Major depression is a highly recurrent and disabling disorder. At least 60% of first depressed individuals will have another episode. Knowledge of the predictors of recurrence is crucial in advising continuation and/or maintenance treatment.

Over the last 20-30 years a number of studies identified several sociodemographic-, psychosocial-, personality-, and clinical factors associated with the recurrence of major depression.

This presentation will give an overview of the most important predictors associated with recurrence of depression. Relevant articles were obtained through a search in Medline, Embase, and PsycINFO with the keywords recurrence, relapse, and major depression. This search covered the period from 1980 to 2007. Criteria to select the best studies will be presented.

The studies were further divided in general population studies, primary care and specialised mental health care studies.

Trainees are during there residency under a lot or pressure. In there first years of training they are busy to adapt to the sometimes extreme circumstances: dealing with complicated patients, who struggle with depressions, psychoses, drugs and suicidal ideas; the trainee will be overwhelmed. How to deal with al these problems in the difficult field of psychiatry?

In the years of training the trainees have to learn to deal with these new responsibilities. If not, they might not survive the training program. Therefore they have to learn not to deal with al these problems by them selves, but to share there experiences with there nearest colleagues in a save environment: the peer group. Such a peer group can be used as a tool to survive but also gives the resident the possibility to keep the joy in the daily work.

This presentation will show the attendees how to built a ‘strong’ peer group, that will help them to keep up during residency and to learn to deal with the responsibility of their daily work. The peer group will also learn the trainee how to help to train the trainee to be a trainer during these sometimes difficult times.

Most medical professionals are at risk to experience stress and negative emotions in the workplace (1), but the risk of high levels of burn-out seems to be particularly high among psychiatrists (2). Early career psychiatrists are probably at higher risk of burnout due to several factors such as lack of experience, work isolation, role conflicts, etc. (3). At present, however, no data are available on workplace conditions and burnout risk among young psychiatrists. The aim of this study is to evaluate burn-out and work-place associated conditions among young psychiatrists. Fifty young psychiatrists were enrolled among different sites in Italy and standardized self-reported questionnaires to evaluate burnout and workplace violence syndromes were administered. The results showed moderate to high levels of burn-out among young psychiatrists. This may imply that young psychiatrists working conditions may represent a major cause for concern and thus further studies are strongly needed in this area. Causative and protective factors for workplace stress among young psychiatrists need to be identified and specific intervention strategies, aimed at improving psychological well-being among young medical professionals, have to be developed.

1) Daly M.G., et al. (2006) MJA, 177: S14-S15. 2) Fischer J. et al. (2007) Australas Psychiatry, 15: 417-21. 3) Ratanawongsa N., et al. (2007) Med Educ, 41: 273-280.

Even before “globalization” has entered our everyday's vocabulary, science and research have always been global. Great scientists of the European Renaissance, such as Nicolaus Copernicus or Andreas Vesalius did not only cross intellectual boundaries set by tradition and dogmas but would perform their work irrespectively of national territories or languages. Science has always benefited from a globalized world and its progress critically hinges on the possibility of the exchange of ideas and people. In no time, modern technology has propelled the possibilities of communication and exchange between researchers across the globe in a way that Copernicus or Vesalius would never have dared to dream of.

This presentation wants to discuss the various ways European researchers in psychiatry can actively participate in such global exchange. As most young European psychiatrists are looking for a research experience across the Atlantic, the presentation focuses on the specifics of doing research in the USA. Issues to be addressed include the following: At what stage of my career should I go, before or after completion of my residency? Where should I go? How can I get into touch with research institutions in the USA? How can I apply? What position can I expect? Which funding sources can I use? Are there only advantages or may there by some risks that I should be aware of? How do I keep in touch with my European institution? When is it time to return to Europe? Should I return at all?

This presentation is meant to be a stimulus for young colleagues considering a research fellowship in the USA, rather than a traditional lecture. A lively discussion is highly appreciated.

This lecture will address the three types of pathways that have to be explored in efforts to improve mental health care. The first are the pathways that people who have a mental disorder (or fear that they might have one) will take to get help. Information about these pathways can be of immense value to public health decision-making and obtaining it is relatively simple but rarely done in a systematic way.

The second type of pathways are those that lead to an integration or at least a coordination of care provided by the various types of institutions and social sectors, that provide care in the community. Parallel to this effort is also the effort to integrate or coordinate the action by health professionals, psychologists, social workers and the many other professionals who are dealing with people with mental health problems. The integration of care provided by families and non-professional carers with that of the professional care system is a neglected area leading to a wasteful and sometimes harmful use of resources that are often very scarce.

The third type of pathways that need exploration (and creation) are pathways that lead from research and educational efforts to those directed to the improvement of care. The gaps that exist between these endeavours grow in parallel with the advances of science and with the separation between academic and clinical (particularly private) psychiatry that can be observed in many countries.

Despite converging treatment guidelines, current treatment practices in bipolar mania still vary greatly. We will review the evidence for various pharmacological options for bipolar mania – in the acute inpatient setting, in continuation therapy, and long-term in the outpatient maintenance setting as well as key treatment guidelines. Potential explanations for the existence of gaps between real life clinical practices and treatment guidelines will be presented. Although there is reasonable satisfaction with current treatments for bipolar mania among European psychiatrists, treatment resistance and early relapses are quite frequent. Thus, there is a need for improved treatments in both the acute and maintenance settings. Patients with an acute episode of bipolar mania often enter the healthcare system at the emergency room and are subsequently moved to a psychiatric hospital ward. Following resolution of an acute episode, prevention of relapse (manic or depressive) becomes the principal aim of treatment. Thus, the focus is moving toward evaluating differently the risk/benefit ratio in the acute inpatient setting and in the long term maintenance setting. The focus also moves towards achieving better patient functioning and long-term outcomes so that patients can achieve functional remission. Different treatment options for each stage of the illness will be reviewed. A core medical need in bipolar mania treatment paradigms in Europe is a rapid-acting efficacious agent, with low potential for excessive sedation. The potential for emerging options to fulfil this need will be reviewed.

Aripiprazole is an atypical antipsychotic with a novel pharmacologic profile of potent partial agonism at D2 dopamine and 5HT1A serotonin receptors and antagonism at 5HT2A and 5HT2C serotonin receptors. Aripiprazole shows rapid efficacy in acute bipolar mania. Four 3-week studies have shown significantly greater symptom improvement than placebo; a recent study showed an onset of significance as early as Day 2. Aripiprazole also demonstrates sustained efficacy, providing maintenance of effect in two recent 12-week studies, each including a control arm (haloperidol or lithium). Adjunctive aripiprazole provides significant clinical benefits when used with lithium/valproate in patients with bipolar disorder who had an incomplete response to lithium/valproate alone. Aripiprazole was superior to placebo in preventing a new mood episode in a double-blind, placebo-controlled, 26-week study. Additionally, aripiprazole-treated patients had significantly fewer relapses than placebo-treated patients. Patients who completed the 26-week phase continued in a 74-week, double-blind extension (providing a total of 100 weeks of double-blind treatment), during which aripiprazole continued to delay the time to relapse. Aripiprazole demonstrates a good efficacy and tolerability profile in bipolar mania.

The safety and efficacy of newer atypical antipsychotics have been demonstrated in recent short- and longer-term studies in patients with bipolar mania. Overall, three key principles for the use of newer atypical antipsychotics in bipolar mania are (1) consider the pharmacological profile of previous medications, (2) switch gradually – avoid abrupt discontinuation of previous medications, and (3) expect a different response with less-sedating antipsychotics. This presentation will provide practical guidance on the use of such agents in bipolar mania. Choosing the right starting dose, titration schedule and adjunctive medications are the key to successful treatment; and it should be remembered that a single dose or treatment algorithm is unlikely to be effective for all patients. Dose adjustments based on response and tolerability can be made, if necessary, in order to maximise treatment outcomes. In situations where additional symptoms or initial side effects are present, adjunctive medications may be useful, including benzodiazepines, anticholinergics, propranolol, antihistamines, and sedatives/hypnotics. Ultimately, the goal is to treat the patient as effectively as possible in the acute period with minimal side effects and achieve a smooth transition to long-term maintenance treatment. Switching to a newer atypical antipsychotic may be of benefit to patients experiencing inadequate efficacy or intolerable side effects with their current medication.

A major goal for the next edition of the APA Diagnostic and Statistical Manual for Mental Disorders (DSM-V) is to take advantage of the multidisciplinary research advances in mental health that have occurred worldwide since the publication of DSM-IV and ICD-10. Toward this end, APA has devoted an extended period of time for research planning in advance of DSM-V. This process involved an assessment of the current state-of-the-science in relevant fields, an assessment of knowledge gaps, and the production of short- and long-term research agendas to stimulate new research. To accomplish these goals, we initiated a “White Paper” process focusing on cross-cutting issues, followed by a National Institutes of Health (NIH)-sponsored conference series coordinated with the American Psychiatric Institute for Research and Education (APIRE) and the World Health Organization (WHO)—to assess the emerging research basis for revising specific diagnostic categories. We have now initiated the DSM-V Task Force and Diagnostic Workgroups, which will build on these past developments in an ongoing collaborative effort with the international research community and the WHO-guided ICD-11 advisory process. The developmental process for this edition of DSM will be discussed as will the potential changes in a conceptual framework for the classification of mental disorders.

The future development of the classification of mental disorders (ICD-11, DSM-V), is a challenge for joint international scientific activities, allowing contributions from various scienti-fic schools and language areas. The Global Scientific Partnership Coordination Group (GSP), led by Norman Sartorius, supports the WHO process of revising the International Classification of Diseases. From this expert network, both research findings and practical experiences from a range of countries with different languages shall give input to the revision process.

The respective scientific group assembling experts from German speaking countries is currently developing. Past and present German language psychiatry has in many ways influenced psychiatric diagnosis and classification. The group, building on this history, shall be led by a steering committee of experts from Germany, Austria and Switzerland. It will consist of sub-groups on various topics including experts with different expertise from German-speaking countries and those familiar with German psychiatry working in other countries. The topics covered include:

1. • Classificatory Concepts

2. • Diagnostic Methodology

3. • Input from Sub- and Neighbouring Disciplines

4. • Areas of Clinical Application/Setting Specific Needs

5. • Spectrum of Disorders

6. • Implementation/Training

The German members will also be members of a Task Force on Diagnosis and Classification of the German Society of Psychiatry, Psychotherapy and Nervous Diseases to contribute country-specific knowledge to the GSP-related German speaking group. Each sub-group of the latter will develop a working plan in close relationship with the steering group and the GSP.

The presentation will give examples and details of the group work achieved so far.

This presentation will focus on two things. First, the process of receiving a psychiatric diagnosis and the reactions that users of psychiatric services might have to this. These reactions vary – they are not homogenous. They include relief, rejection and denial. The presentations will also look at what happens when users receive more than one diagnosis, either concurrently or over time. Secondly, the presentation will consider how users and user organisations may contribute to changes in the system of classification of diagnosis itself. Communication between psychiatrists involved in changing classification systems and organisations of service users will be considered. Recommendations will then be made.

The project described here uses an international psychiatric classification (in this case Chapter V(F) of the ICD-10 produced by the World Health Organization) as a means of international communication and educational discussion about everyday clinical issues. In a first stage, psychiatrists in Central Asian countries (Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan) wrote 20 detailed clinical case histories about patients who suffered from disorders of the main sections of Chapter V of the ICD-10. In the second stage these were then sent to diagnostic assessment in the Eastern European countries of Ukraine, Belarus, Georgia and Russia and the West European countries of Denmark, Switzerland, German and the UK, who made independent diagnostic and clinical assessments. In the third stage all the information collected was sent to five sets of commentators who wrote a brief commentary on the similarities and difference in diagnoses and treatment, the main points can be learned from the discussion of these case histories.

Psychiatrists in central Asia, Eastern European countries and Western European countries reached similar diagnoses on the basis of case histories presented to them. There were however differences in treatment proposed as well as in the assessment of prognoses.

The use of casebooks as an educational tool to introduce a new classification or to improve its use will be discussed.

The evaluation of mental health patients of all age groups in Department of Veterans Affaires (VA) is complicated by the problem of separating symptoms of depression from those of apathy in young and old patients alike. In older patients, dementia of the Alzheimer's type often coexists with depression and at the same time with frontal-lobe signs of loss of executive skills and apathy. Furthermore dementias predominantly involving the frontal lobes have been proving more common than previously thought and these patients often present with psychiatric symptoms including apathy.

In younger patients returning from service in Iraq and Afghanistan symptoms of depression again may overlap with cognitive symptoms in this case due to occult mild traumatic brain injury (TBI) due to exposure of improvised explosive devices (IEDs) on the battlefield. Post-traumatic Stress Disorder (PTSD), which is also common in these groups, further complicates the diagnostic picture, and may exist in any age-group of veterans.

Currently the VA is exploring the most efficient means to effectively screen populations of veterans of all age groups for overlapping symptoms of depression, apathy and cognitive impairment. Data will be presented on the most effective screening paradigms for bringing these veterans to treatment efficiently.

Neuropsychiatric symptoms, also referred to as ‘BPSD’ (Behavioural and Psychological Symptoms of Dementia), are now proposed as a major component of the dementia syndrome and are as clinically significant as disorders of cognition. Behavioural changes are not only important at a symptomatic level but could be a key feature for the future disease modifying therapies.

For clinical trials, the following points have been suggested by members of BPSD European Alzheimer Disease Consortium (EADC):

1. - to limit the use of BNPI total score

2. - to use NPI sub syndrome or single item score

3. - to use in combination with the NPI specific behavioural domains scale

4. For clinical practice, results from the cohort such as the REAL.Fr study help to stress

5. the importance neuropsychiatric symptoms in AD patients. 686 AD patients included

A majority of patients at any stage of the disease presented with one or several behavioral and psychological disturbances. Apathy concerned 43% of patients and, with or without depression, was associated with more pronounced deficits in global cognition, everyday life and instrumental abilities, nutritional status and with a higher burden level. A high level of psychotropic prescription, especially with antidepressant, was observed in patients with apathy. In a multivariate analysis taking into account the cognitive and functional variables of AD, apathy and depression were the only significant predictors of psychotropic prescription.

Other results coming from the 4 year follow up assessment will also be presented.

Informal care plays a substantial role in the provision of total care. The number is expected to increase in the coming decades due to demographic and social-economic developments. More attention to informal care, the position of informal caregivers, the consequences of providing informal care and the inclusion of informal care in economic evaluations is therefore essential.

We conducted a study to evaluate possible effects of an integrated multidisciplinary approach with regard to dementia on caregiver outcomes. The study was part of a randomized controlled trial into the effects of an integrated approach to dementia by means of a Diagnostic Observation Centre for PsychoGeriatric patients (DOC-PG).

We found that significantly more patients in the intervention group made use of informal day care (i.e. day care provided by friends or family) at the baseline measurement. Another difference related to the costs of informal care, measured and valued with the proxy- good method, which were significantly higher in the usual care group at the 12 months follow- up. Finally, significantly more caregivers in the intervention group gave up unpaid work in order to care for the patients at the baseline measurement. No other differences between the groups were found.

Our results suggest that an integrated approach to dementia may have a positive effect on the amount of informal care since this amount increased more in the usual care group than in the intervention group after one year.

There is no generally accepted definition of Severe Dementia. The current evidence suggests that this stage of the dementia syndrome may have clinically relevant sub-divisions.

There is evidence to support the influence of the severity of dementia on neuro-psychiatric symptoms (either singly or in symptom “Clusters”).The frequency,type and impact of BPSD also change with the severity of Dementia (probably irrespective of aetiology).

The measurement of BPSD in severe dementia also poses challenges; Are the “Gold standard” measures (such as the NPI) appropriate in this stage?; Are stage specific measures of BPSD valid & reliable?; Do such measures encompass the range of symptomatology found in Severe Dementia?

How can we measure BPSD in Clinical Trials in Severe Dementia?

This paper will review the current “ State of the art” in BPSD in Severe Dementia, drawing on collaborative studies from the European Alzheimer Disease Consortium (EADC).

Some earlier studies have reported a positive association between alexithymia and delinquency. We studied this association in a sample of Finnish prison inmates. A questionnaire including the 20-item Toronto Alexithymia Scale (TAS-20), the 13-item Beck Depression Inventory and questions on socio-demographic variables as well as current and previous convictions, was delivered to 209 male prisoners. Of these, 113 individuals (54.1%) aged 17-65 years (mean 33.5) returned the questionnaire acceptably filled in. From a general population study, 1300 men aged 30-50 years (mean 40.3) were drawn as a control group.

The prevalence of alexithymia (TAS-20 cut-off point 60/61) was 7.5% in the population sample and 26.5% in the prisoner sample (p<.001). In a logistic regression analysis, controlling for age, marital status, basic education and depression, being a prisoner was still highly significantly associated with dichotomous alexithymia (OR 2.60, p=.003). Moreover, the mean TAS-20 score differed significantly between the samples (45.9 vs. 50.6 points, p<.001).

Of the prisoners, 18 (15.9%) reported having committed homicide. When they alone were compared with the population sample, no significant difference in the prevalence (7.5% vs. 11.1%) or level (mean TAS-20 score 45.9 vs. 46.8) of alexithymia was found. In a logistic regression analysis with confounders, being a convict confessing to homicide was not associated with alexithymia.

Male prisoners are more alexithymic than men in general population. There are, however, differences between different types of crimes. Those who confessed to homicide were, surprisingly, not more alexithymic than controls. Studies with larger samples are needed.