Diogenes syndrome or senile squalor syndrome has been described in the psychiatric literature with an associated mental illness in between one half and two thirds of the cases cited. The occurrence of the syndrome in the absence of a psychiatric disorder has received much attention with many hypotheses proposed. We present the case of a 72-year-old man living for many years in domestic squalor whose presentation, neuropsychological profile and history suggest an underlying autistic spectrum disorder. We are not aware of any similar case in an older adult reported in the medical literature. The co-occurrence of these two conditions is an intriguing one as certain key features of autistic spectrum disorder may predispose to Diogenes syndrome.

Objective: To examine the rate of cognitive decline and occurrence of dementia among patients attending a lithium clinic for those aged 65 years and over.

Method: Retrospective chart review of the cognitive function of 29 patients receiving maintenance lithium treatment attending the Dublin South East Old Age Psychiatry service, over a nine-year time period.

Results: Twenty-nine patients were included in the study (20 female, nine males), with a mean age of 79 years. Two patients had concurrent dementia. Six patients fulfilled ICD10 criteria for mild cognitive disorder and all of these patients also fulfilled revised consensus criteria for mild cognitive impairment amnestic subtype. Sixteen patients were commenced on lithium as an augmentation treatment for recurrent depressive disorder, 12 patients were on treatment for bipolar affective disorder and one patient on treatment for schizoaffective disorder. Patients had been receiving lithium treatment for an average of 109 months with follow-up by the service for a mean duration of 38 months. The initial mean MMSE score of patients at first presentation to the service was 26.9 (SD = 5.6) compared to a mean MMSE score 25.8 (SD = 5.8) (CI of change in MMSE score at 95% level = −2.1 and 0) at follow-up. The mean MMSE of patients with mild cognitive impairment prior at first contact with the service was 26.8 (SD = 3.2) and at follow-up was 26 (SD = 3.2) which was not statistically significantly different (p=0.40) (CI for change in MMSE at 95% level = −3.2 to 1.5). No patient had developed incident dementia during the follow-up period of the study.

Conclusion: The results tentatively suggest that lithium may have a protective effect against cognitive decline and a neuroprotective role in patients with concurrent affective disorder and cognitive impairment. Multi-centre prospective studies of cognitive function in patients attending lithium clinics are needed to examine the neuroprotective properties of lithium.

Objectives: Depression and vital exhaustion are associated with poor cardiovascular prognosis, but there is substantial overlap between these constructs. Factor analytic studies have been inconclusive, and may not be the optimal analytic strategy to assess dimensionality. We assessed whether exhaustion and depression formed a single, hierarchical dimension using a form of nonparametric item response theory.

Methods: Patients with acute coronary syndrome (n = 430) completed questionnaires assessing depression and vital exhaustion. Mokken scaling was used to assess dimensionality.

Results: Mokken scaling formed a strong unidimensional scale, ordered in a hierarchy reflecting prevalence: fatigue (common), depression (less common) and hopelessness (rare).

Conclusions: Depressive symptoms form a clear hierarchy in cardiac patients, from fatigue to hopelessness. Vital exhaustion may be considered a less severe form of depression. Use of hierarchical scales may allow clinicians to better determine clinical significance and target interventions.

Objectives: Neuroimaging is being used increasingly in the investigation of psychiatric disorders. Previous studies have found abnormalities in about two-thirds of all scans done in psychiatry. The aim of our study was to investigate the use of CT and MRI in the management of inpatients in psychiatry department Adelaide & Meath hospital, Tallaght and to examine the relationship between diagnosis and abnormalities seen on scans.

Method: We did a two-year retrospective study of all inpatient referrals for CT scans/MRI scans. A case note review of bio-demographic data, diagnosis, relevant medical history, substance misuse history, indication for tests and results of scans was done. We found that 66 CTs and MRI scans were done over the study period.

Results: Fourteen (21%) of the scans had abnormal results which were mostly atrophic changes. Of the 14 abnormal scans, seven had abnormal findings on neurological examination. We found a lower number of abnormal scans compared to previous studies.

Conclusions: Radiological abnormalities were not disease specific. We wish to propose guidelines on the indications for using neuroimaging in psychiatric patients.

Objectives: Electroconvulsive therapy (ECT) is one of the most controversial psychiatric treatments of the modern era. Few studies have used validated scales to examine attitudes and knowledge regarding ECT in lay people. We examined attitudes, knowledge and experience of ECT using standardised questionnaires in Irish lay people, and compared the present results with the findings from a similar study reported over 25 years previously.

Methods: A total of 103 lay people were recruited from a variety of settings and completed a questionnaire. Data were analysed using independent samples t-tests, χ2 tests and Pearson correlations.

Results: Attitudes to ECT among Irish lay people are negative and knowledge of the treatment is poor. A significant correlation (r = 0.32) was found between knowledge and attitudes, with higher levels of knowledge associated with more positive attitudes. People with relatives who experienced ECT had a significantly higher ECT knowledge than the people without such relatives (p < 0.05).

Conclusion: Results confirmed previous findings and revealed novel statistically significant factors that contributed to attitudes towards ECT. Further replications are required to examine the findings' robustness and the relationship between attitudes, knowledge and experience. Such research can help increase the understanding of ECT and remove the stigmatisation associated with ECT. Mental health education programmes should consider the relation between knowledge and attitudes to better inform programme focus and content.

The use of antidepressants in bipolar illness remains controversial. This controversy continues to be fuelled by short-term studies that inconsistently report efficacy or no benefit. However, long-term studies have been consistently unfavourable, suggesting that understanding the long-term course of the illness in the setting of antidepressant treatment is important. This is an extraordinary case in which prospectively collected daily mood ratings were available in a type I bipolar individual who had experienced minimal medication changes over a 21-year period was reviewed. Data regarding the number of euthymic days in the setting of antidepressant use and after antidepressant discontinuation were collected.

Induction of cycling and increase in the number of depressed days occurred after five years of continuous serotonergic antidepressant administration. Discontinuation of antidepressants after 11 years of continuous use was associated with only a partial improvement which had a delayed onset. Cycling and increase in depression was noted after years of continuous use of serotonergic antidepressant treatment. Antidepressant-associated destabilisation may occur after long-term exposure and may be associated with prolonged worsening even after antidepressant discontinuation.

Objectives: A patient's suicide is arguably the event of most concern to consultant psychiatrists. Given the rise in the rate of suicide in the Republic of Ireland, the impact it has should not be underestimated. The aims of the study were: to assess the effect a patient's suicide has on a consultant's personal and professional life; to identify what factors modulated or exacerbated their response to the suicide; and to highlight what was shown to be beneficial in coping with the aftermath.

Methods: Following a literature review, a questionnaire from a previous study was chosen. This was sent to 74 consultants working in the Munster province. It asked consultants to recall their ‘most distressing’ suicide and their response to it. The results were analysed using quantitative methodology. A further literature review was conducted on the issues raised.

Results: The questionnaire response rate was 67.5%. A total of 80% of consultants had a patient commit suicide under their care. In the case of 27.5%, consultants said that their personal lives had been affected by the suicide and 32.5% said that their professional lives had been affected. The majority of those affected were recently appointed consultants. Consultants' peers and team were significant sources of support, as were team meetings. A total of 57.5% of consultants said that their management of future suicidal patients had changed following the suicide.

Conclusions: A proportion of consultants experience negative effects in their lives as a consequence of patient suicide. However the support of consultant peers, the team and team meetings may help in the aftermath.

We report on the case of a middle aged lady who was referred by her GP with what appeared to be a case of first episode psychosis. Following assessment and investigation an underlying cerebellar tumour was identified. Our aim is to draw attention to the ongoing debates regarding the possible role of the cerebellum in psychosis and cognition and on neuroimaging as a diagnostic modality in cases of first episode psychosis.

Objectives: Although epilepsy and psychiatric disorder are known to be associated, little is known about the nature of epilepsy in psychiatric inpatients and how well psychiatrists manage psychiatric patients with epilepsy. The aim of this study was to describe the nature of epilepsy in patients at a large specialist independent psychiatric hospital and to audit the management of epilepsy using patients' records.

Method: Cross-sectional survey of inpatients and audit of clinical documents. Audit standards were derived from good clinical practice and UK guidelines.

Results: In total, 83/488 (17%) patients had a life-time history of epileptic seizures and 67 (14%) were receiving anti-epileptic drugs. The prevalence of epilepsy was 37% among brain injury patients, compared with 10-11% in adult male and female forensic patients and in the elderly and 2% in adolescents. Generalised tonic-clonic seizures predominated. Common aetiological factors were: traumatic brain injury, antipsychotics, cerebral hypoxia, cerebrovascular disease and learning disability. In 53/67 (79%) cases the care plan stated the patient had epilepsy but in only 20 (30%) was the seizure type recorded. For 30 (45%) there was no history of how epilepsy had been diagnosed. Of those patients with a history of status epilepticus, 5/15 (33%) had a readily accessible emergency treatment plan. The patient's last seizure was incompletely documented in 29/44 (66%) cases, while for only 7/67 (10%) patients was there documented evidence of a review of epilepsy management within the past year.

Conclusions: Epilepsy was common in this group of psychiatric inpatients. Documentation and management needed improvement and to be in line with national guidelines.

Objectives: A significant number of depressed individuals experience inadequate benefit from long-term antidepressant use. This paper investigates the hypothesis that in some individuals persistent use of antidepressants may be prodepressant.

Methods: Literature regarding the effect of long-term use of antidepressants was reviewed by searching PubMed and Ovid data bases with terms: antidepressant tachyphylaxis, treatment-resistant depression, chronic depression and antidepressant tolerance.

Results: Antidepressant treatment-resistant patients frequently had a positive initial response to antidepressants. When resistance appeared, initial increases in dose or medication changes usually resulted in transient improvement. Eventually, the episodic course of the original depressive illness was replaced with a continuous, unresponsive depressive syndrome. We propose the term tardive dysphoria to describe this phenomenon.

Conclusions: The phenomenon of antidepressantinduced depression, or tardive dysphoria, needs to be experimentally examined in blinded, randomised antidepressant discontinuation studies.

The concept of recovery entered the lexicon of the mental health services in the 1980s following the publication of a series of studies and personal narratives which demonstrated that the course of mental illness was not always one of inevitable deterioration and that people diagnosed with severe mental illness could reclaim or recover meaningful lives. For a long time, recovery was not thought possible by many family members, service providers and researchers. However globally, specific policy and clinical strategies are being developed to implement recovery principles although key questions remain. In fact, the possibility of recovery is still debated by some. In this paper, we include information about the recovery model and the medical model; we provide evidence for recovery and document changes in mental health practices and policies incorporating recovery as the guiding principle. We also attempt to address the debate as to whether recovery is an evidence based practice. We propose that evidence based practice should be complementary to value-based and narrative-based practices and we suggest an integrative model that maximises the virtues and minimises the weaknesses of each practices (see Figure 1).