All drugs have side effects and given the increase in litigation for medical negligence that has occurred in Ireland in recent years, it would not be surprising to find that clinicians prescribing psychotropic drugs would also become the target for legal procedures if they fail to warn the patient about the possible side effects and toxicity of the drugs they are prescribing. The two extremes of the problem may be illustrated by the litigation carried out against some pharmaceutical firms and prescribers of benzodiazepines and the lack of such proceedings resulting from deaths of depressed patients who take an overdose of a prescribed antidepressant.

Objective: The identification of personality disorder among psychiatric in-patients is important because of the effect on the course and outcome of illness. The introduction of a multiaxial approach to diagnosis, has resulted in a higher than previously reported rate of occurrence of personality disorder in a variety of psychiatric settings. A prevalence of personality disorder of 4.9% is reported in the official statistics for Irish psychiatric hospitals. The aim of this study is to determine the true prevalence of personality disorders in two Irish psychiatric hospitals, one public and one private, using a multiaxial approach to diagnosis.

Methods: The Standardised Assessment of Personality (SAP) is a validated, semistructured, informant based instrument that reliably generates diagnoses of personality disorder irrespective of current mental state. Over a four month period, 78 consecutive, first ever admissions to two hospitals were examined using the SAP.

Results: The prevalence of personality disorder in this population was 26%. There was no significant difference in the rate of personality disorder between the public and private institutions.

Conclusions: The prevalence of personality disorder amongst in-patients in both public and private psychiatric hospitals in Ireland is far higher than previously reported. This highlights the importance of a multiaxial approach to diagnosis in order to establish the true extent of psychiatric morbidity.

Objective: To determine the prevalence of dementia in an Irish sample of Down's syndrome (DS) patients and to examine the utility of a number of cognitive and functional scales in the assessment of dementia in this population.

Method: 76 DS patients diagnosed clinically (range 33–72 years; mean age 47.3 ± 8.8 years) were included in the study. The diagnosis of dementia was made on clinical grounds using DSMIIIR criteria. Cognitive and functional impairment were evaluated using the following scales; Test for Severe Impairment (TSI), Down's Syndrome Mental Status Examination (DSMSE), Daily Living Skills Questionnaire (DLSQ), and the Mental State Performance (MSP).

Results: The overall prevalence of dementia was 7.9% (95% C.I = 2.95–16.39). The presence of dementia was associated with late onset epilepsy, anticonvulsant medication and deafness. Standard cognitive tests such as the MSP showed an early ‘floor’ effect in this population. In contrast the TSI and DLSQ showed a satisfactory range of scores in these patients with moderate to severe learning disability.

Conclusions: The low prevalence of dementia in this study may be explained by the strict conservative criteria applied in the clinical diagnosis. Prospective assessment of DS patients on a longitudinal basis using decline on scales such as the TSI and DLSQ may allow more accurate diagnosis of dementia at an earlier stage in this at-risk population.

What is striking about Leonard's clarion call to the litigants and the legal profession is that he made similar calls over the last number of years, issuing dire predictions of the poor defence a hapless psychiatrist would have in the wake of a completed suicide as a result of an antidepressant overdose, when safer drugs were available. Such a spate of litigation has not followed nor, have the regulatory authorities expressed an interest in the matter. This is simply because a case against a doctor is unlikely to be successful when he or she is acting in accordance with a recognised body of practice within that profession, even though others hold the opposite view, provided of course there is no evidence of overt negligence such as failing to assess current suicidal ideation. Indeed in circumstances where active suicide ideation is present, to only prescribe an antidepressant, even if it were an SSRI, could be deemed negligent if suicide follows since such a patient should be hospitalised.

Objective: The trends in suicide in Northern Ireland over a 70 year period were examined with respect to sex, age and method used, and then compared with rates of unemployment and homicide.

Method: The records in the office of the registrar general in Belfast were examined to obtain data. Unemployment figures were obtained from the Department of Economic Development.

Results: Suicide is increasing in Northern Ireland and particularly in young men (aged 34 and under). There is a relation to unemployment although it is not felt to be directly causal. Men prefer more violent methods although vehicle exhaust gas is popular. A large number of women still choose drowning.

Conclusions: Despite all initiatives, the suicide rate is increasing in Northern Ireland, in common with many European countries. It represents a major health care issue. Measures of a social or political nature may have more effect than health care advances in reducing the rate of suicide.

Objectives: In view of the apparent public discontent that has been expressed by individuals towards temporary certification and involuntary treatment, this study was set up to assess patients' reactions to their involuntary admission. The study compared the demographic characteristics of voluntary and involuntary patients and assessed their attitudes towards and knowledge of the certification process that presently exists in Ireland.

Method: A total of 68 patients, 38 involuntary patients consecutively admitted over a six month period and 30 voluntary patients selected over the same period, were interviewed with a standard questionnaire, on average six months after discharge.

Results: Involuntary patients were more likely to be single, live with their families and showed no demonstrable gender bias. Involuntary patients had limited knowledge of specific aspects of their individual certifications, particularly with regard to knowledge of their rights, admission status and knowledge of the identity of the applicant of the certificate. Of these, 10% were aware of their rights on admission and only 14% could recall that their rights had been explained to them on admission.

Conclusion: Although patients initially expressed strong feelings of anger on admission towards committal, these feelings were found to reduce over time. Recommendations for improving the present Mental Health Act were suggested by those interviewed and these included a need for an initial assessment period before certification is completed and a need for improved communication by medical staff regarding information on the admission status, the identity of the applicant and on the person's rights.

Objective: The aim of this study was to determine whether patients with possible Alzheimer's disease (AD) who do not meet criteria for vascular dementia but who nonetheless have clinical or radiographic evidence of cerebrovascular disease (CVD), differ in presentation or rate of progression from patients with probable AD.

Method: Baseline cognitive and functional scores were obtained from 154 patients who had either possible or probable AD. Repeat data after a 12 month interval were obtained on 73 of these patients. Baseline data and rates of progression were compared for probable AD patients and possible AD patients with evidence of co-existent CVD.

Results: The diagnostic groups did not differ at baseline with a mean mini-mental state examination (MMSE) score of 18.1. Comparison of the longitudinal data showed a mean annual drop of 4.1 points on the MMSE in both groups.

Conclusions: The patients with and without evidence of co-existent CVD did not differ either at baseline or prognostically suggesting that evidence of CVD does not affect the rate of progression in AD. However, further longitudinal studies using neuropathological criteria are warranted to determine whether such data can be interpreted in favour of including possible AD cases in clinical trials of probable AD.

Objectives: Several reports have suggested that, despite the high prevalence of cigarette smoking, the incidence of lung cancer is lower than would be expected in patients with schizophrenia. In addition, patients with lung cancer have been shown to have a lower expression of glutathione-Stransferase-μ (GST-μ) compared to healthy controls. In this study, we tested the hypothesis that GST-μ was a trait marker that protected patients with schizophrenia from developing lung cancer.

Methods: One hundred patients who fulfilled DSMIIIR criteria for schizophrenia were examined for the presence or absence of GST-μ.

Results: Significantly more male (86%) and female patients (64%) were smokers compared to general population rates of 30% and 30% respectively (p < 0.0001). There were no significant differences in the expression of GST-μ in patients (48%) compared to controls (46%).

Conclusions: We found no difference in the expression of GST-μ in patients with schizophrenia compared to normal controls. It is therefore unlikely that GST-μ acts as a trait marker protecting patients with schizophrenia from lung cancer. However, a significantly large smoking prevalence rate was ascertained in the patient population.

Objective: The original DWR test, which measured delayed free recall, was reported to have high predictiveaccuracy in discriminating Alzheimer's disease (AD) patients from control subjects (overall accuracy of 95%).Comparison of differential performance in free recall and recognition of the same material may be of clinical interest. In the present study a delayed recognition component was added to the DWR test and the utility of both measures in discriminating AD patients from control subjects was evaluated.

Procedure: This extended version of the DWR test was administered to 66 patients meeting NINCDS/ADRDA criteria for probable AD and 42 control subjects.

Results: In a comparison between 42 of these patients (MMSE range 18–29), and 42 age matched healthy controls, both the delayed free recall and recognition measures were highly accurate in distinguishing patients from controls. The free recall measure achieved 98% sensitivity, specificity and overall accuracy, while the recognition measure yielded 98% sensitivity, 95% specificity, and 96% overall accuracy. The recognition performance of all 66 patients, ranging in severity from very mild to severe (MMSE range 11–29), was also evaluated to determine its relationship, if any, to measures of global cognitive impairment. While therecognition measure correlated poorly with MMSE and CAMCOG there was a modest but significant correlation with the CAMCOG memory subscale.

Conclusions: In this study of highly selected AD patients both the free recall and recognition measures were sensitive and specific indicators of AD compared to control subjects. Recognition performance appears to be more closely related to degree of amnesia than to degree of global cognitive impairment.

Objective: This report describes an open prospective study of the effects of clozapine on positive and negative symptomatology in treatment resistant schizophrenic patients.

Method: In this prospective study, 15 DSM-III-R schizophrenic patients, who had failed to respond to various neuroleptics were followed up for a period of 21 months (median: 9; 25th and 75th percentiles: 4-10). When clozapine treatment was initiated, the mean duration of the illness was 16 +/-9 years. Brief Psychiatric Rating Scale (BPRS) scores, BPRS ‘positive symptoms’ and BPRS ‘anergia factor’ scores were all rated at days 0 and 15, months one, two and three and every three months thereafter.

Results: Significant improvements in total BPRS scores, BPRS positive symptoms and anergia factor were recorded and resulted in two distinct patterns of outcome. The improvements in BPRS scores translated into marked changes in health care utilisation and in sheltered employment. Of the side effects noted, dry mouth was more common in the first month after wash-out (three patients), while hypersalivation was more frequent after this period (eight patients). There was no agranulocytosis in this cohort. Two cases of eosinophilla occurred during the first month. Weight gain affected six patients.

Conclusions: We found that clozapine offers particular benefits for some treatment-resistant schizophrenic patients despite the increased hematologic risk. Our study also indicates that the beneficial effects of clozapine are delayed in relation to negative symptoms as compared with positive symptoms.

It is 20 years since the first references to elder abuse appeared in the medical literature. Since then there h as been a growing realisation that although most elderly people are cherished by their families a substantial minority are at risk of abuse. Prevalence studies in different countries have suggested that approximately 5% of those over 65 may be subjected to various forms of abuse including physical, verbal, financial abuse and neglect.

Objective: Examination of the process of therapeutic observation, as performed by nursing staff on acute assessment wards, from the perspective of adult inpatients.

Method: One week after admission, patients were asked to complete a questionnaire, enquiring whether they had noticed their observation, and the extent to which they found it intrusive. Diagnoses were categorised by ICD–9, from the case-notes. Chi-square was used to analyse the results.

Results: Fifty six per cent of patients perceived changes in the intensity of their observation. Psychotic patients were significantly more likely than the rest (p = 0.016) to feel that they were observed too closely, despite not being uncomfortable with this. There was a trend for patients in the traditional psychiatric hospital to feel more discomfort than those on a psychiatric ward in the district general hospital (p = 0.12).

Conclusion: Respect for privacy and dignity may notentirely be attainable for the most vulnerable group of psychotic patients. Opportunities may exist to improve matters with the closure of asylums and attention to ward layout and design.

Objective: As the provision for the involuntary admission to hospital of alcoholics is likely to be discarded in a new Irish Mental Health Act, the characteristics of patients committed under the 1945 Irish Mental Treatment Act were explored and compared with those alcoholics admitted voluntarily.

Method: All alcoholics admitted compulsorily from 1989-1992 to a general psychiatrichospital in Dublin were compared retrospectively with voluntarily admitted alcoholics. Data was taken from case notes.

Results: Results showed that patients admitted compulsorily were older (t = 3.74, df = 62, p < 0.001) and had more physical complications (X2 = 8.4, df = 1, p < 0.004) than those admitted voluntarily. Although results did not reach a statistically significant level, there were proportionately more females in the compulsorily admitted group compared with the voluntary group. The outcome of admission overall was better in those admitted voluntarily, although this was influenced both by length of stay and previous admissions for treatment of alcohol dependence. One particularly interesting finding, regardless of admission category, was that duration of admission was statistically significantly longer for women when compared with men.

Conclusions: Compulsory admission of alcoholics to a psychiatric hospital for very brief periods was not shown to be strikingly helpful, but this study cannot decide whether or not longer periods of compulsory admission would be valuable.