Objectives: Drivers with certain mental illnesses are obliged by the Driver & Vehicle Licensing Authority (DVLA) to stop driving and to report their condition. This study aims to quantify the number of psychiatric patients failing to meet the DVLA standards of ‘fitness to drive’ and to record how frequently psychiatrists failed to advise patients of these standards.

Method: In this prospective descriptive study, 10 psychiatrists reported by questionnaire the diagnosis and driving status of all patients encountered over a four week period. They recorded their advice given to patients failing to meet the DVLA criteria of ‘fitness to drive’ and advice given when prescribing psychotropic medication.

Results: Of 297 patients, 123 (41%) were drivers. 19/123 (13%) of drivers failed to meet the DVLA standards of ‘fitness to drive’. In 9/19 of these cases the psychiatrist did not advise the patient in line with the DVLA guidelines. This was especially the case for alcohol related disorders. Of drivers 49% were prescribed psychotropic medication with potential adverse effects on driving.

Conclusions: Driving amongst mentally ill patients appears commonplace. In this study, 13% of drivers were considered by the authorities to be unfit to drive. Psychiatrists frequently used their own judgement when advising patients regarding driving. This arguably contravenes doctors' responsibilities to patients and has potential legal implications for both the patient and psychiatrist.

Objectives: To investigate effects on one psychiatric inpatient service of a 40% reduction in the number of acute beds and the establishment of an acute day hospital.

Method: A retrospective review of all public admissions to the acute inpatient unit during two three-month study periods; before and almost three years after the changes. Review of attendance at the acute day hospital during the second study period.

Results: The number of admissions actually increased by 3% from 169-174; the mean duration of stay fell from 27-17 days; and the number of brief admissions of three days duration or less almost tripled from 15-43. Although fewer patients suffering from schizophrenia were admitted in the second study period than in the first, their mean duration of stay and the frequency of re-admission within 28 days of discharge changed little, while patients with diagnoses of mild/moderate depression and substance misuse experienced significantly shorter admissions and higher readmission rates. The use of temporary orders under the Mental Treatment Act (1945) doubled, and the readmission rates within 28 days increased by over 60%.

The acute day hospital treated 98 patients who had a diagnostic profile similar to that of the inpatients; 53% of them required admission before and/or after attendance at the day hospital.

Conclusions: The major reduction in the number of acute inpatient beds and the opening of an acute day hospital resulted in greater concentration of inpatient resources on the more severely ill patients. The increase in re-admissions and the failure to effect a reduction in admissions and may have a complex aetiology and merits further investigation.

Objectives: To review recent use of psychosurgery in Britain and Ireland; to outline the indications and contraindications; and to summarise the Irish experience of psychosurgery.

Method: The Geoffrey Knight National Unit for Affective Disorders (GKU), now based at the Maudsley Hospital has performed the largest number of psychosurgical operations in the last 30 years. This paper reviews criteria for referral and outcome of stereotactic subcaudate tractotomy at the GKU. The twenty-one referrals from Ireland to the Unit, resulting in eight operations over the fifteen year period 1981-1995, are considered separately.

Results: The efficacy of stereotactic subcaudate tractotomy is of the order of 30-60% and there is a low incidence of long-term adverse effects. The outcome of the eight Irish patients who underwent psychosurgery compare favourably with the overall outcome figures for the Unit.

Conclusions: Stereotactic subcaudate tractotomy remains a treatment of last resort in the rare cases of severely treatment-resistant affective disorders and obsessive compulsive disorders.

Objectives: This study examines the frequency of childhood sexual abuse and physical abuse in a cohort of opiate addicted patients and looks at clinical correlates in those abused.

Method: Fifty-two consecutive patients attending an out patient drug treatment programme were interviewed using a semi-structured technique. Demographic details, details of schooling, marital status and number of children were recorded. The duration of drug abuse, age of onset of opiate abuse, early life experiences of both child sex abuse and childhood violence and a family history of alcohol abuse were also investigated.

Results: 21.2% of patients gave a history of sex abuse, with 23.1% of patients having a history of exposure to violence as a child. Those exposed to sex abuse had an earlier age of onset of opiate injection. A correlation between parental alcohol abuse and sex abuse and violence was noted.

Conclusions: A history of child sex abuse was associated with earlier onset of opiate abuse in this group of patients. The relatively frequent incidence of abuse and violence in those with opiate abuse must be born in mind when providing treatment. The addressing of issues relating only to addiction leaves earlier traumas continuing to exert an influence on the patient.

Objectives: 1) To ascertain the stability of a diagnosis of compulsive water drinking (CWD) among psychiatric rehabilitation inpatients after a period of four years. 2) To ascertain the discharge status of CWD inpatients in comparison with matched control inpatients after a period of four years.

Method: A follow-up study was performed. Urine specific gravity testing was used to determine CWD status among psychiatric rehabilitation inpatients. Originally, 21 CWD subjects were identified, and 21 age and sex matched control subjects were selected from the non-CWD rehabilitation inpatients. Four years later those CWD and control subjects successfully traced (18 and 15 respectively) were retested for CWD. In addition each subject's living situation (inpatient or community resident) was recorded. Chi-square, Odds Ratio, and Fisher's Exact Test were used as tests of statistical significance.

Results: While the original CWD status was associated with the follow-up CWD status using Chi-square (p < 0.05), there was no statistical association using Odds Ratio (95% CI was 0.95 to 71.6). Half of the 18 original CWD subjects retested negative for CWD. Two of the 15 control subjects retested positive for CWD. Original CWD status was not associated with subsequent living situation, however all seven community dwelling subjects (four original CWD, three original controls) that were successfully traced were negative for CWD.

Conclusions: CWD status may not be as stable as implied in the literature.

Objectives: The objectives of this paper are to review the presentation of hyponatraemia and diagnose its cause in psychiatric inpatients.

Method: Episodes of significant hyponatraemia (sodium <130mmol/L) were identified from computerised biochemical data and a retrospective review of patients' notes was carried out.

Result. The diagnoses of hyponatraemia reached were different for the two groups of patients studied, adults of over 65 years and under 65 years. Carbamazepine, polydipsia and medical conditions were found as causes in the below 65 age group. Diuretics, medical conditions and lofepramine were identified as causes in the over 65 age group. Inpatients with polydipsia below the age of 65 had lower sodium (p = 0.013) and urea levels (p = 0.00059) than other groups and patients with carbamazepine induced hyponatraemia tended to have episodic hypocalcaemia (p = 0.056). These groups were compared using Fisher's exact test. This study also showed the overall frequency of serum sodium of less than 135mmol/L to be 9.5% in psychiatric inpatients.

Conclusion: Hyponatraemia is a not uncommon finding in psychiatric inpatients. Attention to drug therapy and biochemical findings are helpful in its diagnosis. Accurate diagnosis is usually possible and may vary according to age-group.

Objectives: To identify the number of cases, and hence the prevalence of, early onset dementia within a defined catchment area in Dublin. To identify the associated clinical characteristics of those identified, and to measure service use and carer burden.

Method: A comprehensive case finding study was carried out, and all those identified were contacted and sufferers and carers were interviewed using both standardised and semi-structured questionnaires.

Results: Twelve cases were identified, yielding a prevalence rate of 45/100,000 in the 45-64 year age group. Sufferers exhibited a high level of cognitive impairment and associated psychiatric and behavioural symptoms, and carers exhibited a high level of stress, especially those still actively caring. Service provision for this group was patchy and did not tally with their level of dependency.

Conclusions: Recommendations are made for appropriate provision of services for dementia sufferers, regardless of age.

Objectives: This study investigates the problem of assaults on psychiatrists by their patients.

Method: A postal questionnaire was circulated to 178 psychiatrists and trainees working in the Dublin area enquiring about assaults experienced in the previous three years.

Results: Of those 147 (82%) who responded 57 (39%) had been assaulted. There were few discriminating factors between those assaulted and those not but those in child psychiatry were less likely and those in general adult psychiatry were more likely to have been the victim of an assault. Only 10% of respondents had received any formal training in violence management. Assailants tended to be male (63%) and known to the doctor involved (71%). Personality disorder (37%), schizophrenia (29%) and substance abuse (26%) were common assailant diagnoses. Management responses to the assaults were generally internal with administrative staff involvement in only four cases.

Conclusions: Factors which potentially protect or expose clinicians to a greater risk of assault are not well defined and need to be further explored. Simple clinician or patient variables are not especially predictive of violence risk. Clinicians need to acquaint themselves better with the basic practices of violence prevention and management. External measures (such as involving administration) could be used more frequently to combat this common problem.

Objective: This study aims to determine if there is a relationship between antenatal depression and maternal depression in the following three to four years. Secondly, to establish if there is a relationship between maternal depression and behavioural problems with the pre-school child. Thirdly, to investigate if social parameters are correlated with maternal health and childhood behaviour.

Method: In a longitudinal study, a sample of women were screened for depression at the antenatal stage and followed up four years later. Mothers were screened for depressive illness on both occasions. Children's behaviour was assessed at four years. Social parameters were also measured at the pre-school stage.

Result: Depression at the antenatal stage was not found to be significantly related to depression at the pre-school stage. The existence of a behaviour problem was not significantly related to the depressive state of the mother antenatally, however a currently depressed mother is approximately six times more likely to have a child with behaviour problems than a mother who is not depressed. Social factors were also assessed and found to correlate with maternal depression.

Conclusion: In managing a child with behavioural problems the child psychiatrist should consider the mental state of the mother. The social world of the individual would appear to be important and should not be ignored when treating either a child with behavioural problems or an adult with depression.

Objectives: To provide a methodology for the examination of costs and clinical outcomes in two distinct care settings for psychiatric patients inpatient and day hospitals. The major emphasis is on the relationship between costs and outcomes in the two care regimes.

Method: The study is a retrospective cost-effectiveness analysis. People living in Sector B catchment area in the Mid-Western Health Board who were admitted to inpatient care, or treated as day hospital patients, between June 1st 1994 -February 28th 1995 are eligible for inclusion in the study. Information on resource use and clinical outcome is available for 92 of these patients.

Results: The average weekly cost of care for mentally ill patients in the inpatient setting is over twice the level of the cost of care for people attending the day hospital facility. Pay costs and hotel costs are higher in the inpatient facility. Day hospital care is also more cost-effective than inpatient care, when account is taken of the relationship between cost and clinical outcomes.

Conclusion: The study supports the general literature view of the superiority of community care settings for certain categories of mentally ill people. However, the absence of randomisation in the study, incomplete data, and the retrospective nature of the analysis suggests that caution is needed in the interpretation of the results.

Objectives: To audit the incidence of a history of childhood sexual abuse (CSA) in women with diagnoses of drug and alcohol misuse disorders.

Method: A definition of CSA encompassing the US National Centre on Child Abuse and Neglect's definition of child sexual abuse was used. In the six month period of audit details of CSA were recorded from clinical data for all consecutive female new patients (n = 49) of the substance misuse service in St. Luke's Hospital, Armagh.

Results: Of the 49 new patients, information on childhood sexual abuse was available for 44 subjects. Sixteen (36.36%) of 44 had a positive history of CSA.

In 13 (81.25%) abuse occurred before the age of 16 years. Sexual intercourse was described by 50% and sexual contact by 50%. Only one patient had reported CSA to the police and only one patient had received counselling. There was a difference noted in the addiction profile of those with a history of CSA, 44% of this group had either alcohol dependence syndrome/harmful use of alcohol compared with 66% of the non-CSA group. The perpetrators were all male.

Conclusions: Our audit confirmed other work which showed a high incidence of childhood sexual abuse histories in addicted women. This is one of the areas which may not be properly addressed by conventional addiction treatment programmes, which are male centred and male dominated. It adds to the growing body of evidence that suggests adaptations must be made as increasing numbers of women present for addiction problems.

Objectives: To determine the frequency with which abuse, parental separation and bereavement occur on their own or together in children attending child psychiatry services and to assess the relationship between these traumas and attendance and outcome.

Method: A review of all case notes over a 12 month period (n = 435) was conducted and a proforma completed. Information was gathered on clinical presentation, rate of attendance, the presence of sexual abuse, non-sexual abuse including bullying, bereavement and parental separation and a measurement of outcome by subjective assessment was made.

Results: Fifty-nine per cent of the children had experienced at least one of the specified traumas; 13% had experienced two and 2.5% had experienced three. The children who had been abused or bereaved were more likely to require fairly long-term work; those who were adjusting to parental separation required less intervention over time. The children who had been sexually abused had, relatively, the poorest outcome in contrast to those adjusting to bereavement where 87% were considered to have made significant improvement.

Conclusions: Bereavement, abuse and parental separation are common in children referred to the child psychiatric services and these children often require long-term intervention. Increased resources will be required in order to continue to provide adequate intervention and treatment for these children.

Objective: To clarify the effect of age on behaviour disorders in adults with learning disabilities, and the differentiation of behaviour disorders from other psychiatric disorders.

Method: Detailed assessments, measuring maladaptive behaviours, psychiatric disorders and demographic factors were completed on 93.7% of all people with learning disabilities aged 65 years and over, living in Leicestershire, UK (n = 134), and also a random sample of adults with learning disabilities aged 20-64 years (n = 73). Behaviour disorders were distinguished from other psychiatric disorders. Descriptive and inferential statistics were calculated.

Result: Equal rates (15%) and types of behaviour disorder were found in the two groups. The presence of behaviour disorder was associated with the severity of learning disabilities, but age was not associated, and nor was presence of epilepsy or gender. In many cases, positive scores on the behavioural assessment, which carers attributed to challenging behaviour/ behaviour disorder, were actually symptoms of psychiatric illness.

Conclusion: Behaviour disorders persist into old age, and therefore require management from the appropriate services. This need will increase, due to increasing lifespan. The accurate interpretation of behaviour scales requires that a comprehensive psychiatric assessment is also undertaken, particularly in elderly people where rates of psychiatric disorders are higher than for younger adults.

Objectives: The object of this paper is to evaluate the evidence suggesting an association between the use of the anti-acne agent isotretinoin and the subsequent development of depression.

Method: Three case histories of individuals who had received treatment with isotretinoin and subsequently developed depression are reviewed.

Results: All three individuals were noted to have a depressive illness which was notable by the prominence of symptoms of irritability, agitation and aggression.

Conclusions: The indications from the three cases described suggest that there appears to be an association between depression and the recent use of isotretinoin. This may relate to the ability of isotretinoin to simulate hypovitaminosis A, with aggression, irritability and depression as a direct result of this effect. Young males may be particularly prone to developing this response.