49 product reviews, was employed. Themes were identified.

Results: According to the study population, these powders mimic the effects of cocaine, ecstasy and amphetamines. These substances were snorted, ingested or injected by people and were not used as bath salts or plant food. The users' experience indicates that these powders have the potential for dependence, and exhibit side effects such as insomnia, anxiety and other mental health effects. The users report that the effects of the substances vary over time indicating that the chemical contents of the powders may change.

Conclusion: Though users' descriptions of effects varied, there were indications of health and dependency effects which were more severe and more common among problematic opiate users, who also experienced increased social vulnerability. In general the recreational drug users considered their side effects to be mild and worth the drug induced experience.

Objectives: This study aims to assess the rate of six monthly communications between specialised psychiatric services and primary care and to determine factors which predict such communication.

Methods: A retrospective review of the clinical records of all patients attending the relevant local psychiatric outpatient clinic was carried out by all members of the multidisciplinary team to identify patient demographic and clinical variables as well as to determine if there has been documentation of communication with primary care in the preceding six months. Letters were sent to the relevant primary care teams regarding progress on their patients in cases where it was identified that no communication had occurred in the preceding six months.

Results: A total of 145 patients' charts were reviewed. Of these, 53.3% of the patients were females and 46.7% were males. The mean age was 47.9 years (SD = 14). Patients' diagnoses included; depression (41%), bipolar affective disorder (6.7%), schizophrenia/schizoaffective disorder (27.6%), anxiety disorders (6.7%), alcohol dependency syndrome (11%) and other disorders (7%). Overall, only 36% of patients' charts had a record of communication with primary care in the last six months. Only one variable, ‘changes made to the patents medication in the last six months’ was significantly associated with the likelihood that there had been communication with primary care with an odds ratio of 15 and a p-value of 0.00.

Conclusion: A six monthly review has a potential to improve the level of communication between specialised psychiatric services and primary care.

Dr Adeline (Ada) English (1875-1944) was a pioneering Irish psychiatrist. She qualified in medicine in 1903 and spent four decades working at Ballinasloe District Lunatic Asylum, during which time there were significant therapeutic innovations (eg. occupational therapy, convulsive treatment). Dr English was deeply involved in Irish politics. She participated in the Easter Rising (1916); spent six months in Galway jail for possessing nationalistic literature (1921); was elected as a Teachta Dála (member of Parliament; 1921); and participated in the Civil War (1922). She made significant contributions to Irish political life and development of psychiatric services during an exceptionally challenging period of history. Additional research would help contextualise her contributions further.

We report two cases of acute onset and rapid resolution of psychotic symptoms, the first following oral ingestion and the second following intravenous injection of some head shop products (HSPs). Both were associated with autonomic instability and negative results on urine toxicology screening using standard techniques. They highlight the potential dangers of managing such cases in acute stand-alone psychiatric units. Recent advance in characterising some HSPs by toxicology screening is also discussed.

Objectives: Primary care teams have the potential to deliver much of the care currently provided by specialist services. The aim of this review was to determine from patients' clinical records and multidisciplinary team discussions, those that may be suitable for discharge back into primary care.

Methods: A retrospective review of the clinical notes of all patients attending a psychiatric outpatient clinic was carried out by all members of the multidisciplinary team to determine the appropriateness of continuing to provide psychiatric services in a specialised psychiatric clinic rather than in a primary care setting, taking into account the patients demographic and clinical variables.

Results: It was recommended that 60% of all the patients needed to continue attending the local mental health service, 35.2% could be discharged back into primary care for continuing management whilst the remaining 4.8% could be managed jointly between primary care and the community mental health service. The bulk of the patients recommended for discharge into primary care had a diagnosis of anxiety disorder or depression and all of them had been stable on their treatment for more than six months.

Conclusion: Regular multidisciplinary team review has a potential to identify patients who could be discharged back into primary care.

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.

We describe an unusual cause of autobiographical memory loss in a 55 year old man who presented with prominent memory loss for significant events in his life over a period of five years with evidence of patchy memory loss for events prior to this. It was associated with emotional lability and was complicated by a number of tragic events in his life in the previous four years. In addition there were a number of brief episodes (< 30 mins) where he would transiently lose his memory for events including for hours, days or months prior to the event. Neuropsychological assessment confirmed prominent autobiographical memory loss with minimal deficits in other domains. An electroencephalogram (EEG) revealed a simple partial seizure arising from the right temporal lobe, pointing to a diagnosis of Transient Epileptic Amnesia. He was commenced on anti-epileptic medication and responded both subjectively and objectively. There are approximately 94 cases of TEA described in the literature and the diagnostic criteria and postulated aetiology of this illness is discussed here. Clinicians need to have high index of suspicion of epilepsy when assessing a patient with prominent autobiographical memory impairments.

‘Whack’ is a new psychoactive substance available until recently in ‘head shops’. It contains two active constituents, 4-fluorotropacocaine and desoxypipradrol. We present two case reports of subjects who developed acute psychotic states after using Whack. Both individuals displayed similar affective and anxiety symptoms in the presence of significant psychotic symptoms. Both required inpatient treatment but displayed a good treatment response to atypical antipsychotic agents. To our knowledge, this is the first published case series relating to this psychoactive substance.

Objectives: This study describes the social, demographic and clinical characteristics of all the new referrals in a mental health catchment area. This study aims to compare Irish and non-Irish service users in terms of their mental health needs and service utilization.

Method: Case notes were reviewed retrospectively to investigate demographic, clinical and service utilization parameters among new referrals to the psychiatric services in Galway, Ireland over a six-month period.

Results: One hundred and fifty-four new referrals, of whom 41 were non-Irish, presented over a six-month period. Results showed no difference between Irish and non-Irish service users in terms of socio-demographic variables. Alcohol problems and subsequent need for detoxification and counselling were significantly higher among service users from the new EU accession states with a significant impact on the duration of their hospital stay and the need for intensive psychiatric care.

Conclusions: There is an urgent need for enhanced resources for the delivery of mental healthcare to immigrants. Service utilisation and mental health needs are not explained merely by illness-related aspects in immigrant service users. Social and cultural factors have to be recognised in order to prevent disadvantages in psychiatric care.

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.

Benzylpiperazine is a psychotropic compound that has been widely available until recently from licensed premises such as ‘head shops’. This report describes a case of a 48 year old man with schizophrenia who developed an acute delirium secondary to benzylpiperazine use, although he initially presented as a diagnostic conundrum. Investigation of his delirium unearthed a temporal meningioma which appears to be an incidental finding. This is the first documented case of delirium due to benzylpiperazine use. Benzylpiperazine has significant abuse potential and psychiatric complications. Its sale and possession have recently been made illegal in Ireland, which may limit its abuse in the future.

Objectives: Cognitive stimulation therapy (CST) has been shown to produce improvements in cognition and quality of life which compare favourably with trials of cholinesterase inhibitors. The aim of the present study was to evaluate the efficacy of CST, replicating the methods of Spector et al in the British Journal of Psychiatry in 2003 in a smaller sample using a control group engaged in routine activities.

Methods: Eligible participants (mild to moderate dementia; MMSE range 10-23) were randomised to CST group or control conditions. Pre- and post-intervention testing was undertaken by assessors who were blind to condition. Measures included MMSE, CDR (sum of boxes), ADAS-cog, RAID (anxiety), abbreviated GDS (depression), QoL-AD, and the CAPE Behaviour Rating Scale (BRS). Analysis was by non-parametric statistics. Occupational therapists facilitated two sessions per week for seven weeks in two long-term care facilities and the same programme was run by the activity co-ordinator in a nursing home unit.

Results: Fourteen CST and 13 control participants completed the study. Between group difference scores analysis showed that the CST group improved compared to controls on MMSE (Mann-Whitney U = 32, p = 0.013) and on the QoL-AD which just fell short of significant (U=51.5, p = 0.055). Qualitatively, therapists noted that CST participants demonstrated good interaction and enthusiasm in the group environment, with continuity and carryover between sessions.

Conclusions: Even though the sample sizes are small the current study is consistent with the Spector et al's findings in 2003 of beneficial effects in people with dementia following CST. The programme is recommended as an intervention for people with mild to moderate dementia.

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.

Although hyperprolactinaemia is associated with galactorrhoea, galactorrhoea often occurs without any hyperprolactinaemia. This has been well established, and it has been documented in women prescribed/using methadone and other opiates. One case series described amenorrhoea and galactorrhoea in ‘female heroin addicts’, but it has not before been described in a patient with hypoprolactinaemia.

We report a case of a 30 year old non-pregnant, non-puerperal, opioid-dependent, HIV positive woman on long-term methadone maintenance programme, who presented with bilateral, milky nipple discharge, associated with painful breast lumps, but with serum prolactin levels below the normal range. She was not prescribed any other medications likely to have effect on the endocrine system. This case highlights the need for prescribers to be alert to the implications of long-term use of opioids.