In the conceptual history of abnormal personality, in today's diagnostic nomenclature Personality Disorder, there has always been a large amount of overlap between issues of psychopathology and issues of dissocial behaviours. This is one reason why in this field there are close connections between sociological, political and psychiatric approaches. The dissent of irresponsibility because of insanity, which is clearly acknowledged for true mental disorders, is put in question in the realm of personality disorders in many countries and legal systems. There are also different modalities how to deal with abnormal types in the legal systems. During the process of unification in Europe the rulings of the “European Court for Human Rights” has become of major impact. This has led to a severe controversy with higher courts in Germany, concerning the question of detention for highly dangerous persons in security institutions. Diagnostic decisions and the validity of ICD-10- and DSM-categories for judgements in forensic psychiatry and in court are at present heavily debated. In this paper I will discuss the consequences of diagnostic concepts for legal and forensic decisions.

Results of EPA initiative on Guidance on the Conflicts of Interest (CoI) following the presentation at 19th European Psychiatric Congress (Höschl and Fialová, 2011) and the publication in extenso in European Psychiatry (in press) will be presented. CoI is a set of circumstances that creates a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest. In psychiatry as well as in other medical disciplines it might happen in clinical practice, research, and education. Primary interests include wellbeing of patients, objectivity and independence of medical education, and the objectivity and integrity of medical research. Secondary interests might involve financial interests, pursuit of recognition and professional career advancement. CoI might result from the multiple roles of physicians in medical care, education, research, administration, provision of expert opinion and policy advice, and consultancy to commercial organizations. The purpose of the COI policy is to protect the primary interests, keep the integrity of the profession, and preserve public trust in medicine and psychiatry. The desired aim of the guidance is to prevent CoI from arising rather than coping with them ex post. This is why it is so important to identify and publicize factors that might lead to CoI, offer a framework for their assessment, and provide recommendations for their transparent resolution. CoI represent an ethical problem in everyday psychiatric practice.

Outgoing from an international european survey directed to national psychiatric asssociations and national ethical reference persons, we have collected data about the use of international regulations, the eventual existency of national guidelines and codices as well as the character of frequently experienced ethical problems in different parts of europa.

By doing this, a great diversity became appearant, guided by the psychiatric professional dcevelopment in the countries, but even showing significant sensitivity to cultural and societal - political influences.

Thus, it appears important to maintain a continous professional discussion on ethical issues, even considering the processes and changes ongoing due to the political and sociocultural dcevelopment as well as psychiatric scietific improvements and research implications.

A need to put ethical issues and development on the EPAs agenda seems evident as well as the need to continously improve and discuss international and national ethical guidelines and practical clinical strategies.

The talk will focus on the interplay between stress and resilience, risk and vulnerability, and competence and positive adaptation. These concepts are to a large extent intertwined and not to be blended or missed in a proper longitudinal design/study of positive human development. However, the literature on resilience reflects considerable confusion regarding issues related to measurement of the resilience construct. One misconception may be that a successful process of resilience is mainly a responsibility of the individual (e.g., genetics, temperament, or intelligence), thus omitting the significance of the surroundings. Another is the exaggerated focus on measuring outcome states in preference of resilience factors or processes that may lead to a favorable outcome, despite high risks of an unfavorable outcome. I will not provide clear-cut solutions to these methodological challenges in research on resilience and competence, but delineate how measurement of protective factors, rather than outcomes per se, may be a more fruitful approach in order to answer substantive questions involving resilience processes and development of competence.

Experiences and stressful encounters during early development profoundly influence development of the brain to convey either risk for or resilience to later psychopathology. Whereas a considerable proportion of the population will develop stress-related conditions such as anxiety disorders or depression in later life, the majority are resilient, cope with stress and escape such outcomes. The biology for this heterogeneity is multi-factorial, involving a complex interplay between genetic and environmental factors. Although substantial heritability is predicted, recent genome-wide approaches have reliably linked only a few genes to resilience, indicating that also the environment is of critical importance when it comes to developmental processes. It therefore appears that subtle differences in either of these may be responsible for altering developmental trajectories that confer vulnerability or resilience. Current research is providing compelling data that epigenetic processes translating environmental stimuli into changes in expression of established and novel candidate genes play a pivotal role in establishing long-lasting changes in brain function related to resilience. Experiments in rodents and non-human primates reveal that experiences during sensitive periods of development influence DNA methylation patterns of numerous genes. These experience-induced DNA methylation patterns represent stable epigenetic modifications that alter gene transcription throughout the lifespan and promote specific behavioural outcomes. Recent clinical and pre-clinical data suggest that epigenetic differences in various regions of the brain are associated with a range of stress-related psychiatric disorders. Here, an overview is provided of how these epigenetic differences, and hence susceptibility to neuropsychiatric disorders, might arise through exposure to stress during critical periods of development.

In 1951 psychoanalysis dominated psychiatry. Treatment for psychotic patients was in the form of sleep treatment with barbiturates, ECT and insulin coma treatment; depressed patients received amphetamines or opium.

1952/3 saw the first neuroleptics, 1957 the antidepressants and 1968 clozapine. This development allowed effective intervention, many closed wards were opened and the walls surrounding psychiatric hospitals demolished.

In this early phase, drug testing was mainly clinician-led and progress came through observation and serendipity. For example, imipramine was tested as a neuroleptic drug and identified as an antidepressant through clinical observation; the drug company assumed clozapine to be ineffective, and lithium prophylaxis was developed purely by clinicians.

In the 70s all somatic treatments were discredited as inhuman on ideological grounds and psychotherapy recommended for all disorders.

The 90s saw the start of the era of modern atypical neuroleptics and SSRIs; there was no progress in efficacy but unwanted effects decreased.

Regulatory agencies (FDA, EMEA) made placebo-controlled trials mandatory but excluded severe patients, leading to an unjustified generalisation of efficacy from moderate to severe states of disorders.

Today treatment is determined by overwhelming administrative/management demands, which distress and demotivate staff and drive up the costs of care. Several big pharmaceutical companies have reduced their interest in psychiatry.

Nothing will change unless society becomes more positive towards and governments allow greater freedom to psychopharmaceutical research; psychiatrists should take the lead of development again and follow up patients into old age in order to identify, for instance, correlates with dementia and suicide.

After many decades of strenous relations between psychotherapy and pharmacotherapy - especially from psychoanalytic quarters -, Ostow (1962) was one of the first and foremost clinicians to develop a constructive and synergistic relationship between psychoanalysis and psychopharmacology. In his 1962 book “Drugs in Psychoanalysis and Psychotherapy” he outlined his position that drugs alone subdued the symptoms but did not treat the underlying disturbance of mental illness. Recently the issue of combining those two approaches is no longer controversial; the focus of attention has moved to questions of shared responsability between the drug-providing psychiatrist and the psychotherapist. The term „psychodynamic pharmacotherapy” has become fashionable.

From the standpoint of a researcher in psychotherapy the issue is embedded in the well established fact that the portion of outcome variance explained by technique is fairly small. Larger portions are explained by the capacity of patients to use psychotherapy, and by the capacity of therapists to provide psychotherapy (Lambert & Barley 2002). Combining the two approaches has become a matter of individualized strategy. Further research is needed to identify those clinical situations in which psychotherapy is especially helpful, f.e. to overcome resistance against medication. Moreover, as greater insights are gained into the brain mechanisms responsible for therapeutic changes, more specifically targeted combined approaches can be developed (Gabbard 2007).

Recent meta-analyses have shown that combined treatments of pharmacotherapy and psychotherapy are more effective than either of them alone. These meta-analyses show that patients receiving combined treatments score about 0.3 standard deviation better than those receiving one of the treatments. It is not clear, however, whether this is actually clinically relevant. In this presentation, the results of a series of published systematic reviews is presented on direct comparisons of: pharmacotherapy versus psychotherapy, pharmacotherapy versus combined treatment, psychotherapy versus combined treatment, and combined treatment (pharmacotherapy plus psychotherapy) versus psychotherapy plus placebo. In this overview, the results will be presented in terms of Numbers-needed-to-be-treated, which may be a good indicator of clinical relevance. These systematic reviews show that psychotherapy and pharmacotherapy have comparable results. Drop-out from treatment is significantly lower in psychotherapy than in pharmacotherapy. SSRIs may be somewhat more effective than psychotherapy, but after adjusting for the higher drop-out rates in pharmacotherapy, no significant difference remains. Pharmacotherapies, especially SSRIs, are more effective in chronic depression and dysthymia. This series of meta-analyses also shows that combined treatments are more effective than pharmacotherapy alone and than psychotherapy alone. In dysthymia the additive value of psychotherapy to pharmacotherapy is less strong. Drop-out rates in combined treatments are lower than in pharmacotherapy alone. More research is needed to clarify which patients need combined treatments and which do not not. The problems in developing such personalized treatments will be illustrated with meta-analytic data.

Combination treatments including psychotherapy and pharmacotherapy are considered for the majority of mental disorders more effective than monotherapy alone. The effects of psychotherapy added to pharmacotherapy are significantly better than pharmacotherapy alone in patients with depressive and neurotic disorders as reported in several meta-analyses. Psychotherapy in combination with antidepressants significantly improves response rates and for studies longer than 12 weeks, the combined therapy also significantly reduces dropout rates, improves adherence, social functioning and quality of life. Data form controlled trials suggesting that psychological interventions also offer prophylactic effects by providing patients with coping skills to prevent or delay relapse.

However, the inverse question related to the additive effect of pharmacotherapy to long-term psychotherapy is not yet systematically elaborated. In addition, only few studies examined how pharmacotherapy coupled with psychotherapy could produce a long-term neurobiological effect by improving the response to negative and stress events. Studies in depression indicate that additional effects from providing combined psychotherapy and pharmacological treatment could produce a protective effect on stress regulation systems as shown in a diurnal cortisol pattern. Congruently, the neuroimaging analyses have documented that antidepressants and psychotherapy exert similar impact on regional brain activity. Our group compared the changes of regional brain metabolism (18FDG PET) induced by cognitive behavioral therapy (CBT) and antidepressants in patients with panic disorder. Changes in 18FDG uptake after the treatment either with CBT or with antidepressants were similar in number of brain areas, with prominent right-left difference (decrease of metabolism in the right frontal and temporal lobe, and increase in the left hemisphere). These findings support the regionally specific additive neurobiological effect if both therapeutic approaches are combined.

This research was supported by the project 1M0517 MSMT CR and grant NT 11226 IGA MZ CR.

Patients with major depressive episodes require effective treatment to reduce depressive symptoms and improve functional disability. Various alternative treatment strategies have been proposed for non- or partially responsive depressions in unipolar and bipolar disorder. However, achieving an adequate response in patients with MDD continues to be a challenge. Possible treatment strategies for patients with a depressive episode who are non-responsive to an adequate trial of any antidepressant treatment strategy include switching, combination with another antidepressant with a different mechanism of action, or augmentation with a non-antidepressant drug. Augmentation options include lithium, anticonvulsants, and the thyroid hormones, triiodothyronine, T3, and levothyroxine, T4. Add-on lithium as the first-choice augmentation strategy in treating patients with resistant depression is currently the most well-documented augmentation strategy, with more than 30 open-label studies and 10 placebo-controlled studies in the acute treatment of depressive episodes, and has been shown to augment the therapeutic effects of a broad spectrum of antidepressants. More recently, attention has turned to the atypical antipsychotics, e.g. aripiprazole, olanzapine, risperidone and quetiapine. Several controlled studies show favourable outcomes of augmentation treatment with these antipsychotics in unipolar and bipolar depression.

It is not much more than a hundred years ago that psychiatry started to become a scientific discipline in the sense of a modern medical science. This statement is especially true if we focus on psychiatry as a discipline of neurobiology/neuroscience. The key inventions in psychopharmacology were reached not earlier than the 50ies of the last century. The detection of antipsychotic, antidepressive, tranquilising and mood stabilising medication at that time can be regarded as a therapeutic revolution in psychiatry, given the fact that from today's point of view no meaningful biologically oriented treatment procedures were available apart from ECT. In this pioneer time of psychopharmacology, psychopharmacological treatment became one of the main treatment approaches. This was in principal a success story, however also several limitations such as unsatisfying efficacy, tolerability problems etc. were to be observed in the following decades. In the last 20 to 30 years second generation of antipsychotics and antidepressants entered the market, developed to overcome some of these problems.

There are still unmet needs in treating mental disorders with polypharmacy which can hopefully be reduced significantly in the near future. These unmet needs are related among others to delay of onset of therapeutic action, unsatisfying effect size, problems in treating medication refractory patients, side effect which are subjectively or objectively disturbing, some of them leading to problems e.g. in terms of metabolic issues. Although there has always been the theoretically based postulate that patients should be treated with monotherapy, clinicians tried to overcome at least some of these problems by switching strategies, comedication and augmentation strategies, believed to be meaningful due to clinical experience, although still lacking in evidence.

Polypharmacy is widespread in many areas of psychiatry, but it is associated with a number of risks and uncertainties:

1. 1. The side-effect burden increases

2. 2. There is a risk of drug-drug interactions and increased or decreased plasma-levels

3. 3. When a patient is prescribed several drugs at one time and responds, it is often difficult to say which drug was effective. Due to this uncertainty, patients are often unnecessarily continued on a number of agents.

4. 4. The mechanism of action of many psychotropics is unclear. What the exact mechanism of combining several drugs on the brain is, is even more unclear.

5. 5. While it is already difficult for patients to compliantly take one drug, compliance becomes even more difficult if patients have to take several drugs. This is a particular challenge of people with cognitive deficits such as many patients with schizophrenia.

6. 6. Finally, there is simply no evidence for many augmentation strategies.

Therefore, monotherapy should be the rule, and polypharmacy should be restricted to treatment resistant cases, knowing the limited available evidence.

When we use the term “mental illness,” not “brain illness,” do we put our patients in harm's way? This is an appropriate time to ask, because it has become apparent in recent years that disorders of the brain and nervous system are among the most serious and prevalent health problems globally.

If this debate were held 25 years ago I would probably be taking the position that chlorpromazine is the best ever. The fact that this lecture is taking place now could well be a result of the fact that almost all of the second generation antipsychotics are now off patent. This debate would have been far more important 10 or 15 years ago when the question clearly had huge economic importance. In those days I did not succeed in getting this issue into any major psychiatric forum. After CATIE and CUTLASS and numerous subsequent works few would argue today that the atypical antipsychotics are more effective clinically than the first generation ones (I exclude from this debate clozapine). The claim that second generation antipsychotics have a stronger effect on negative symptoms has completely disappeared from the psychiatric literature. These new antipsychotics cause less EPS and tardive dyskinesia, but the price our patients have paid in metabolic side effects is huge and it is really a tough choice as to which side effect is worse. The amount of propaganda “spin” that we have heard over the last 20 years about these issues is indeed discouraging: for instance the claim that atypical antipsychotics do not cause metabolic disturbance but that these disturbances are part in parcel of the illness. Recent studies demonstrate conclusively that even a single dose of olanzapine to normal volunteers causes a 45% increase in the area under the curve in a glucose tolerance test.

It is possible that in the future we will have antipsychotics that cause neither EPS nor metabolic disturbances and I am moderately optimistic about two new compounds in this regard. However, this is a far cry from our field's claim that a slew of new patented compounds were all far better than haloperidol and equivalent to clozapine without agranulocytosis. I am optimistic that in the long run that we will find better antipsychotics, but overpromising will not get us there any faster. In this sense haloperidol is the best ever.

Research is one of the most attractive fields for young doctors training in psychiatry. The acquisition of research skills by all trainees has been recommended by recent consensus documents on standards of psychiatric training in Europe. However, not always trainees have adequate access to all the phases of a research project during their residencies. Joining professional associations provides opportunities for participating in research activities and establishing networks with other colleagues. In this respect, the European Federation of Psychiatric Trainees (EFPT) in 2008 started a research group with the aim of facilitating trainee-led collaborative studies. Over the years several international research projects on training-related areas have been conducted and published in international peer-reviewed journals. EFPT members can participate to all the phases of the projects as national coordinators and share with other colleagues their research competencies. Furthermore, many EFPT research projects have had the possibility to rely on supervision by internationally renowned experts.

Currently, the topics of the main ongoing studies are: 1) Early career psychiatrists views on psychiatric training (in collaboration with European Psychiatric Association - Early Career Psychiatric Committee); 2) Relationship between trainees and pharmaceutical industries; 3) Child and Adolescent psychiatric training; 4) Trainees’ views on the future of psychiatry and psychiatric training; 5) Trainees’ access to information and use of information technologies during training. In this presentation, issues in research training will be discussed, the EFPT cooperative trainee-led research network will be described and an overview of the results of the ongoing studies will be provided.

More than other disciplines in medicine psychiatry is closely connected with legal and medico-legal issues. Mental disorders can influence the individual capacities of cognition and affectivity which are necessary to comply with social norms and rules. Disturbances of impulse control, affect regulation and reality control may lead our patients to aggressive, disruptive, or disorganized behaviours which result in different forms of conflicts with the law. The psychiatrist must be able to detect the influence of disturbed mental functioning in offenders and to protect his patients against the usual consequences in society for deviant and criminal behaviour. Mentally ill offenders need treatment, not punishment. This is the reason that we need a well developped subdiscipline of forensic psychiatry. Important tasks are the evaluation of legal responsibility, the treatment and rehabilitation, last not least the prognosis of dangerousness. In addition, forensic psychiatry is based on detailed and differentiated analysis of abnormal mental conditions including psychopathic behaviours. Therefore, this subdiscipline is a resort for general and for clinical psychopathology, which have lost some of their importance in other fields of psychiatry

The relationship that people have with their work and the difficulties that can arise when that relationship becomes problematic, have been long recognized as a significant phenomenon of our time. The use of the term “Burn-out” for this phenomenon began in the 1970s in the United States especially among people working in human services. What has emerged from all this research since then is a conceptualization of job-bourn-out as a psychological syndrome in response to chronic interpersonal stressors on the job. The three dimensions of this response are (1) an emotional exhaustion, (2) feelings of cynicism and detachment from the job and (3) a sense of ineffectiveness and lack of accomplishment. Bourn-out has been associated with various forms of job withdrawal, i.e. absenteeism, intention to leave the job and actual turnover. However, for people who stay on the job, burn-out leads to lower productivity and effectiveness at work. Consequently this is associated with decreased job satisfaction and a reduced commitment to the job or organization. People who are experiencing burn-out also can have a negative impact on their colleagues. There is also some evidence that burn-out has a negative impact on people's private life and their social relationships. This presentation deals with the individual development of burn-out, the organizational framework, which promote burn-out and the interplay of different determinants of burn-out. Finally several effective intervention approaches on the individual and organizational level will be pointed out.

Psychiatrists of today are expected to be experts in prevention, diagnostics and treatments of mental illness; understand human genome and pharmacogentics, integrate it with psychotherapy and sociotherapy; and have great management and communication skills that would facilitate all previously listed. Crucial period to gain “superpowers” are residency training and early-career years. Even though choices made during this period can have long lasting consequences and strongly define one's professional pathway, majority of training programs worldwide does not include consultations or supervisions that would enable people to choose what best fits their personality and professional capacity. This can have significant implications on clinical performance and patient care, academic performance (in terms of research and publications), but also mental health and well being of residents are early career psychiatrists. The latter probably needs additional consideration since our study on this topic (The International Psychiatry Residents/Trainee Burnout Syndrome study) shows that European psychiatry residents suffer from moderate level of burnout syndrome, 5% meet criteria for major depression, 1% attempted suicide, while the number of those with serious suicidal ideation goes up to 20% in some countries. Our aim is to increase awareness of this issue and discuss prevention and treatment strategies.

The process of choosing a career is one that requires not only self knowledge but a certain amount of vision about what one finds meaningful. It is important to take time and consider exactly what one wants, not only in terms of the ideal job, but also all aspects that surround it, such as its location, pay, and distance from home. One should also consider the aspects of home life that are important and how a compromise between work and non-work can be achieved. Balance is an important part of this process, and therefore taking care of oneself is extremely important. Although the choice of a career is not easy, it becomes easier with self knowledge, an ideal in mind of what is personally fulfilling work, and a balanced approach to life. Also deciding on priorities in professional life is not an easy task. A doctor in medicine should decide as soon as possible if orientating his/her activity toward public health, research, clinical activity, or academic life. So, how can someone select the appropriate priority when he/she does not have the relevant basic knowledge to choose? Some practical advices on how to choose a career in psychiatry and how to set priorities are identified. The role of leisure activities and satisfaction in order to prevent work stress and burnout is emphasized.