Clinical reality presents us with a series of continua in the area of mood disorders: between “normal” sadness and depression, between “normal” elation and hypomania, between a “pure” depressive episode and a “pure” manic episode, between unipolar depression and bipolar disorder, between anxiety disorders and depression, and between mood disorders and psychotic disorders. Most of our classificatory efforts and controversies in this area center around how to deal with these continua, where to fix boundaries and how to delineate intermediate or mixed conditions. in this presentation, I briefly review how the ICD-11 and DSM-5 are going to handle these continua. The two systems will address the continua between “normal” elation and hypomania, between unipolar depression and bipolar disorder, and between anxiety disorders and depression in a more consistent way than in the past, while there will be differences in the characterization of mixed states and schizoaffective disorders. A major weakness of both systems will be the fact that the boundary between “normal” sadness and depression will not be based on a solid empirical evidence.

We are in the ‘age of the old’ and should be celebrating this incredible achievement by the human race but like many things, an ageing population brings with it a number of social challenges: the importance of the carers - and in turn their health - plus the longer we live the more diseases we acquire. A further challenge is the infertility of the European populations. The consequent burden to our health system means that there has to be a far closer understanding between patients and the pharmaceutical industry about the medicines that are produced, side effects, adverse effects and how necessary it is for these patient reported outcomes to be fed back to the industry. For too long, the industry and patients have been kept apart by clinicians and certainly, in more recent times, by the media. This is having a very adverse effect upon our health economy and should be rectified wherever possible. Partnership and constant dialogue between industry and patients using the well established Dr/Patient relationship is essential for the joint responsibility of managing health.

Conventional treatment of auditory hallucinations in patients suffering from schizophrenia is successful in about 60-70% of cases. Therefore repetitive transcranial magnetic stimulation (rTMS) has been suggested to be promising alternative to conventional therapy. However, both positive and negative reports have recently been reported. Thus there seems to be responders and non-responders, but not yet any clear possibility how to identify responders. The aim of this study was to test if cerebral neuronal activity before treatment would be a possible biological marker of response to rTMS. Twenty four medicated patients underwent resting brain perfusion magnetic resonance imaging with arterial spin labeling (ASL) prior to rTMS treatment. Neuronal activity in the left superior temporal gyrus predicted the response to rTMS, suggesting this parameter as a possible bio-marker of response in patients with schizophrenia and auditory hallucinations. Being non-invasive and relatively easy to employ, ASL measurement before treatment might be a clinically relevant way to identify possible responders to rTMS in conventional treatment resistant patients.

Suicide is one of the leading causes of death worldwide, and the third leading cause of death among people aged below 25. Mental health promotion is a central aspect of the battle against suicide and mental ill-health. The internet and the media are effective tools for disseminating information and education to adolescents and improving their mental health and well-being. in 2011 there were 2.1 billion Internet users world-wide. in a random sample of over 3000 American adults, it was found that 58% of the Internet users reported searching for health information for themselves (Atkinson et al. 2009).

The main objective of the SUPREME project is to develop a website aimed at mental health promotion and to investigate its efficacy. A secondary goal is to compare two different strategies for promoting the use of the website: one where peers are the main promoters and another with mental health professionals. The study is partly funded by the EACH and comprises 7 European countries: Estonia, Hungary, Italy, Spain, United Kingdom, Lithuania and Sweden.

Adolescents in this study approached in a random sample of schools, in each participating country, yielding a total of 2100 participants. The schools were randomized into control (minimal intervention), and intervention conditions (minimal intervention + website access). Pre-, post- and follow-up measures are used to test the efficacy of the intervention. Each intervention school is also randomized into peer and pro dissemination groups for comparison of recruitment efficiency. Preliminary results are presented.

ADHD is a common developmental disorder with onset in childhood that persists into adulthood in two-thirds of cases. The disorder is defined by symptoms of inattention, overactivity and impulsivity; however case-control, family and twin studies all find high rates of emotional lability that strongly co-vary with the core ADHD syndrome. 80% or more of adults with ADHD report significant levels of emotional lability, often severe, and causing impairments beyond that accounted for by inattention, hyperactivity or impulsivity. Drug treatments for ADHD have all been shown to improve symptoms of emotional lability. in children, a robust effect of methylphenidate has been demonstrated on aggression, although this has not been linked directly to the control of emotional symptoms. in contrast, the adult literature has focused more on emotional dysregulation, including affective lability, temper control and emotional over-reactivity. All these symptoms have been shown to improve following treatment with methylphenidate or atomoxetine, and to the same extent as core ADHD symptoms. Characterising the nature of the emotional symptoms in ADHD more detail, we found an increase in negative emotions such as frustration, anger and irritability, as well as an increase in their moment-to-moment variability. We conclude that patients with chronic forms of emotional instability should always be screened for ADHD, due to proven effectiveness of available treatments in the subgroup of emotionally labile patients who meet clinical criteria for ADHD.

2004 there have been other reviews on specific treatments (forms of psychotherapy Cochrane review)_ and (medication World Biological Psychiatry).

In essence however the gist of treatment for eating disorders has not altered over the last 10 years. Involving the family is helpful as an early intervention for anorexia nervosa. It is possible that interventions with several families seen together may be more cost effective.

Less is known about which form of treatment is most helpful for those with a more chronic, adult form of illness. Common factors may be relevant as no form of therapy has found robust advantages over another.

CBT is effective for about 50% of cases of bulimia and the addition of medication and self directed treatment may increase the remission rate. A similar pattern is apparent for binge eating disorder. More evidence is becoming available on guided self directed care which aside of the advantages of lower cost and transferability appears to have benefits for long term effects even for those with complex presentations. The results of several RCTs are due to be disseminated. Also more brain based interventions are being tried.

Time based composite measures of disability have replaced the traditional use of death rates to evaluate society's mental health status as a more meaningful measures for the burden of diseases and the need for treatment and care. These measures have revealed with some variability and increasing precision that mental and neurologic disorders account for a major and further increasing proportion of the all-cause disability burden worldwide.

In Europe, mental and neurologic conditions combined are already now the most disabling diseases. A recent pan-European study covering 30 countries and the EU-population of 514 million people, recently examined comprehensively the size and burden and cost of mental and other “disorders of the brain”. Findings e. g.:

• Each year, 38.2% of the EU population (64.8 million people) suffers from a mental disorder.

• The treatment situation remains highly deficient. Only 1/3 of all cases affected receive treatment, those receiving treatment do so with considerable delays of several years and rarely with appropriate, state-of-the-art therapies

• Additionally, many millions patients suffer from neurologic disorders such as stroke and Parkinson's disease, cases that may add on top of the above estimates.

• The total cost burden is immense (approx 800 billion €), mainly due to indirect costs. The low direct (treatment) cost proportion is unique to mental disorders and markedly different from other prevalent somatic diseases (e.g. cancer, diabetes).

During the last few years the economic crisis has focused attention on the dual need to protect the wellbeing of the population and safeguard the care and treatment of people with mental disorders. Many countries are facing budget cuts, resulting in higher rates of unemployment, which is associated with depression and suicide. Countries are also committed to reform in mental health. This commitment is attributable to a combination of the aim to stop obsolete institutional forms of care, awareness of modern and effective forms of treatment, concerns about human rights and a stronger voice of advocacy groups. This combination of factors is raising the priority of mental health, and in response the WHO Regional Office for Europe is drafting the European Mental Health Action Plan, outlining strategic objectives to address the need for effective and efficient mental health promotion and for the prevention and treatment of mental disorders. The European Action Plan is developed in close cooperation with the Global Action Plan.

The European Mental Health Action Plan puts forward actions that have the potential to improve wellbeing of populations and access and quality of services. Particular emphasis is given to the point that service structure, however excellent, is necessary but on its own insufficient. Safety, effectiveness and absence of stigma as experienced by patients and their families will determine acceptability and outcome of care.

This is an important time to advocate for sustained investment in mental health care. The European Action Plan offers a platform for such consensus.

Bipolar disorder is a chronic, severe illness with high rates of relapse, suicide rates, and a remarkable psychosocial burden. Despite the existence of well tested newer drugs that, together with classic mood stabilisers constitute quite a large number of pharmacological treatment options, bipolar patients are symptomatic for almost half their lives.1 This might be due to several accompanying features of bipolar disorder, including poor pharmacological adherence, unhealthy habits, and lack of illness insight. This is why pharmacological treatment, although essential, may not be enough for most patients. Thus, complementary interventions are needed to reach syndromal and functional recovery. Psychoeducation, a user-friendly, common-sense-based psychosocial strategy, has been shown to prevent all sorts of relapses at 5-year follow up and to be efficacious even with fully adherent patients, so the effect does not rely completely on adherence enhancement.2 The content of the Barcelona Psychoeducation Program focuses on the illness, its causes and its consequences, rather than on other issues such as personality, psychodynamic features and so forth.3 Topics are divided in five main areas:

• Illness insight

• Adherence enhancement

• Early detection of prodromal symptoms and early intervention

• The importance of avoiding street drugs

• Routines and stress management

This presentation will discuss the role of psychoeducation in improving social functioning and long-term outcomes in maintenance treatment for bipolar I disorder. Through the use of a case study, this presentation will provide practical considerations of how to implement psychoeducation techniques into routine clinical practice.

Following remission of an acute episode, patients with bipolar I disorder remain at a high risk for relapse, regardless of the nature of their index episode.1 in particular, if the medication regimen in the acute phase is different than that used in the maintenance phase, there may be a potential loss of efficacy or a change in adverse-event burden associated with the switch. Therefore, choosing the right pharmacotherapy is essential to allow patients to achieve and maintain stability, and prevent the recurrence of mood episodes.

Current clinical practice guidelines recommend combination therapy of atypical antipsychotics and lithium or valproate as firstline treatment in acute patients, or for maintenance treatment in patients with an inadequate response to monotherapy with mood stabilisers.2 Therefore, exploring the long-term benefits and risks of monotherapy compared with combination therapy are essential for improving patient outcomes in the course of routine clinical practice.3 Recent clinical trial evidence suggests that combination therapy is effective in patients with an inadequate response to monotherapy, and that there are relatively lowrisk options regarding adverse events and comorbid physical conditions that are frequently encountered in patients with bipolar I disorder.3

This presentation will explore how to manage patients with a partial response to pharmacotherapy or with persistent residual symptoms long term, and how to address the unmet needs of this patient population in the context of recent clinical trial evidence.

Bipolar I disorder is associated with a number of physical health concerns and a higher prevalence of eating, anxiety, and substance abuse disorders compared with the general population. in addition, patients are prone to exhibit risk factors for cardiovascular disease such as obesity, hypertension, hyperglycaemia, dyslipidaemia, and type 2 diabetes.1 Moreover, pharmacotherapy has been linked to metabolic abnormalities that may exacerbate the physical health risk factors and comorbidities prevalent in patients with bipolar disorder.

Choosing an initial treatment regimen that takes into account the significant physical health risks associated with bipolar disorder may minimise the subsequent common problem of polypharmacy and may reduce the side-effect burden associated with the disease. Regular monitoring of physical health in the months after initiating pharmacotherapy is essential in preventing and correctly managing comorbidities. Clinicians should gain a comprehensive insight into patient lifestyle choices and should, as part of preventative care, choose treatments according to individual patient risk profiles. If required, clinicians should make recommendations to specialists or facilities offering therapies to minimise key risk factors.2

This presentation will review the physical health risks associated with bipolar disorder and with chronic exposure to pharmacotherapy. Because practice guidelines recommend regular physical health monitoring in patients with bipolar disorder, this presentation will discuss approaches to incorporate regular monitoring in routine clinical practice.

The choice of pharmacotherapy for the treatment of bipolar I disorder should balance acute efficacy and long-term effectiveness with minimal side effects. During acute treatment, the primary goal is rapid stabilisation of symptoms, whereas the goal for the long-term management of bipolar I disorder should include relapse prevention, maintenance of a stable mood, and minimise risk of comorbid conditions.1

Despite the shift in treatment goals between the acute and the maintenance phase, if a patient responds well to the agent used in the acute phase, this agent frequently will be continued in the maintenance phase. However, achieving continued stability may collide with the goals of minimising the adverse-effect burden associated with treatment, and the subsequent goal of improving patient functioning and quality of life. Sometimes, changing medication regimens may help achieve a balance between efficacy and side-effect burden. However, switching may also be associated with an increased risk of destabilisation. Evidence has shown that patients with bipolar I disorder often have a predominant episode polarity, which is a predictor of treatment response.2 Therefore, when assessing long-term treatment options, consideration should be given from the outset to the available clinical evidence for preventing the recurrence of mood episodes, as well as the predominant polarity of the patient.3

Because patient polarity plays an important role in the success of pharmacotherapy, this presentation will review the concept of predominant polarity in clinical practice and discuss the potential value of considering a drug's polarity index in the development of individualised long-term treatment regimens.