Objective: Community organisations provide care for psychiatric patients at multiple levels. With increasing emphasis on joint planning and purchasing of care it is important to ascertain the views of such organisations towards statutory organisations and services the latter provide.

Method: All community organisations working within one inner city catchment area in London were approached in order to obtain their views and experiences on the mental health services provided by the secondary care services. This was a postal survey and non-responders were contacted by personal calls.

Results: Sixty organisations out of a total of 100 in the database responded. More than half had experiences of statutory services and these were generally negative. The services provided were perceived as being rigid and inflexible. A large majority of the organisations wished services to be more flexible as well as provide more training for voluntary organisations.

Conclusion: The survey suggests that the perceptions of the statutory services and co-working with voluntary organisations can succeed only if the two groups work together closely to make good quality community care possible.

Objectives: To assess the experience and attitudes of trainees towards a range of aspects of their training in Psychiatry.

Objective: The report considers the utility of the Achenbach Child Behaviour Checklist in the differential diagnosis of the disruptive behaviour disorders.

Method: Subscale scores on the parent completed Achenbach Child Behaviour Checklist were compared for three of 15 boys, the first diagnosed with attention deficit hyperactivity disorder, the second diagnosed with oppositional defiant disorder and a third non-clinical control.

Result: The attention subscale of the Achenbach Child Behaviour Checklist was found to have a high level of sensitivity to children diagnosed with attention deficit hyperactivity disorder, but relatively poor specificity. The delinquent subscale was found to have limited sensitivity for oppositional defiant/conduct disorder group, but high levels of specificity. The aggressive subscale were found to have relatively high sensitivity for the oppositional defiant/conduct disorder group and relatively high specificity.

Conclusion: The Achenbach Child Behaviour Checklist is useful in distinguishing between children with disruptive behaviour disorders and a non-clinical sample. The aggressive subscale appears to have potential clinical utility in the differential diagnosis of the disruptive behaviour disorders.

Objective: It has been suggested that presentation with self-neglect, domestic squalor and hoarding, represents a distinct syndrome, widely known as Diogenes' syndrome. The validity of this syndrome is controversial and we suggest that in previous series of such patients other psychiatric diagnoses, particularly obsessive compulsive disorder (OCD), may have been missed.

Method: A series of 50 patients admitted for treatment of OCD were examined, looking for presentation with self-neglect, domestic squalor and hoarding. Response to treatment was also measured by comparing pre and post-treatment scores on the Beck Depression Inventory and Activity Checklist.

Results: Of the sample 8% presented with all three features. This sub-group of patient had a poorer outcome than other patients with OCD.

Conclusion: Presentation with self-neglect, domestic squalor and hoarding is not uncommon in patients with severe OCD and this supports the suggestion that patients previously described as having Diogenes' syndrome may have had undiagnosed OCD.

Objective: To evaluate the reaction of local general practitioners to a new psychiatry of old age service 10 months following its inception.

Method: An anonymous questionnaire was sent to all GPs in the catchment area of the Service. Questions asked the opinion of GPs on structure and process of the Service, and also asked for suggestions as to how the Service could patients did not have any reservations about being seen by a psychiatrist, but 72% of rural GPs felt the location of the service base (in the city) was a problem.

Conclusion: The results of the study suggest that GPs are reasonably satisfied with the initial service offered by the new specialty. Future service developments must address issues highlighted such as access to the service for patients living outside the city, improving the inpatient facilities for patients with a functional mental illness, and improving communication with GPs.

Many Irish graduates chose to pursue specialist psychiatric training in Britain. Regulations governing UK specialist training are currently changing in response to European Union (EU) directives. Furthermore, over the past five years the UK national health service has undergone significant reforms. This paper reviews the current status of British postgraduate training and examines the options for Irish doctors who take this route to a career in psychiatry.

Objective: The blood platelet has been proposed as a model of central neurons and may therefore be used as a peripheral marker of psychiatric illness. One method of investigating serotonin function in panic disorder has relied on the use of the platelet as a model of serotonergic neurons. This article reviews the studies of platelet function in panic disorder.

Method: A literature search and review of relevant papers was undertaken.

Result: Studies examining platelet serotonin uptake and concentration in panic disorder patients have to date yielded conflicting results, with some investigators reporting increased serotonin uptake, others reduced uptake. Similarly studies of platelet 3H-imipramine binding have also yielded conflicting results. Two studies of platelet 3H-paroxetine binding have shown a reduction in the density of binding sites (Bmax) in patients with panic disorder. Platelet monoamine oxidase activity in anxiety disorders has been reported to be increased by some investigators but decreased by others. Methodological considerations may have been responsible for these differences. Finally, studies of α2 adrenoceptor density have also produced contrasting findings.

Conclusion: The findings of these studies indicate that platelet function is altered in panic disorder. Such changes may allow an insight into the biochemical aetiology of the illness. Further studies are required to delineate the role of serotonin and non-adrenaline in panic disorder.

Objective: In line with Irish government and health board policy, existing district psychiatric hospitals are scheduled for rundown and closure, with ongoing care being transferred to general hospitals and community based resources. However it is unclear as to what resources will be required if this policy is to proceed. The objective of this study is to obtain the current needs profile of the inpatient population of one such hospital and to predict what facilities would be needed in the event of closure.

Method: Using a staff completed questionnaire, specially constructed by the hospital rehabilitation team, and which has been used to help predict needs for past successful relocations, information was obtained on all inpatients on a designated day. Each patient was rated as requiring independent, low-support, or high-support accommodation, the nature of which depending on the perceived needs.

Results: This survey shows that the residual population is predominantly middle-aged and elderly with many disabilities and persisting challenging behaviours. The majority have high dependency needs which limits the placements options to high support facilities, which as yet are under provided for in the community.

Conclusion: Further planning and resources will be required if the above policy is to be realised.

Objectives: The aims of this study were to review the outcome of those long-stay patients two years after identification and to compare those discharged with those remaining in hospital in order to identify factors which might contribute to their continuing stay.

Methods: All the new long-stay patients who were more than one year and less than six years on 1st March 1992 were included in the study. Their current placement. Legal status and demographic and clinical details were recorded. Findings: Sixtynine percent of the original cohort remained in hospital, 9% had died, and 22 % had been discharged, mainly to highly staffed accommodation. Approximately half of those remaining in hospital were considered suitable for community placement. Those remaining in hospital were older, had longer durations of illness and were more likely to be dangerous than those discharged.

Conclusions: Despite continuing developments in community services a considerable number of new long-stay patients still remain in hospital and the proportion of those compulsorily detained remains unchanged.

Objective: The objective of the present study was to examine the use of medication in an elderly psychiatric inpatient population.

Method: This was a retrospective survey of medication prescribed to the total elderly inpatient population of a single psychiatric hospital. Data collected included basic sociodemographic information, length of stay, number of admissions, frequency of psychiatric disturbance, diagnosis and medication prescribed.

Results: A total of 340 cases were studied, 229 (67%) were female, 324 (95%) had been inpatients for more than one year, 111 (33%) suffered from dementia, while the remainder were in the functional category. In 57% more than one psychotropic drug was used. Over half (56%) of those with dementia were on neuroleptic medication.

Conclusion: Psychotropic polypharmacy was found in this population of elderly patients. Management issues emphasised include the risk of polypharmacy in this age group, the need for staff education, an active pharmacy committee and alternative methods of managing behavioural disturbance in elderly patients in particular those with dementia.

Residency training in psychiatry in America is an option which has been little explored by Irish psychiatric trainees, although one which is readily available to them. This article attempts to illustrate this option by providing a brief outline of residency training, and by comparing this with psychiatric training in Ireland or the UK.

There has been increased interest recently in the implications of Darwinian theory on psychology, psychiatry and in medicine generally. As a result a large number of publications have appeared that attempt to reformulate a range of psychiatric disorders in the light of evolutionary theory. However, relatively little attention has been paid to the subject of suicide from the evolutionary perspective with some notable exceptions. The purpose of this brief paper is to bring the Darwinian perspective to the notice of a wider psychiatric readership hoping that this will add a further dimension to the debate on suicide and selfdestructive behaviour. Darwinia n theory had found it difficult to account for the existence of altruistic behavioural strategies in social animals until it was explained by Hamilton that the focus for selection was not the individual but the gene. Altruism here refers to any behaviour that reduces the reproductive fitness of the donor while increasing the reproductive fitness of the recipient. According to Hamilton's formulation (the kin selection theory) the individual will behave in a nepotistic manner (ie. altruistically towards kin) as this will enhance the overall chances of his genes to pass to the next generation not only through his own descendants but through non-descendant kin, a measure he termed ‘inclusive fitness’. Therefore it would not be surprising that individuals would be more likely to behave altruistically towards kin than non-kin.

Objectives: Rapid cycling mood disorder is an important clinical phenomenon. The concept of rapid cycling has evolved since it was first described in 1974. The purpose of this review is to summarise current diagnostic criteria, postulated risk factors and suggested management strategies.

Method: A Medline and Psych-Lit computerised literature search was supplemented by tracing back through the references from existing review work.

Results: Over 80 papers were identified which discussed diagnosis and management of rapid cycling.

Conclusions: DSM-IV provides a useful but narrow definition of rapid cycling. Standard treatment of affective disorder may exacerbate rapid cycling. If a rapid cycling course develops, discontinuation of antidepressants and use of mood stabilisers is recommended.

What is probably one of the most exciting potential advances in psychiatry is occurring slowly, possibly too slowly and has gone unnoticed by many. I am talking about ‘Chaos theory’, which is a mathematical concept that has influenced the study of such diverse subjects as the weather, evolution and the electroencephalogram. Is it our lack of mathematical training that makes us so fearful? This may be so, but we can still understand chaos theory without having to learn large mathematical formulae.

Chaos theory is about dynamic non-linear systems that are orderly at first, but may become completely disorganised over time. That is initial conditions that are alike in the beginning, may have markedly different outcomes over time. An analogy commonly drawn from weather studies is the butterfly effect. This draws on the premise of initial conditions which is a butterfly fluttering its wings in Tokyo can lead over time and distance to a storm for example over New York. In other words a small perturbation in a non-linear system can lead to great variations in outcome. The chaos theory is about how phenomena can vary between different kinds of states around what is called a ‘strange attractor’ and obtain from this a semblance of order out of what initially can be perceived as disorder.

In this way chaos differs from random behaviour and causal systems. Eventual outcome in a random system is not determined by initial conditions. The eventual outcome in a causal system has a linear relationship with its initial conditions. In other words a small change in initial conditions will lead to a small change in the eventual outcome. But in Chaos theory a small change in the initial conditions can lead to major changes in the eventual outcome. These changes become exponential over time.

The original example of a chaotic system was developed by Lorenz. In his early work on weather systems he found using computer simulations that started with similar, but slightly different initial data, orbits would stay close to each other for a while but would eventually diverged in a manner that turned out to be exponential over time. His model was deterministic, that is the orbits were unique in the sense that there was only one orbit passing through a given point of the space in which the orbit lay. The three variables he was measuring were convective air circulation in relation to vertical and horizontal temperature variations.

We report a case of neuroleptic malignant syndrome (NMS) secondary to clozapine treatment in which re-introduction of two different antipsychotics led to elevation of creatinine kinase (CK) levels without associated symptoms of NMS. The significance of CK levels as a marker for NM S is discussed in the light of previous findings in this area. We suggest clinical guidelines for antipsychotic rechallenge after the occurrence of NMS.

Objective: To measure the effects of providing a therapeutic community environment for patients suffering from severe mental illness.

Method: 35 patients who remained in a therapeutic community environment for a minimum of 18 months were administered three instruments which measured psychiatric symptomatology (Brief Psychiatric Rating Scale), intrapsychic and interpersonal functioning (Therapeutic Community Questionnaire) and overall psychiatric and psychological functioning (Global Assessment Scale). Assessments were carried out at zero and 18 months.

Results: The Brief Psychiatric Rating Scale revealed significant positive changes on the two items of blunted affect and un-cooperativeness while the global assessment scale revealed that patients significantly improved after 18 months.

Conclusion: Patients who remained in a therapeutic community environment for 18 months demonstrated benefits on three particular variables. While no causative link can be proposed in this study, it does seem that this environment does improve the functioning of severely mentally ill patients.

Objective: The objective of this article is to review the use of the opiate antagonist naltrexone as an alternative to opiate agonist maintenance in the treatment of opiate addiction.

Method: An extensive literature search, via Medline, Biosis, Psycinfo and other databases was carried out.

Results: Naltrexone has been used in the treatment of opiate addicts in a variety of settings. A number of methods of induction onto naltrexone of recently abstinent addicts have been used in different settings. Naltrexone has had a wide range of outcome success with different populations and associated treatment regimes.

Conclusions: The benefits of naltrexone can be compared with alternatives such as methadone maintenance and therapeutic communities. Naltrexone can be made more effective in the general population of opiate addicts with the use of adjunctive therapies.