Vincent Russell

Assessment following deliberate self-harm: who are we seeing and are we following the guidelines?

OBJECTIVES To determine whether assessments of patients admitted to a general hospital following deliberate self-harm (DSH) were in line with the Royal College of Psychiatrists guidelines. To examine the profile of cases and presentations and to make recommendations for improvements to the service. METHOD Clinical and demographic data recorded on 70 admissions after DSH during 1997-98 were analysed retrospectively. A checklist was also developed, using factors shown by previous research to be associated with future risk of suicide, to determine the quality of assessments. RESULTS The majority (70%) of assessments took place within 24 hours of admission thereby meeting College recommendations. Medical personnel performed all adult assessments. Circumstances of the overdose, recent stresses, psychiatric diagnosis, immediate risk and follow-up arrangements were documented in the majority of cases. Family psychiatric history, past suicidal behaviour, alcohol and drug abuse history, and previous violence, were frequently not documented. A copy of a discharge summary to the GP was found in 41% of charts. Overdoses accounted for 93% of cases of DSH. The most frequently recorded problem (37.5%) was adjustment disorder. CONCLUSIONS Despite evidence showing that non-psychiatric medical staff are competent in assessing DSH and guidelines encouraging multidisciplinary involvement, DSH assessments remain the preserve of the medical psychiatric team. Closer attention should be paid to all the risk factors associated with suicide by assessors; a checklist could prove helpful. There is room for improved communication between psychiatric services and GPs following DSH. The setting up of a self-harm service planning group could improve the co-ordination and efficiency of delivery of general hospital services to this patient group.

Integrating mental health and primary care services : a challenge for psychiatric training in Ireland

A Vision for Change, the report of the Expert Group on Mental Health Policy asserts as one of its key recommendations the enhancement and formalisation of links between specialist mental health services and primary care. As part of a higher training post in psychiatry a consultation-liaison service was provided by a senior registrar in three rural general practices. This paper describes the experience of this initiative from an educational perspective and discusses the broader implications for Irish psychiatric training. With an emerging emphasis on collaborative mental health care there needs to be an appreciation of the specific set of skills that psychiatry trainees must learn in order to be effective in primary care settings. The tandem development of the appropriate services and training in an Irish context will require dedicated funding and resources.

Attitudes to visits by children to parents hospitalised with acute psychiatric illness

BACKGROUND There is no published research on attitudes of psychiatrists towards children visiting parents who are acutely-unwell and inpatients in psychiatric hospitals. Nor is there information on facilities available for such visits. OBJECTIVES (I) To assess the attitudes of Irish psychiatrists towards children visiting. (II) To determine the availability of child-friendly facilities within admission units. METHOD A questionnaire was posted to every consultant psychiatrist accepting acute adult admissions in the Republic of Ireland and Northern Ireland. RESULTS The response rate was 69%. Ninty-seven per cent were in favour of children visiting. Almost half felt that decisions on visits should depend on the particular situation, considering the child, parent, ward, etc. However, only 11% of units had a room/area designated for children visiting. 90% had no facilities they considered child-friendly on their unit. A majority felt that arrangements for children visiting were inadequate. CONCLUSIONS This topic is of interest to psychiatrists, and can be contentious, particularly when considering supervision of, and legal responsibility for, children visiting. Guidance on these issues would aid psychiatrists and hospital management. Poor facilities and infrequent visits may be a factor in the early development of stigma towards mental illness. Further research, improvements in facilities and staff training in liaison with children are needed.

Primary care mental health - A new direction?

Current health policy in Ireland, as articulated in the HSE’s Transformation Programme (2007-2010), has a focus on the health and wellbeing of the whole population and demands a shift from the hospital system to the primary care setting as the central locus of service delivery.1 The main vehicle for this change is the Primary Care Strategy (2001) which recommended the establishment across the country of primary care multidisciplinary teams (PCTs) supported by specialist services in primary care networks (PCNs).2 The Primary Care Strategy and Transformation Programme documents both emphasise that successful implementation depends on close liaison and integration between PCTs and networks and secondary care services so that the patient journey from one service to the next is “seamless and delay free”.1 Consistent with the broad thrust of the national health strategy, the Vision for Change (2006) policy framework for mental health services makes the ambitious statement that it is not enough for a comprehensive mental health policy to make recommendations relating solely to specialist mental health services – it must also deliver mental health activities capable of improving the wellbeing of the population as a whole.3 However, while Vision for Change recommends that links between specialist mental health and primary care services should be enhanced and formalised, most of its recommendations relate specifically to specialist mental health service provision. It envisaged that multidisciplinary community mental health teams (CMHTs) occupy community mental health centres in proximity to other community services, but did not go as far as to recommend the actual co-location of CMHTs and PCTs. In a significant recent development, the HSE has now committed to the provision of physical space to accommodate community mental health teams (CMHTs) and day hospital services within all primary care health centres as the Primary Care Strategy is rolled out nationally. This decision represents a potential milestone in the evolution of mental health service delivery. It presents particular challenges to the historic relationship between primary care and specialist mental health services both of which have been relatively underdeveloped in Ireland, have evolved separately and between which deficiencies in communication and collaboration have been reported by service users and providers alike.4,5 While the health strategy documents describe overall structures designed to increase primary care capacity and improve integration between primary care and secondary care services, other than the inclusion of a clinical psychologist in the envisaged networks, no detailed working arrangements are described. The Vision for Change document identifies the need to build mental healthcare capacity within primary care through enhanced primary care mental health resources, as well as through education and training initiatives, and it recommends the consultation-liaison model in order to achieve greater integration with specialist mental health services. However, at present there is no specific guidance available to either the newly formed PCTs or to existing mental health services in how to pursue these goals. In a worsening economic climate both services can be seen as entering unknown territory without a road-map and both services may have an understandable anxiety as to whether the goal of improved mental health for the population as a whole can be delivered without compromising the quality of service provided to society’s most vulnerable individuals.6

First episode psychosis and an underlying cerebellar tumour

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.

Brain biopsy and a case of dementia that wasn't

Dear Editor This is a case report of a patient incorrectly diagnosed with dementia with lewy bodies (DLB) principally on the basis of a brain biopsy. Review of the case revealed that he had none of the core clinical features of DLB and that the history of cognitive decline was less than six months. This case highlights a number of issues, most notably that dementia is a clinical diagnosis; a good history is most important in making the diagnosis of dementia and investigations are not an adequate substitute. This case also demonstrates similarities between DLB and delirium.

ECT and etomidate-induced seizure-like activity

Following the withdrawal of methohexitone from the market place psychiatrists and anaesthetists have been forced to seek out alternative anaesthetic agents for ECT. We report a case of etomidate-induced seizure-like activity. We review the literature on ECT and anaesthetic agents and discuss the alternatives available in accordance with a statement by The Royal College of Psychiatrists.