In the past few years, it has become a sort of cliché to state that psychiatry is in a crisis. In particular, it has been repeatedly argued that: (a) psychiatric diagnoses are invalid; (b) psychiatric research has not progressed significantly (in particular, it has not been able to identify “the cause” of schizophrenia, depression or bipolar disorder); (c) psychiatric treatments are of limited value, and their widespread use has not been able to reduce the incidence of mental disorders. This perception of crisis has been at least in part generated by an identification of mainstream psychiatry with the neo-kraepelinian paradigm, so that the crisis of confidence in that paradigm has expanded into a crisis of confidence in the psychiatric discipline. According to Kuhn, the crisis of confidence in a paradigm is accompanied by a period of “extraordinary science”, marked by a proliferation of competing methodologies, the proposition of a variety of divergent solutions for the problem defining the crisis, and the recourse to philosophy and to debate over fundamentals of the discipline. The crisis of confidence in the neo-kraepelinian paradigm has generated such a period, in which we are all now immersed. In this presentation, I will summarize the main components of the neo-kraepelinian paradigm; I will illustrate why that paradigm has failed, or at least has lost people's confidence; and will summarize the main elements which are emerging in the current period of “extraordinary science”.

Public mental health and clinical psychiatry: Are they two separate worlds?

Stefan Priebe, unit for social and community psychiatry, Queen Mary University of London.

Public mental health focuses on health indicators and interventions on population level with an emphasis – although not exclusively–on prevention. In contrast, clinical psychiatry involves treatment of individuals in the setting of a health service and deals with people who usually already have a mental disorder. The theoretical background, the underpinning evidence and the practical approach of public mental health and clinical psychiatry differ from each other and concepts of one of the two cannot easily be transferred to the other.

Nevertheless, the presentation will argue that there are also links between the two. These links may be based on overall applicable values, a common understanding of mental disorders, and social models of overcoming mental distress. These links can have implications for how clinical psychiatrists are engaged in political and societal activities, get involved with local communities, and work in daily practice with their patients.

The public mental health perspective, used in a wide sense of the term, has played a substantial role in the historical development of psychiatry, including its major reforms, and might also open up how clinical psychiatry might be attractive as a career option and relevant as a profession in the future.

The concept of schizophrenia has undergone many changes since its first inception in the early 20th century. Basically, the concept has stood the tests of time, as it provides useful information about the clinical picture, the clinical course and the available treatment modalities. Any alternative concept will need to show that it provides similar information. The concept has also been useful to establish evidence–based guidelines for diagnosis and treatment, and to provide valuable information as regards psychosocial outcomes. In addition, recent genetic and neurophysiological studies have shown that common grounds of aetiopathogenesis can be identified, in that schizophrenia is a mental disorder with some genetic influences and a common pathway in complex disturbances of brain circuits due to altered neurotranmission. Current research focuses on identifying biomarkers for early detection, another area of mental healthcare in which a staging model of schizophrenia proved useful. This presentation will highlight the most pertinent arguments for keeping schizophrenia as a useful diagnostic and therapeutic concept of a mental disorder.

The analysis of the historical development of the currently used diagnosis schizophrenia in DSM or ICD classification indicates that sticking to established terms and methodologies more and more develops to an obstacle in schizophrenia research. The aim of the currently used operational diagnostic approach was to reach reliability of diagnoses between different psychiatrists and researchers as high as possible. This should improve the communication between different research groups and better the comparison of study results. The aim of a high reliability has surely been reached, however, the expected striking progress in research and clinical praxis failed to materialize till today. Reliability, which means agreement, does not simultaneously means validity. Modern brain and genetic research requires more homogenous clinical syndromes or ‘diseases’ to examine them with scientifically based methodologies and technologies. The prerequisite for doing this, however, is going back to clinical and empirical realities and to integrate these realities into the development of a new generation of classification systems that are free of dogmatic thinking.

Major depressive disorder (MDD) is a severe psychiatric syndrome with very high prevalence and socioeconomic impact. Monoamine-based antidepressant drugs (AD) display slow onset of action and limited efficacy. Preclinical studies show that ADs trigger a series of slow adaptive mechanisms that limit the clinical response. These mechanisms result from the pharmacological blockade of monoamine transporters (SERT, NET) and involve presynaptic, such as autoreceptor desensitization (e.g., 5-HT1A and 5-HT1B for serotonin neurons) as well as postsynaptic mechanisms, such as increased neurogenesis and expression of trophic factors, increased dendritic complexity, etc.

Given the strong homeostasis of serotonin and noradrenaline neurons, a way to improve antidepressant action is to prevent self-inhibitory presynaptic mechanisms mediated by auto- and heteroreceptors after reuptake blockade. This strategy was used in the past with the non-selective 5-HT1A antagonist pindolol and has been incorporated by two recently developed AD (vilazodone and vortioxetine). Likewise, new molecular strategies using RNA interference (RNAi) show that the modulation of gene expression in serotonin neurons offers a great potential. Hence, local or intrnasal administration of small interfering RNA (siRNA) molecules targeting SERT or 5-HT1A autoreceptors evokes rapid and robust antidepressant-like effects in rodents.

Moreover, glutamatergic drugs such as the non-competitive NMDA receptor antagonist ketmaine, offer a potential for the development of fast-acting AD due to its rapid and persistent antidepressant effects in treatment-resistant unipolar and bipolar patients after single i.v. infusion, an effect that likely involves the activation of AMPA receptors in ventral areas of the cingulate gyrus and the subsequent fast activation of serotonergic function.

Response to antidepressants in major depressive disorder is highly variable and determinants are not well understood. Presentation will provide clinical trial data on time to response and determinants of response to antidepressant treatment. Data is from the Innovative Medicines Initiative funded NEWMEDS collaboration, a large public-private collaboration which assembled the largest dataset of individual patient level information from randomized placebo-controlled trials of antidepressant drugs. Studies were conducted by four large pharmaceutical companies. Dataset includes placebo-controlled trials of citalopram, duloxetine, escitalopram, quetiapine and sertraline in adults with MDD. We examined patient and trial-design-related determinants of outcome as measured by change on Hamilton Depression Scale or Montgomery–Asberg Depression Rating Scale in 34 placebo-controlled trials (drug, n = 8260; placebo, n = 3957). While it is conventional for trials to be 6–8 weeks long, data presented will show that drug-placebo differences were observable at week 4 with nearly the same sensitivity and lower dropout rates. Having any of these attributes was significantly associated with greater drug vs. placebo differences on symptom improvement: female, patients being middle aged, increasing proportion of patients on placebo, excluding all patients from centers with high placebo response regardless of active treatment response, using active run in periods and including self-report measures. Proof of concept trials can be shorter and efficiency improved by selecting enriched populations based on clinical and demographic variables, ensuring adequate balance of placebo patients, and carefully selecting and monitoring centers. In addition to improving drug discovery, patient exposure to placebo and experimental treatments can be reduced.

There are large treatment gaps in relation to schizophrenia across all European countries, either because the illness is not recognised or because the response from treatment and care services is inadequate - not evidence-based. This could be because of resource or other constraints. The consequence can be very damaging indeed for individuals with schizophrenia, their families and for the wider society. In this talk I will set out the economic consequences of not identifying or responding appropriately to schizophrenia. Evidence will be drawn from a number of studies, but will be channelled to show new findings in relation to both England and Czech Republic. These figures add to the argument for earlier and better treatment, to benefit everybody including public and private budgets.

Early Intervention services with team-based intensive case management and family involvement are superior to standard treatment in reducing psychotic and negative symptoms and comorbid substance abuse and improving social functioning and user satisfaction. The results of the OPUS-trial will be presented together with meta-analyses based on similar trials. The implementation of OPUS all over Denmark will be presented together with the Danish OPUS-fidelity study. Specialized elements are being are being developed such as inclusion of new methods in CBT for psychotic and negative symptoms, neurocognitive and social cognitive training programs, interventions for supported employment and focus on physical health. Results of long term follow-up studies indicate that the prognosis of first episode psychosis is very diverse with the extremes represented by one group being well functioning and able to quit medication without relapse; and another group having a long term chronic course of illness with a need for support to maintain daily activities. The Danish TAILOR-trial–testing dose reduction versus maintenance therapy will be presented. It will be of immense value to be able to intervene in risk groups identified in the premorbid phase, and there are few examples of ongoing trial for children of parent with schizophrenia and bipolar disorder.

In Italy, despite the favourable conditions created by the 1978 reform law and the community psychiatry, at the end of the past century there were no culture or initiatives oriented to innovative and evidence-based founded interventions in early psychosis. The watershed was the setting up in the MHD of Niguarda (Milan) of Programma 2000, addressed to FEP and HR mostly inspired by the knowledge of existing studies and experiences and with the recommended characteristics of specificity, multicomponentiality, assertiveness and doctrinal orientation. From the very start, one fundamental aim was to disseminate information, training, supervision, and to raise consensus and initiatives throughout Italy, as well as to improve international links. In many ways, the consequences have been extremely positive. In 2005, Angelo Cocchi and Programma 2000 team founded the AIPP (Italian Association for Early Intervention in Psychosis), now named Italian Association for Prevention and Early Intervention in Mental Health. Over the years, the Association has organized conferences, scientific days, working network, two national surveys on EIS and produced a document to favour their development. The results of the second survey are the more updated and articulated about the number of early interventions services, their characteristics and distribution in the different Italian regions. The survey conclusion is that EI Services implementation in Italy has been proceeding, albeit slowly. Nevertheless, there is still a great variability of therapeutic strategies and further efforts are then necessary to stimulate resources allocation as well as to assess and address adherence and fidelity to guidelines recommendations.

Both psychological and pharmacological therapies have been found to be effective in the treatment of adult depression and anxiety disorders. Psychological treatments include cognitive behavior therapy, interpersonal therapy, behavioral activation, exposure therapies, and several other types of therapy. Pharmacological treatments include SSRIs, SNRIs TCAs, MAIOs and several other types. In this presentation the results of meta-analyses of trials directly comparing the effects of psychological and pharmalogical treatments will be presented, as well as meta-analyses of combined treatments versus either psychotherapy alone or pharmacotherapy alone. Results show that psychological and pharmacological treatments are probably about equally effective at the short term, and combined treatment is more effective than either psychotherapy or pharmacotherapy alone. In the presentation several other issues related to this group of trials will be discussed, like the influence of conflicts of interest and the (lack of) blinding in psychotherapy trials.

The economic downturn worldwide since 2008 has raised many issues, including an increase in homelessness. Individuals who are homeless are visible across the globe. Definitions of homelessness also vary. Living on the streets in all kinds of inclement weather, brings a different set of issues and problems including physical and mental illnesses. Here homelessness is defined as a lack of customary regular access to a conventional dwelling unit. It has been shown in several studies that nearly half were either depressed or had substance use disorders and half had traumatic brain injury. Homelessness is a social issue and the role of the psychiatrist in reaching these vulnerable individuals is a matter of critical importance. In the UK health services are geographically delineated making it more difficult for ‘out of area’ individuals to get help. The responsibility for looking after people who are homeless, have mental illness or physical co-morbidity, lies with policymakers as well. As clinicians we must advocate for vulnerable patients and psychiatry care needs to be in a joined-up manner. Early interventions and home treatments where and if available are suitable and can be effective but are often linked with secure addresses. Policies must take into account huge variations across cultures and societies and the contributions that unemployment and poverty can play in increasing homelessness. Whether psychiatric disorders lead to homelessness and whether homelessness leads to mental illness is a circular argument and this vicious downward spiral needs to be broken by adequate care and policy support.

Mental health services worldwide are only able to serve a minority of patients. Expert advice is in most cases not accessible even in developed countries with a functioning mental health care system. Threshold to care are high and the time between first critical developments and symptoms and first professional interventions is long, sometimes several years.

The evolving communication tools through social media and web-based services may provide new and exciting opportunities to change that. Especially young people have a different approach to interact, learn and access services through the Internet. The momentum there is as crucial as it is in education. Our mental health care system in all its components will most likely very different than today. E mental health will be an integrated component contributing to more capacity, higher quality of care and better accessibility.

What is the key in developing new tools and what can today's clinicians and researchers do to be an active partner in this process? What are the major concerns and how should we address them also as professional organization? This may be an opportunity of a lifetime for a paradigm shift. Its success relates to good integration and implementation of these exciting tools to create a new continuum of tools addressing a continuum of needs.

The impact of social determinants on women's mental health is becoming clearer worldwide. Poverty, violence and communal insecurity are among the main challenges to women's mental health and the health of their families. Depression is one of the most common mental disorders experienced by women. It typically has an early onset in life and is more frequently found in women made vulnerable by trauma.

Improving mental health for women and girls requires early intervention for depression and other mental disorders; with gender sensitive clinical care and support for recovery in primary health care, and mother, child and reproductive health settings. Early intervention in primary health care and collaboration with patients and family carers encourage integration of mental health with the health care system, in turn protective of human rights.

In addition, gender equity and observance of human rights need to be embedded in policy and practice in health and non-health sectors to ensure that women's mental health is promoted and mental illnesses adequately prevented and treated. Effective promotion of mental health and prevention of mental disorders is possible in countries of all income levels.

“Trafficking in persons,” “human trafficking,” and “modern slavery” have been used as umbrella terms for the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts through the use of force, fraud, or coercion. Trafficking in persons is an insult to human dignity and an assault on freedom, and robbing basic human rights (US Report, 2015). Reliable data on trafficking are difficult to obtain owing to its illegal nature; the range and severity of trafficking activities; and variations in how trafficking is defined. It is supposed that 49 per cent of the victims are women, 21 per cent girls, 18 per cent men and 12 per cent boys. 53 per cent were involved in sexual exploitation and 40 per cent in forced labor (UN, 2014).

Research findings show that the limitations of current methodologies affect what is known about human trafficking and health. Moreover, findings demonstrate an urgent need for representative and non–purposive recruitment strategies in future investigations of trafficking and health as well as research on risk and protective factors related to human trafficking and health, intervention effectiveness, long-term health outcomes. The psychological impact of victimization may be more severe than the physical violence. Victims who have been rescued from sexual slavery, typically present with various psychological symptoms and mental illnesses, including the following: Post-Traumatic Stress Disorder (PTSD), depression, anxiety, panic disorder, suicidal ideation, Stockholm syndrome, and substance abuse. In this talk current findings will be presented and discussed.

Demographic changes and successes of medicine in preserving and prolonging life are among the main reasons for the significant increase of comorbidity of mental and physical illness. The simultaneous presence of these disorders leads to a worse prognosis of both types of disorder, significant increases of cost of treatment and heightened mortality.

Although these facts are becoming known among members of the profession and among decision makers in the field of health little is done to provide adequate and timely treatment and care for all the diseases from which a person suffers. The fragmentation of medicine into ever finer and more narrow specialties contributes to the decreasing quality of care for people who have the misfortune of having comorbid mental and physical illnesses as does the stigma of mental illness which decreases the probability of timely help and leads to well documented discrimination of those who have mental illness in health services.

The paper will present some information about comorbidity of mental and physical disorders and suggest reforms of health care that might help to resolve the problems which comorbidity produces.