Over the last five years the adjective ‘evidence-based’ has become difficult to avoid. Indeed, a MEDLINE search for articles containing the phrase ‘evidence-based medicine’ in their titles or abstracts reveals one mention in 1992, rapidly increasing to 53 in 1996. So great has been the increase that the National Library of Medicine now includes ‘evidence-based medicine’ as a MeSH heading for indexing papers.

But what is evidence-based medicine (EBM)? First and foremost, EBM is a set of strategies designed to help the clinician keep up-to-date and to base his clinical decision making on the best available external evidence. EBM has been espoused by policymakers, purchasers and others — and, although the approach is open to misuse by these groups as a cost-cutting exercise, there are refreshing signs that they will be able to use the approach to help produce real improvements in patient care. However, the essential focus of EBM is on assisting doctors and other clinicians make decisions about individual patients. The steps involved in EBM include: a precise definition of the clinical problem (a crucial first step — in medical practice it will usually include making a diagnosis), an efficient search for the best available evidence, critical appraisal of the evidence and integration of the research findings with clinical expertise. Finally, the clinician assesses the outcome of the process and continues to improve his EBM skills.

Objective: The aim of this study was to determine the one-month frequency of hopelessness and suicidal feelings in a community dwelling elderly sample in Dublin.

Method: A total of 891 individuals of 65 years and over, without a dementia, were interviewed using the Geriatric Mental State (GMS)-AGECAT system. Items from the GMS relating to reports of hopelessness and suicidal feelings over the previous month were identified and the relationship of these items to gender and age was studied.

Result: Serious suicidal feelings were rare with 0.2% of the sample expressing a pervasive wish to die, but less intense feelings were more common with 15.5% reporting that life was not worth living. Hopelessness and suicidal feelings were present with similar gender frequencies unlike other studies which have demonstrated a higher frequency among females. Any feeling of hopelessness or suicidality was present in 18.4% of those aged 65-74 years (‘young elderly’) compared with 14.8% of those over 75 years (‘old elderly’). Depressed elderly who reported hopelessness or suicidal feelings were not more likely to be taking antidepressants than the depressives without such feelings.

Conclusion: Cultural factors may explain the pattern of suicidal feelings reported in our sample, with the more intense feelings being rare, and may influence the gender distribution. Hopelessness and suicidality is not more common in the ‘old elderly’ than in the ‘young elderly’ and should not be regarded as an integral part of ageing. The small number of elderly depressives with feelings of hopelessness or suicidality wh o are being treated with antidepressants is a cause for concern.

Objective: To ascertain the views of Irish GPs with regard to local child psychiatry provision.

Method: 180 randomly selected general practitioners were sent a questionnaire designed to ascertain their views on child psychiatry services. They were asked to rate service provisions, professional staff and therapies offered in terms of priority.

Results: 74 (41%) returned completed questionnaires. Written reports, short waiting list times and emergency inpatient provisions were accorded the highest priority by the largest number of GPs (77%, 64.9%, and 63.5% respectively). Expertise in child sexual abuse, mental handicap and alcohol/drug addiction were also prioritised (77%, 66.2%, & 58.1% respectively). The core staffing required included child psychiatrists, community psychiatry nurses, psychologists and social workers. Family therapy followed by counselling were the most popular treatment modalities. However, more than two thirds (68.6%) of the sample rated their current service as unsatisfactory.

Conclusion: In planning service provision it is important to take into account the needs of the community, referrers' views and accessibility in order to provide optimum services for both users and referrers.

Objective: This study reviewed all inpatient admissions in a community oriented old age psychiatry service with the aim of assessing the appropriateness of admission criteria, obtaining a profile of those admitted, and providing information about service utilisation.

Method: A retrospective chart review of all first inpatient admissions from 1989-1993 was carried out. Information concerning sociodemographic and clinical variables, and outcome measures in terms of discharge destination, was obtained.

Results: There were 205 first admissions in the study period. There were 37 patients (18%) admitted on an involuntary basis. One per cent of admissions were not assessed at home prior to admission. Six patients had no formal psychiatric disorder, of the remainder 53% had an organic, and 47% a functional psychiatric disorder. Of those admitted 68% were discharged to their original destination. Patients with dementia were more likely to be discharged to nursing homes. Other discharge destinations were also used.

Conclusions: The policy of initial domiciliary assessment of all referrals prior to admission is feasible in the majority of cases. Defined admission criteria clarify reasons for admission, and ensures appropriate use of beds. The range of discharge destinations highlights the need for maintaining close ongoing links with other service providers.

Objective: To determine whether the previously reported relationship between menstruation and emergency psychiatric admissions still pertains.

Method: All females admitted on an emergency basis to a general psychiatric unit of a DGH, were interviewed and data regarding menstrual function was collected on those fitting the inclusion criteria who consented to inclusion in the study.

Results: Ninety three people were included in the study, of whom significantly more were admitted in the late luteal and menstrual phases of the cycle. Symptoms suggestive of premenstrual syndrome were significantly commoner in those admitted in the late luteal and menstrual phases.

Conclusions: The findings suggest that the premenstrual syndrome is either a risk factor for psychiatric admission or is important in determining the time of admission. Adequate detection and treatment of premenstrual syndrome, could in theory, reduce some psychiatric admissions. The methodology and limitations of the study are discussed.

Objective: To examine the treatment of and outcome for elderly patients presenting with depressive symptoms.

Method: 100 consecutive elderly patients presenting to an old age psychiatric service with depressed mood were studied, 51 met DSM-III-R criteria for major depression and 49 met criteria for a range of other diagnoses. Demographic details, psychiatric history and clinical examination including Hamilton Depression Rating Scale, Mini-Mental State Examination and Cumulative Illness Rating Scale scores were recorded at first presentation. Treatment of index episode was recorded and outcome assessed at time of follow up (mean of 19.1 ± 9.1 months later).

Results: 57% of the major depressives and 41% of the other diagnoses had a good outcome. Within the other diagnoses group 30% of the comorbid anxiety/depression patients and none of the patients with dysthymia or personality disorder had a good outcome. In the major depression group there was no clear association between outcome and any clinical or demographic measure. Within the other diagnoses group a good outcome was significantly associated with being younger, having had more psychiatric admissions and being less likely to require benzodiazepine treatment (p < 0.05). The two groups received similar treatment except that the other diagnoses group were more likely to have had psychotherapy and the major depressed patients to have had ECT (trend) than the major depressed group.

Conclusions: The outcome for patients with major depression is similar to that found in previous studies. Patients with depressive syndromes associated with dysthymia, personality disorder, or comorbid anxiety/depression respond poorly to conventional treatments of depression.

Objective: To determine the effect on clinical response to clozapine of increasing the plasma levels of clozapine and its major metabolite N-desmethylclozapine in 19 patients with schizophrenia who had plasma clozapine levels ≤ 370ng/ml, a level previously determined to identify patients who were unlikely to have an adequate response to clozapine.

Method: The dosage of clozapine was increased by 20% in 11 patients and left unaltered in the other eight patients. Clozapine and N-desmethylclozapine plasma levels were measured after six weeks at the higher dose.

Results: Nine of the 11 patients in whom clozapine dosage was increased subsequently achieved plasma clozapine levels ≥ 370ng/ml. However, in this group of patients who already had partially responded to clozapine, increasing the dosage of clozapine did not produce additional clinical improvement.

Conclusion: Clozapine plasma levels are useful in clinical practice to guide dosage strategies. However, these results suggest that increasing the dosage of clozapine to achieve plasma levels ≥ 370ng/ml is unlikely to produce further improvement in patients who have already achieved a partial response to clozapine at plasma levels ≤ 370ng/ml.

Objective: Gender appears to have a significant impact on the prevalence, age at onset, symptoms and outcome of schizophrenia. This study examines gender effects in a population of familial schizophrenic patients in Ireland.

Method: Families with two or more siblings suffering from schizophrenia, as defined by DSM-III-R were ascertained in Ireland. The final sample comprised 169 siblings from 80 families. Siblings were interviewed using the Structured Clinical Interview for DSM-III-R (SCID), the Scale for the Assessment of Negative Symptoms (SANS) and the Strauss-Carpenter Levels of Functioning Scale. The difference between males and females for various clinical features were calculated.

Result: There was a marked excess of affected males (65% male and 35% female). When the excess of male subjects was taken into account there was no significant excess of same-sex as compared to opposite-sex pairs. There were no significant difference between males and females for age at onset, age at first admission, symptoms or level of outcome.

Conclusion: The excess of males and the lack of gender differences for clinical features found in this study may, in part, be due to the narrow diagnostic criteria used. Alternatively, at least some of these findings may be specific to this Irish sample. Further research is a need to see if these findings can be replicated in other countries.

Objective: The repeated, self-inflicted, non-accidental injury known as Self Injurious Behaviour (SIB) is a cause of severe stress to carers and a challenge to multi-disciplinary teams working with people with a mental handicap. A need for Irish data on this problem was answered by collecting a representative cohort and following its members up to record the prevalence of SIB.

Method: The group studied included all people with an IQ of less than 50 (that is those in the moderate, profound and severe range of intellectual ability) whose place of origin was within the geographical borders of a single community care area. Following a preliminary tracing process, each person was followed up for one calendar month using a specifically prepared format to record daily occurrence of SIB.

Results: The group resulting from the tracing process consisted of 429 people (= 0.4% of the total population), 62 (=14 %) of this group exhibited SIB, during the time of the study. Of the demographic variables studied SIB was found to be related to IQ. Of those who self-injured those who showed multiple topographies and those who showed the greatest frequency of SIB were more likely to be found in the population who lived in a residential facility.

Conclusions: SIB is related to IQ but in a non-linear way suggesting that factors other than IQ militate against more severely handicapped people displaying this behaviour. SIB is not caused by living in a residential centre however our results suggest that living in a residential facility is the result of displaying SIB. This study suggests that implications for future treatment approaches and service provision for those exhibiting SIB in Ireland can be made with reference to research from other countries.

Objective: It is now widely recognised that personality disorders play a significant role in psychiatric practice. This study was set up to examine the diagnostic accuracy of the assessment of personality disorder in normal practice by a multidisciplinary community mental health team when compared with a formal assessment using a structured interview.

Method: Forty-four patients originally assessed by team members of the Early Intervention Service (EIS), were re-examined using the Personality Assessment Schedule (PAS ICD-10 and original version) at a mean period of 16.3 months after first assessment. Specifically we tested the extent to which three personality disorder (PD) clusters (flamboyant, odd/eccentric, anxious/fearful) could be differentiated from either no PD at all or from the remaining PD clusters.

Results: As expected, both flamboyant and odd/eccentric PD clusters were much more easily differentiated from no PD at all (overall accuracy of 87 % and 85 % respectively) than from other PD clusters (corresponding accuracy of 65 % and 50%) . In distinct contrast, the anxious/fearful cluster was much less accurately differentiated from no PD (accuracy of only 52%) than from other PD clusters (accuracy of 85%).

Conclusion: The diagnosis of personality disorders in routine clinical practice is fraught with difficulties, especially when mental status symptoms closely resemble personality traits. The present results suggest that greater knowledge, training and experience can facilitate diagnostic accuracy.

Objective: With the increasing demand for clinical psychology services and the existing shortage of clinical psychologists, it is theoretically and clinically important to identify variables associated with non-attendance for clinical psychology appointments. The study reported here attempted to: (a) examine the effect of waiting time for an appointment on non-attendance to clinical psychology services; (b) investigate variables associated with prolonged waiting time; (c) explore the nature of the relationship between waiting time and length of psychological treatment.

Method: The records of 49 3 patients offered an appointment to attend a clinical psychology service over a period of 24 months were analysed. Subsequently information on sex, age, type of referring problem, previous treatment history, treatment venue and waiting time for appointment, was collected and statistically analysed.

Results: Non-attendance was significantly related to prolonged waiting time and young age. Controlling for the effects of waiting time and age, patients with complex problems and new patients wh o had never sought psychological treatment in the past were less likely to attend. Length of waiting time was higher in groups with previous treatment history, patients seen at a hospital based department, and patients with complex problems and anxiety disorders. Finally, length of psychological treatment (total number of sessions required) was not affected by prolonged waiting time.

Conclusion: Non-attendance for clinical psychology appointments was associated with (a) young age, (b) prolonged waiting time (over six months), (c) complex psychological problems, and (d) new patients. The limitations and clinical implications of these findings are critically discussed.

Objective: To compare the quality of care offered by a community hospital hostel and three hospital rehabilitation facilities (two traditional rehabilitation wards and an innovative normalisation unit) for people with longterm mental illnesses.

Method: Quality of care is assessed here on three different levels: those of Input using Programme Analysis of Service Systems; Assessment of Care Environments; Process using Ward Management Practices Questionnaire; Attitudes to Treatment Questionnaire; Outcome using Rehabilitation Evaluation Hall and Baker and the Life Experiences Checklist and resident and staff questionnaires. These measures cover a range of perspectives from staff to residents, and include both standardised assessments as well as specific schedules developed for the study.

Results: On Input measures, the community hospital hostel had the best scores on the Programme Analysis of Service Systems schedule, which measures the degree to which services meet predetermined normalisation criteria. On the Assessment of Care Environments it also scored favourably against other community facilities. Process measures showed no differences between units in terms of their management practices, all scoring well, but suggested some differences in staff attitudes. Staff in the community hospital hostel had the most medical approach to care, however this was accounted for by the scores of untrained staff. Qualified nurses had a more psychological approach to care. Finally on Output measures, residents in the community hospital hostel were found to be the most disabled on the REHAB scale. Despite this, they had a significantly better quality of life as assessed by the Life Experiences Checklist. Staff in the community hospital hostel had the clearest perceptions of their roles, though there were differences again in how qualified and unqualified staff perceived their work. Residents were generally satisfied with services, though residents in the community hospital hostel and in the hospital normalisation unit had the highest satisfaction levels.

Conclusion: The results of this comparative evaluation show that a high standard of care, equal to or surpassing some of the best hospital provision, can be provided in the community. This is despite the fact that the residents in the community hospital hostel were more disabled. Community patients' quality of life is better in a number of domains than their hospital counterparts and even patients initially reticent about the move into the community report higher levels of satisfaction, especially regarding their home environment. There-were interesting differences between trained and unqualified staff in the community hospital hostel. Trained staff had a more psychological view of patient care and felt more supported and appreciated by the team than their untrained colleagues. The implications of these findings for community residential care are discussed.

Objective: The following case report describes a child with autistic symptoms who experienced early emotional deprivation and institutionalisation. The paper discusses her symptoms in relation to Melanie Klein's theories on object relationships.

Method: LM was a four year old Rumanian adoptee, when she was first assessed by a child service in Dublin. On presentation, she exhibited a spectrum of autistic symptoms including an impairment in social interaction, absence of separation anxiety, poor attachment formation with others and restricted, repetitive, stereotyped patterns of behaviour. While attending the pre-school, she was involved in an individualised programme which focused on her specific needs.

Result: After attending the pre-school programme, L exhibited a greater ability to express various emotions and her social interaction with others had improved, but she continued to have marked deficits in her personality. This child's symptoms are discussed with reference to the paranoid schizoid and depressive positions associated with ego development.

Conclusion: By applying Melanie Klein's theories on object relations, one can gain a further understanding of a child's pathological symptoms, ego development and the necessary treatments required to improve these symptoms.

Objective: To explore the nature of the relationship between the Greysteel massacre and the low number of admissions with overdose to the area general hospital in the following week.

Method: Ward records over a ten year period were examined for seasonal and yearly trends for admission with overdose.

Results: In the two year period surrounding the week following the Greysteel massacre there were no similar periods of low admission with overdose.

Conclusion: A direct relationship between the Greysteel massacre and the ensuing dearth of admissions with overdose seems likely.

Objectives: To examine the process and outcome of use of clozapine in patients with mental handicap, with particular reference to selection of patients, response to treatment, adverse effects and withdrawal from treatment.

Methods: The case notes and medication charts of all patients commenced on clozapine between January 1991 and December 1994 were examined.

Results: Seventeen patients had been commenced on clozapine, the majority in the mild and moderate range of handicap. Fifteen had ICD-9 diagnosis of schizophrenia and all were refractory to conventional neuroleptics. Improvement was marked in 47% and substantial in 76%, with a mean daily dose of 453.8(sd = 238.5)mg and a range of 200mg-900mg. Reduction of aggressive behaviour was an important indicator of improvement. Five patients were withdrawn but only one related to side effects. Four patients had a past history of epilepsy and six others either developed seizures or EEG changes on treatment.

Conclusion: Clozapine use has been associated with considerable benefit in patients with mild and moderate handicap wh o have schizophrenia. In this population aggression responded well but a high prevalence of drug-induced epilepsy was evident.