Aims and Method We sought to identify changes in the quality of information in referrals to an old age psychiatry service before and after the introduction of the single assessment process. Referrals were compared in terms of length, legibility, information and clinical utility. Results Compared with letters before the introduction of the single assessment process, referrals made on the new forms took longer to read (mean 96 v . 124 s, P =0.001), had more illegible sections ( P =0.011), contained less information ( P =0.026) and were judged to be less clinically useful ( P =0.001). Clinical Implications The introduction of the single assessment process has impaired clinical communication between general practitioners and psychiatrists, and might be prejudicial to patient care.
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Summary Seventy-seven patients with diagnosis of schizophrenia (62) or schizoaffective disorder (15) were studied 2–20 years since onset of illness, when in a stable condition. The investigation included clinical assessment, measurement of plasma concentrations of neuroleptics and prolactin, computed tomography brain scan, neuropsychological and neurological examination. Outcome of illness was classified according to the presence of chronic psychiatric symptoms and social impairment, and response to neuroleptics according to the effect of treatment in the most recent psychotic episode. Neither outcome nor response to neuroleptics was related to duration of illness. The groups with good and poor outcome differed in premorbid adjustment, age at onset and symptoms of the initial episode, but not in drug bio-availability or prolactin response. Large cerebral ventricles and cognitive impairment, but not neurological ‘soft’ signs, were associated with unfavourable outcome. The three measures of organicity were not inter-related. No clinical differences were found between chronic patients with and without signs of organic dysfunction. The findings suggest that schizophrenia with good and unfavourable outcome may be separate sub-types. However, the role of organic factors in the latter group remains unclear.
SUMMARY At first sight, a psychoanalytic perspective on clinical work may seem to some to have nothing to offer the old age psychiatrist and his team. However, psychiatrists' daily work involves unconscious as well as conscious phenomena. In this paper the present value and future possibilities of a psychoanalytic understanding are emphasised, both in terms of therapy for individual patients and also to inform other work within the department. Clinical material is introduced to illustrate these ideas. It is suggested that psychoanalytic psychotherapy is used not to replace other treatments, but as an adjunct to biological, social and other psychological approaches, to the benefit of individual patients, staff, and the service itself.
Four hundred and fifty-three general medical in-patients were screened for mood disorder (anxiety and depression), organic mental states and alcohol problems. Using the Present State Examination, affective disorder was identified in 14.6 per cent, being especially common in younger women. Organic psychiatric disorder was very common in the elderly, occurring in 31 per cent of those over 70 years, and 18 per cent of men and 4 per cent of women admitted to a drink problem. Mood disorder was not related to the type or severity of physical illness, but was significantly associated with previous psychiatric history and social problems. Two-thirds of those with mood disorder on admission who were still alive four months after discharge were improved. House officers and family doctors identified approximately half the cases of depression and anxiety, but house officers were no more likely to recognise the more severe cases than the milder ones. Organic psychiatric disorder was often missed, alcohol problems less so.
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Summary Fifty-six patients with RDC schizophrenia (42) or schizoaffective disorder (14), of two to 20 years' duration, were assessed for neurological ‘soft’ signs and cognitive impairment when in a stable condition—the ‘outcome’. Neurological dysfunction (46% of 50 examined patients) was associated with a history of developmental abnormalities, but was unrelated to outcome, psychiatric symptoms, or treatment. Deficits in particular cognitive fields were related to two independent factors: overall severity of residual psychiatric disorder (outcome) and neurological dysfunction. There was no relationship between the size of the lateral brain ventricles on CT scan and either ‘soft’ signs or cognitive impairment. The findings do not provide evidence for an association between the presence of organic brain disorder (as indicated by the joint occurrence of neurological dysfunction and cognitive impairment) and either poor outcome or particular symptoms of schizophrenia.
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