Aims and method To explore the experiences and support needs of consultant forensic psychiatrists, whose patients had committed homicide while under their care. We circulated a survey to all forensic psychiatrists in the UK, through the Royal College of Psychiatrists, asking about their experiences of a homicide by a patient under their care. Respondents were invited to discuss their experiences further in a structured telephone interview and themes were identified from these discussions. Data were analysed quantitatively and qualitatively. Results One-third of the 86 respondents had had at least one patient who had committed a homicide while under their care. Of these, over three-quarters (78%) reported that the homicide had a significant impact on their personal life, professional life and/or mental/physical health. For some respondents, the impact was severe and long term. Respondents generally felt that they would have been helped by receiving more support in the aftermath of the homicide. Clinical implications Greater recognition is needed of the impact on treating psychiatrists of homicide by a patient and more support is needed for affected clinicians. Further research is necessary, including the effects of such events on colleagues in other specialties and examination of the costs versus the benefits of mandatory inquiries after homicides.

Aims and MethodThe aim of the study was to investigate whether psychiatrists consider that patients with schizophrenia present a greater risk of violence than patients with other forms of mental illness. Two pairs of clinical vignettes were devised. In each pair, one contained a history of violence and one did not. One vignette was mailed to each of 2000 consultant psychiatrists in the UK. Respondents were asked to give a preferred diagnosis. Rates of diagnosis of bipolar disorder, schizoaffective disorder and schizophrenia were compared within vignette pairs.ResultsFor each pair of vignettes, the rate of diagnosis of schizophrenia was higher (33 v. 21.5%, P=0.008 and 44.4 v. 32.1%, P=0.011), and the rate of diagnosis of bipolar disorder was lower (44.2 v. 62.6%, P<0.0005 and 34.9 v. 49.3%, P=0.004), among those who received the vignette containing a history of violence.Clinical ImplicationsA history of violence may lead to an increased likelihood of receiving a diagnosis of schizophrenia as opposed to bipolar affective disorder. This bias in diagnostic decision-making may affect the treatment received by a patient and may perpetuate and exacerbate the stigma associated with a diagnosis of schizophrenia.

The authors compared the effects of desipramine or carbamazepine to placebo in an intensive outpatient program for cocaine abuse. Subjects recruited from an urban drug treatment program were randomly assigned to a double-blind, placebo-controlled, eight-week trial of desipramine, carbamazepine, or placebo. Patient ratings, urine drug screens, and blood samples were obtained weekly. Using survival analysis, the three groups did not differ in time to drop out of treatment. While subjects improved over time on all self-ratings related to cocaine use, mood, and craving, only two items related to mood were significantly different over time as a function of treatment group. Subjects in the two treated groups reported significantly more improvement on self-ratings of depression and irritability. No treatment differences were noted for sustained abstinence or for proportion of positive urine drug screens. Desipramine subjects who attained a minimum blood level were retained in treatment significantly longer than placebo or other non-compliant treatment groups. This finding supports previous reports of a possible role for desipramine in cocaine abuse treatment.

Donezepil and those with learning disabilities Sir: We read with interest of the protocolbased approach for prescribing donezepil described by Jani and Prettyman (Psychiatric Bulletin, May 2000, 25, 174-177). However, the criteria suggested as guidelines for making the diagnosis of Alzheimer's disease and tests used to determine the therapeutic outcome are not appropriate for assessment of the population with learning disability, in whom, particularly in those with Down's syndrome, there is a high prevalence of dementia. There are, however, scales such as the Dementia Questionnaire for Mentally Retarded Persons and the Dementia Scale for Down's syndrome, which can give useful measurements. It is therefore unfortunate that the guidelines on prescribing donezepil and similar treatments recently produced by the National Institute for Clinical Excellence lean so heavily on the Mini Mental State Examination, which is not a validated instrument for this purpose in those with learning disability, who will score poorly whether they have dementia or not. They also seemingly limit the initiation of such treatments to old age psychiatrists, neurologists and care of the elderly physicians, many of whom do not deal with those with learning disabilities. This policy would seem to clash with the recent White Paper Valuing People, which states that all health services should be available to those with learning disabilities with a significant role for learning disability psychiatrists such as ourselves, who know this patient group best, and should surely also be authorised to initiate these treatments.

Objective. Schizoaffective disorder is an established diagnosis in both ICD-10 and DSM-IV, but research evidence relating to its nosological status and aetiology is conflicting. This study aimed to examine the attitudes of practising consultant psychiatrists, and to see whether there is a consensus about its classification and value in everyday clinical psychiatry. Method. A questionnaire was mailed to 2000 consultant psychiatrists drawn randomly from the membership list of the Royal College of Psychiatrists in the United Kingdom. Respondents were asked to rate their level of agreement with a series of statements about schizoaffective disorder and give some basic demographic data. Results. Of over 800 respondents, almost all reported using the diagnosis in clinical practice, but a small minority reported that they never use the diagnosis. Most psychiatrists considered the diagnosis to be clinically useful but there was little agreement about its nature, its relationship to other mental illnesses, its aetiology, or its characteristic clinical features. Conclusions. Schizoaffective disorder is an established diagnosis in psychiatric practice and is valued by clinicians but there is little consensus of opinion or practice in relation to it. Psychiatrists should be careful to use the diagnosis in accordance with current classificatory schemes, and further research should continue to investigate both its conceptual validity and its use in clinical practice.