How is the brain shaped and refined by children's early social and emotionalexperiences? In this colloquium, I will focus on the development of children whohave endured environments marked by toxic levels of stress early in theirdevelopment. These children are known to be at increased risk for a variety ofhealth, academic, and social problems. Some of these problems appearimmediately, but others may not manifest themselves until much later indevelopment. I will highlight ways in which we can address central issues inhuman development by studying the quality and timing of children's socialexperiences. To do so, I will describe recent research involving children whohave experienced child abuse and neglect, children raised in poverty, childrenraised in institutional settings, children who have endured traumatic lifeexperiences, and typically developing children. Through these studies, I willhighlight new insights about the developmental processes underlying children'ssensitivity to their social environments as a way to understand the emergence ofboth adaptive and maladaptive human emotional behavior. Defining and specifyingways in which the environment creates long-term effects on brain and behaviorholds tremendous promise for improving the health and well-being ofchildren.

Suicidal behaviour is the most common life-threatening psychiatric emergency. Reliable and precise tools to predict suicidal behaviours and to get support in the clinical practice are frequently requested.

Several measurement tools for suicide risk assessment, both psychometric and biological have been studied. However, the low precision of the predictions make these tools insufficient from the clinical perspective. To date, the same applies to the search of genetic predictors. The best information is gained in a standard clinical evaluation, which puts focus on the need of acquiring the best possible knowledge and skills by practicing clinicians.

The European Psychiatric Association (EPA) issued a guidance paper on suicide treatment and prevention, which was published in the European Psychiatry in 2012 [1]. This guidance paper elucidates the process of systematic evaluation of suicidal risks in the clinical interview, an overview of the best treatment possibilities and strategies for follow-up. As psychiatric patients constitute the majority of people who commit suicide, the adequate treatment of depression, substance use disorders, schizophrenia and other psychiatric diseases is a must.

We will probably never be able to have perfect measurements to predict if an individual will or will not commit suicide, due to the complexities of human behaviour. However, with a good clinical praxis, suicide is an unnecessary death [2].

While the plurality of approaches is a richness of psychiatry, we need today a unitary framework in which the vast majority of psychiatrists are able to place and recognize themselves. An essential component of this framework should be the awareness that a major outcome of research efforts of the past thirty years is the notion that a simple deterministic etiological model cannot be applied to mental disorders, which instead represent the product of the complex interaction of a multiplicity of vulnerability and protective factors of different nature (biological, intrapsychic, interpersonal, psychosocial). Most current significant etiological research in psychiatry can be accommodated within this framework, thus appearing much less chaotic, inconsistent and fragmentary. This first level of the framework affects in a probabilistic, not a deterministic, way the second one, that of neurobiological, cognitive and psychological intermediate processes. It is unavoidable that different languages be used to describe these processes, but these languages may be translatable into each other to some extent. Furthermore, comprehensive pathogenetic models usually require the integration of different languages. This second level leads, again in a probabilistic way, to the third level, that of symptoms, signs, cognitive dysfunctions and psychopathological dimensions. These are the elements composing the fourth level, the syndromal one. The ICD/DSM formulation of this fourth level is not optimal, but it is the best we have at the moment. Certainly, the fact that two major diagnostic systems exist in psychiatry adds to the confusion and the uncertainty, and should be overcome in the future.

The WHO European Mental Health Action Plan encompasses promotion, prevention, treatment and recovery, within the context of a model of mental health that proposes a set of socio-economic and biological determinants that predispose to vulnerabilities and increase the risk of disorders. These determinants also negatively affect access to and quality of care. Such risk factors are shared with common non-communicable disorders, increasing the risk of morbidity and early mortality for people with mental disorders.

Mental health promotion and prevention actions should therefore be addressing determinants such as alcohol and smoking. However, such determinants are not equally distributed in the population, but cluster among vulnerable groups, such as those with a low income, the unemployed and minority groups. These groups overlap with the populations services struggle to reach. In addition, both primary care and specialist mental health services struggle to identify and treat people with co-morbidities. This suggests that connections need to be established between public health, primary care and specialist mental health services.

WHO is focussing on the strengthening of primary care and the interface with mental health services. In particular, there is an urgent need to screen people who present with symptoms of NCDs or mental disorders for common determinants and co-morbidities. Effective health promotion activities need to be offered to populations at risk, in addition to universal health promotion interventions such as taxation or advertising bans. Some examples will be presented.

Future of psychiatry is discussed in the context of modern human rights principles, evidence-based policies and sustainable development goals.

After international community agreed on sustainable development goals to be reached by 2030, there is a good opportunity to address mental health as a priority and to substantially invest in promotion of mental health and emotional well-being.

Psychiatry, as an influential specialty, needs to reconsider its strategy in this context, and to rethink strengths and weaknesses of its role and image.

Protection of dignity and human rights of persons with psychosocial disabilities, in the post-CRPD framework, should become a priority for psychiatry. Common ground for search of a new consensus between different views on non-consensual treatment in psychiatry could be equilibrium within the principles of “first, do no harm”, “right to treatment” and “no hierarchy within human rights”. For mental healthcare practice, this would mean that good intentions to provide evidence-based interventions do not justify the use of force and deprivation of liberty which threatens dignity and universal human rights principles.

Psychiatry, while rethinking future directions, should critically reconsider its current focus on neurobiological paradigm and tradition of using force in the name of medicine and social control. These two paradigms, traditionally perceived as strengths of psychiatry and sources of its power, are now too often misused and increasingly discussed as lacking evidence, ignoring human rights and thus threatening image of psychiatry. Instead, psychiatry could consider accepting post-CRPD challenge as a unique opportunity for change, through strengthening strategic alliance with human rights mechanisms, social sciences, general and community medicine, modern public health approach and users’ perspective.

This paper will describe four initiatives in England to protect the mental health of the population.

1. Lobbying government – presenting the evidence about how mental health services can reduce the impact of austerity on families and communities.

2. Building psychosocial resilience in schools through well being programmes and through “enabling environments” in the workplace.

3. Delivering sustainability in mental and physical healthcare:

– prevention – don’t get ill in the first place;

– patient empowerment – if unwell patient to self manage where possible;

– lean service design – if healthcare services necessary, these should be efficient and high value;

– low carbon – reducing carbon footprint and waste.

4. Working across medicine – choosing wisely:

– promoting conversations between doctors and patients to choose care that is:

– supported by evidence,

– not duplicative of other tests of procedures already received,

– free from harm,

– truly necessary.

Overuse and underuse in healthcare is a chronic problem in most healthcare systems. Inspired by the North American Choosing Wisely Initiative, the Association of Scientific Medical Societies in Germany (AWMF), which actually counts 173 member organisations, decided to address the problem. The aim of the German “Gemeinsam klug entscheiden” (deciding together wisely)-initiative is to reduce overuse, underuse and misuse of health interventions in areas where recommendations of clinical practice guidelines (CPG) are not adequately implemented or missing. Starting point are the positive and negative recommendations of the CPGs, which the AWMF-member societies have developed for more than 20 years, following the manual and rules set up by AWMF. To identify and select recommendations methodological criteria have been developed by a working group in a consensus-based process. The development of AWMF-CPGs follows a methodology that aims to ensure the full integration of evidence, an interdisciplinary and interprofessional perspective, the prevention of bias as a consequence of conflicts of interest and full transparency of the development process.

Choosing wisely, a program developed by the American Board of Internal Medicine in 2012, is advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments or procedures. Recommendations are chosen that have a strong evidence base. There are now over seventy specialty society partners including the American Psychiatric Association. The program attempts to involve patients in the dialogue and an important partner in the program is consumer reports. In this presentation, information about the origins of the program, its development and the impact it has on the practice of medicine will be reviewed. Also the measures developed and submitted by the American Psychiatric Association will be discussed and potential additional psychiatric measures will be discussed. The strengths and weaknesses of the program will be identified.

The international debate on priority setting in health care has been around for more than 30 years now, Denmark, Norway, the US state of Oregon, Sweden, UK and the Netherlands being among their vanguards. From the beginning, the debate has been related to – or was even seen as identical to – the discourse on rationing in health care. Based on these international debates, the presentation will introduce different understandings and characteristics of the priority-setting concept in health care and will argue for a clear distinction between priority setting and rationing. Different ways of implementing priority setting, i.e., by means of guidelines or ethical frameworks, will be introduced to set the frame for the current choosing-wisely initiative. It will be argued that priority setting is important for the organisation of mental health care, as it is for health and social care of different chronic disorders.

The mental health of women and girls is endangered when they experience violence and gender-based discrimination, including poor access to education and lack of autonomy in the family and broader community. The conditions of conflict and poverty that foster violence against women, including systematic sexual violence, are growing across some world regions including parts of Africa and Asia, even while women are becoming more empowered in others. The prevalence of abuse of women at home appears to be high across the regions, and the widespread nature of other forms of violence such as genital mutilation and trafficking is increasingly recognised.

The psychological consequences of violence increase the risk of mental illnesses such as depression and anxiety, including the risk of these conditions in the perinatal period. The services provided for women with mental ill health in primary health care, maternal and child health services, community mental health services or hospital settings do not in many places respond adequately to their needs. The inadequacies in response can reproduce or amplify the difficulties and injustices that women face in their lives, especially maltreatment as girls and intimate partner violence as adults.

The World Psychiatric Association aims to increase awareness of the need for improved mental health of women and girls worldwide, especially in settings of disadvantage, conflict and adversity. It is also aiming to work in partnership with other health and non-health organisations to develop a platform for action to respond to the need – for health promotion, risk reduction and access to prevention and treatment services.

The 1990s saw an inexorable wave of globalization. This came as a massive jolt to the culture of Japan, which until then had been in a state of balance and stability. However, unlike the West, in Japan this economic globalization is not a manifestation born of individualistic value systems and socioeconomic systems that had previously been in place. The spirit that was imported together with economic globalization was not mature individualism. At the risk of overstating the case, Japan went too far in ripping apart the complex, intricate interpersonal relations that had been in place and moving toward the individualism.

I will explain that the relationship between culture and the mind takes the form of a cooperative organization. The relationship between culture and the brain therefore also takes the form of a cooperative organization. Culture has a top-down influence even on simple visual perception.

I will state that the phenomenon of the depressive state generally known as “modern depression” occurring in epidemic proportions can be explained in terms of a loss of etiquette due to cultural intermingling as well as cultural affordance. Public opinion tends toward the argument of whether or not those who have sunk into this depressive state simply want to slack off. However, from the point of view of psychiatry, it is more important to consider the fact that while manifestations and popular names may differ, mental disorders will continue to develop in the future, regardless of the era, and we need to cultivate a better understanding of their structure. The essential challenge in this respect is the merging of cultural psychology and cultural neuroscience.

In Asia, while the postgraduate training in psychiatry employs the World Psychiatric Association (WPA) core training curriculum for psychiatry as a standard course, some adjustment to the course is required for the unique demographic and sociocultural characteristics of its region.

From the small group work in the 14th course for the academic development of psychiatrists (CAD), organized by the Japan Young Psychiatrists Organization (JYPO) in 2015, young psychiatrists form Indonesia, Japan, Philippines, South Korea, Taiwan and Thailand agreed that the core psychiatric curriculum must include both general and psychiatric knowledge which are fundamental to clinical practice and continuous learning. General knowledge consists of knowledge management, academic skills, epidemiology, research methodology and statistics, evidence-based medicine, bio-ethic and medicolegal issues, professionalism, and medical anthropology, while psychiatric knowledge incorporates basic science, diagnostic assessment skills, etiopathogenesis, pharmacological and non-pharmacological treatments, disease prognosis, and mental health promotion and prevention. Moreover, the curriculum for junior psychiatric residents has to be composed of courses from various departments that encourage them practice in holistic care and multidisciplinary approach including emergency medicine, internal medicine, neurology, pediatrics, community based medicine, anesthesiology, radiology and palliative care. For senior psychiatric residents, the training program should consist of in-depth psychiatric knowledge, general psychotherapy concept and basic skills, and free elective subjects.

Since Asia is different from Europe in terms of large population, shortage of psychiatrists, aging society, racial and cultural diversity, and high risk of natural disasters; the postgraduate training in psychiatry in Asia should focus on the subjects regarding health economy, geriatric psychiatry, cultural and trans-cultural psychiatry, ethnopsychopharmacology, disaster psychiatry and mental health. Furthermore, the cooperation among Asian countries should be promoted in order to initiate knowledge exchange and research collaboration. These could contribute to the sustainable advancement of Asian psychiatry and mental health in the future.

As of May 21, 2015 UNHCR has information about 1,299,800 IDPs, the data provided by the Ministry of Social Policy of Ukraine. Since the process of establishing a centralized system for registration is still pending, the actual number of persons displaced within the country may be higher.

We have a complex psychopathological and clinical research psychodiagnostic 97 internally displaced people in volunteer center, located at the central train station in Kharkiv to study the clinical features of neurotic disorders.

The results showed that 75.9% of IDPs observed have violations of adaptation: long-term depressive reaction (F 43.21) and predominant disturbance of other emotions (F 43.23). The clinical picture is dominated by the depression, anxiety, inner tension, inability to relax, asthenic symptoms, various fears and paroxysmal autonomic instability.

The results of the diagnostic psychological studies have found that men reactive alarm indicators (average – 37,7 ± 3,0) were higher than trait anxiety (average – 32,6 ± 2,9). On the contrary, women figures trait anxiety (average – 38,6 ± 2,9) were higher than reactive anxiety (average – 34,7 ± 3,0). Severity of depressive symptoms also slightly prevailed in women. The mean score on the Hamilton scale for men was 17,0 ± 2,3 points, women – 18,0 ± 2,3 points.

Warfare in different parts of the world has led to a humanitarian emergency: forced displacement of millions of people. Global forced displacement in 2014 was the highest displacement on record since WW 2. By the end-2014, 59.5 million individuals forcibly displaced worldwide, as a result of persecution, armed conflicts, general violence, wars, or human rights violations. The number of individuals forced to leave their homes per day reached to 42,500 in 2014, hence, increased 4 times in the last 4 years. Top five refugee hosting countries are Turkey, Pakistan, Lebanon, Iran, Ethiopia and Jordan. While Turkey hosted 1.6 million forced displaced people in 2014; it is estimated that this number reached 2.5 million by the end of 2015.

Forced displacement of people due to warfare may be considered as a psychosocial earthquake. Especially after the deaths of thousands of them in the Mediterranean in the last couple years has brought this issue sharply into the focus of the whole world. While the deaths of the forced displaced people on across the borders of the whole world in the first nine months of 2014 were slightly over 4000; it reached the same number of human loss only in the Mediterranean region in 2015.

Refugees fleeing with few possessions leading to neighboring or more developed countries face many life-threatening risks on the way, as they have nowhere to turn. A refugee is a person who has lost the past for an unknown future. Experiences of loss and danger are imprinted in their selves. It is shown that, in the short/medium term, 60% suffer from mental disorders, e.g., posttraumatic stress disorder (PTSD), depressive disorders, anxiety disorders, psychosis, and dissociative disorders. In the long term, existing evidence suggests that mental disorders tend to be highly prevalent in war refugees even many years after resettlement. This increased risk may not only be a consequence of exposure to wartime trauma but may also be influenced by post-migration socioeconomic factors.

In fact, “we are seeing here the immense costs of not ending wars, of failing to resolve or prevent conflicts.” Once more, psychiatry and mental health workers are facing the mental health consequences of persecution, general violence, wars, and human rights violations caused by the current prevailing economy-politics and socio-politics. So, a serious challenge here is avoiding the medicalization of social phenomena. This presentation will discuss the issue of forced displaced people considering it as a humanitarian tragedy with some examples of its mental health consequences from Turkey.

This presentation will offer information about latest number of refugees and internally displaced people across Europe, their (mental) health problems and activities and interventions coordinated by WHO. It will also suggest ways by which EPA and WHO could continue their effective partnership to assist countries.

The WHO European mental health action plan was adopted by all countries in the European region in Izmir in September 2013. Its 6 objectives cover promotion and prevention, human rights, services and partnerships. Since its adoption, the WHO mental health programme is working in some 25 countries, supporting policy development and implementation. Priorities are the introduction of health promotion programmes for vulnerable groups; the competence of primary care to identify, diagnose and treat people with mental disorders; and the implementation of community-based service models sensitive to the culture and resources of countries.

Particularly successful have been countries where a consensus was established between policymakers and professional leaders, and where different levels of government worked together. Obstacles experiences have been funding cuts and lack of incentives. Some examples will be presented.