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.

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 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.

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.

Serotonin aggregation is a measure of function of platelet 5-HT2 receptors. The test has been proposed as a valid peripheral model of central 5-HT2 receptor function. Receptors of this subtype are implicated in theories of the aetiology of depressive states.

This pilot study proposes a normal range for the test for both males and females. Untreated depressed subjects had results which grouped at the lower end of the range. The test proved reproducible with a correlation coefficient of r = 0.939 with an interval of at least six weeks between sampling. A small number of successfully treated patients were retested with no empirical difference in their results, which are included in the reproducibility studies.

Our provisional results indicate the reliability of serotonin aggregation scores for an individual. The difference in scores noted in depressed subjects is more likely to be a trait rather than a state marker.

Effectiveness of verapamil as a psychotropic and verapamil toxicity when used as a psychotropic are presented in this case study with literature review.

Objective: The aim of this paper was to elucidate factors associated with inpatient suicide.

Method: A retrospective review of inpatient suicides over a 20 year period in the Cavan/Monaghan mental health service was undertaken. Clinical files, statutory reports and Central Statistics Office returns were studied and information was obtained on demography, diagnosis and circumstances of the event.

Results: Eight patients committed suicide, giving a rate of 0.55/1,000 discharges and 0.39/100,000 population per year. Depressive illness and Schizophrenia were the diagnoses found. Repeated admissions and long duration of illness were noted. Previous suicidal behaviour was common. Four of the patients were considered a suicide risk at some time during the index admission. Underreporting of the suicides and inaccurate registration of institutional location by the Central Statistics Office were found.

Conclusion: More formal clinical procedures in registering suicide risk are recommended. New procedures for investigating inpatient suicides are suggested. Largescale studies at a national level are essential in defining more specific and sensitive risk factors. Procedural changes involving accurate central registration of data are required.

Objective: In view of the Royal College of Psychiatrists Defeat Depression campaign, to review the existing literature on depressive episodes in people with learning disabilities.

Methods: Review of all papers identified to cover this area. Papers were identified by Medline search and also by direct checking of the contents in the preceding five years of eight key learning disabilities journals, the British Journal of Psychiatry, Psychiatric Bulletin and bibliography in Current Opinions in Psychiatry. Papers about children or odd ‘depressive’ symptoms (rather than the syndrome of depression) were excluded.

Findings: For over a century it has been recognised that depression can occur in people with learning disabilities. However, the number of studies in this area is very limited. There remain many unanswered questions, such as those of prevalence, clinical presentation and diagnostic criteria, associated social factors, and the evaluation of treatments. Suitable rating scales have yet to be evaluated or devised. The authors propose diagnostic criteria for future use.

Conclusions: Research in this important area is very limited. Advances are yet to be made in the clinical assessment and management of the illness.

Doll phobia is a rare phobia that has only been reported twice in the literature, both times in male patients. The following case is the first to be described in a female patient. The characteristics of the dolls that caused most fear in all three cases are compared and the possibility that this indicates a similar genesis of the phobia that could be explored by psychodynamic psychotherapy is discussed. A Hellenic derivation of doll phobia for future use is suggested.

Factitious post-traumatic stress disorder, a variant of the psychological Munchausen syndrome, was first recognised in Vietnam war veterans but has not been described since. The case is described of a young man who claimed to have been involved in a fishingdisaster, feigning the symptoms to post-traumatic stress disorder to gain admission to hospital This appears to be a novel presentation of a Munchausen variant which has not been describedin connection with peace time disasters. It would appear that the psychopathology of factitious disorder, like that of other phenomena, such as delusions, is keeping pace with the views ofsocietyand current media concerns. This issue is discussed in the context of a review of recently reported variants of this interesting clinical syndrome.

The Mayan people of Mexico have a radically different concept of illness than that of western countries. In the absence of any formal psychiatric service in their area, the people continue to rely on the interventions of the traditional healers, which include the use of herbal medicines, prayers and magico-religious rituals. A case history of a Mayan patient with a chronic psychotic illness is described, which illustrates the gulf in concepts of mental illness that exists between Western and folk cultures. These cultural differences may have a profound impact on the application of modern psychiatric interventions in developing countries.

The international pilot study of schizophrenia (IPSS) was the first major study to show that the use of standardised assessment and classification instruments allows the reliable comparison of data on the prevalence, psychopathology and prognosis of major psychiatric illness between different cultures. Important questions about the methodology used in cross-cultural research remain to be answered, however These include the inherently ‘Eurocentric’ nature of much of western psychiatric terminology and the absence of directly comparable concepts and language to describe emotional and psychological distress between western and non-western cultures. These difficulties especially arise in relation to illness where organic factors appear to contribute little to aetiology, such as the neurotic and Axis II disorders, and need to be overcome before useful crosscultural research into these disorders can be accomplished.

Thomas Willis [1621-1675] was not the first to describe the circle of vessels at the base of the brain that bears his name, but it was he who first recognised its functional significance in maintaining cerebral perfusion even after one of its feeding vessels was completely closed. Although Willis made many astute, original clinical observations (concerning myasthenia gravis, paracusis, restless legs syndrome and diabetes mellitus) his reputation suffered because he was an inveterate theorist in an age that frowned on hypotheses. Nonetheless he is now recognised as one of the earliest neuropsychiatrists who attempted to understand and explain mental illness, as he encountered it in his daily practice, in terms of brain dysfunction more than 300 years ago.