Objectives: To identify whether a simple marker of nonpsychiatric health service contact (weight of general hospital case notes) is helpfulin identifying patients with evidence of psychiatric disorder in a medical and surgical population.

Method: Hospital case note review identifying evidence of past and current psychiatric disorder in patients with heavy, medium and low weight case notes. Responses to letters to general practitioners and review of local psychiatric hospital records were used to validate findings. Setting: A large general teaching hospital in the centre of Leeds, UK. Subjects: Random sample of 240 patients aged 16-65 attending general hospital medical or surgical teams as an inpatient or day patient between April 1, 1991 and March 31, 1992. Patients whose index admission was to the gynaecology or obstetrics unit were excluded. Main outcomes: Non-psychiatric service contact was measured by case note weight and thickness, lifetime admissions and number of consultants seen. Psychiatric disorder was identified using global judgements based on a standardised assessment of the case notes, and also general practitioner statements of current or past psychiatric disorder and record of contact with psychiatric services.

Results: In a detailed examination of 75 cases, 92% of patients with lightweight notes had solely physical factors to account for their presentations, compared to 88% in the middleweight group and 64% in the heavyweight group. Heavier case notes more often contained comments about psychiatric problems affecting the physical presentation (lightweight 8%; middleweight 20%; heavyweight 64%). Patients with heavy case notes more often had a history of contact with psychiatric services as confirmed by the GP or contact at local psychiatric hospitals (lightweight 28% middleweight 24% heavyweight 48%). Amongst the heaviest service users, patients with a psychiatric problem had seen a median of 12.0 lifetime consultants compared to 8.5 in those where a purely physical cause was present.

Conclusions: Patients who have heavy hospital case notes are more likely to have evidence of psychiatric disorder than those with lower levels of hospital contact and this is more likely to have an impact on their physical presentation and clinical course as judged by case note review using structured assessment criteria.

Objectives: To establish suicide rates of psychiatric inpatients in Ireland and the characteristics, demographic, social and medical, of the patients involved.

Method: Clinical, post mortem and inquest data on all such deaths from 1983-1992 were examined. Suicide rates were calculated using ‘person year method’.

Results: The suicide rate for short stay inpatients (stay less than one year) was 319/100,000, and 118/100,000 for long stay patients. The average duration of illness at time of suicide was 10 years. A fourfold increase in suicide rate of inpatients over the century was associated with a similar increase in the suicide rate in the general population. Thirty five per cent of suicides were aged 25-34 years. The risk of suicide was higher the shorter the time interval after admission. Three quarters of suicide deaths in registered inpatients occurred away from hospital grounds.

Conclusions: Social factors which contribute to an increase in the suicide rate in the general population are relevant to the increase in hospital inpatient suicides. More effective and comprehensive services to meet the needs of those with severe mental illness, particularly young adults, are essential. The results emphasise the importance of managing inpatients in a safe, secure environment. The person year method is appropriate for monitoring changes in suicide rates.

Objectives: This study explores the gender difference in patterns of drug use, risk behaviour, health and well-being among 934 new attenders at a Dublin syringe exchange.

Method: Over the period May 1997 to April 1998 data was collected by means of structured interviews with all clients who presented for the first time at Merchant's Quay health promotion unit. All information collected was based on clients' self-reported behaviour.

Results: Of the new clients, 24.3% were female and 75.7% were male. The female clients were significantly younger than their male counterparts (p < 0.0001). The women were significantly more likely to report having a sexual partner who was an injecting drug user (OR 9.04, 95% CI, 5.9-13.9) and to be living with an injecting drug user (OR 1.69, 95% CI, 1.2-2.3). They were also significantly more likely to share injecting equipment with their sexual partner (OR = 3.83, 95% CI, 2.7-5.5) and to report recently sharing injecting paraphernalia (OR = 1.79, 95% CI, 1.3-2.5). However, the interval between initiating intravenous drug use and first presenting at the Merchant's Quay health promotion unit was significantly shorter for female clients (p < 0.0001).

Conclusions: One of the most important concerns with regard to illicit intravenous drug use is that of needle sharing, and the associated risks of infection with human immunodeficiency virus and hepatitis. This study highlights the greater personal involvement of women with other drug users, and its consequences in terms of healthrelated problems and risk behaviour. There is a need to address this issue, by taking advantage of the fact that women present for treatment at a younger age than their male counterparts and at a much earlier stage in their injecting career.

Objectives: To determine to what extent official suicide rates in counties Kildare and Mayo underestimate the rates as clinically determined, and to examine and compare the association between the sociodemographic characteristics of the two Irish counties and trends in the suicide rates.

Method: Populations for the two counties for the years 1988-1994 were calculated. Official suicide mortality data was obtained from the Central Statistics Office. Following examination of the coroners' files for both counties the number of suicides was estimated using clinical criteria.

Results: Neither county showed a significant change in suicide mortality over time from 1988-1994. Suicide was underestimated in official mortality data for each county. There were significant differences in the choice of method of suicide with an excess of drowning in Mayo and of shooting in Kildare. Mayo suicides were more likely to be single and unemployed.

Conclusions: Much local research is needed before implementing suicide prevention programmes due to the many demographic differences and differences in traditions and choice of method of suicide that exist between counties.

Objectives: To outline the limitations of traditional studies of outcome in schizophrenia and to review the findings arising from ‘first episode’ psychosis studies.

Method: An extensive literature search was performed and relevant papers were examined and analysed.

Results: Current knowledge regarding outcome predictors in schizophrenia has primarily been derived from a series of ‘consecutive admission’ and ‘long-term follow-back’ studies. However, methodological considerations may limit the generalisability of these studies' findings. The prospective evaluation of first episode cohorts has advanced our knowledge regarding the relative importance of premorbid and intercurrent factors in determining outcome in schizophrenia.

Conclusions: To date, the ‘first episode’ strategy has highlighted some potentially clinically modifiable outcome predictors. These findings may open the way for targeted introduction of measures aimed at preventing poor outcomes in schizophrenia.

The failure to recognise the pervasive developmental disorders/autism spectrum disorders is probably not uncommon in adult psychiatry. Indeed some of the treatment-resistant chronic mental illnesses are due to the failure to make this diagnosis and apply more appropriate treatment.

Patients with PDD/ASD cause considerable diagnostic difficulties in both inpatient and outpatient adolescent and adult psychiatry. Clinical experience suggests that patients with PDD/ASD in adulthood have been misdiagnosed as having schizophrenia resulting in inappropriate treatment. Mesibov and Handlan state that the diagnostic situation is complicated because the characteristics of autism are less pronounced in older clients. It is critical that an accurate diagnosis is given because of the specific treatment implications. In the past decade there have been considerable developments in our understanding of autism. The importance of bringing the developmental viewpoint into adult psychiatry is now highly relevant. Unfamiliar diagnostic categories now have to be considered by adolescent and adult psychiatrists. Grounds for the deletion of adult psychiatric disorders, eg. simple schizophrenia from ICD102 may exist. Instead PDD/ASD disorder may need to be considered.

As the purpose of diagnosis is to ensure appropriate client management, it is essential that diagnostic criteria are continually reviewed in view of clinical observation and research developments. In this paper, diagnostic categories causing confusion are outlined, and that these are variants of the core deficit of autism is suggested. The major PDD/ASD diagnoses in adolescence and adulthood are listed below.

Two of the following are required for the diagnosis of autism:

Lead encephalopathy is a relatively rare medical condition. It can present with multiple seizures, delirium, blindness, aphasia and dementia. Usually it is due to environmental exposure. This paper describes a case of delayed diagnosis of lead encephalopathy secondary to petrol sniffing which responded to chelating agents therapy. A high index of suspicion must be maintained to diagnose this treatable cause of encephalopathy.