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: 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: 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: 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: 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.

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.

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.

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.

Our objective in writing this paper was to present a case of Diogenes' syndrome and to examine the evolution of thinking about the phenomenon. To do this we looked at original case material and then carried out a literature review, the results of this showed the syndrome has been reported most often in the elderly and in higher socio-economic groups. It represents a non-specific final common pathway for many interacting variables.

In our conclusion we found that a detailed multidisciplinary assessment is indicated in all cases. Further work is required to estimate the role of personality disorder and organic frontal lobe dysfunction in the aetiology of this syndrome. A multiaxial approach to diagnosis should be employed. Intervention should be based on objective findings and risk-assessment, rather than on ideological grounds. Irish law does not allow a large variety of options to the helping professions.