Late-life depression (LLD) is currently a hot topic for neuroimaging studies, while an increasing number of imaging modalities are now available for the characterization of brain structure and function. Changes in brain volumes, including hippocampal volume, have been observed in LLD, although results are inconsistent. Vascular lesions are more consistently associated with LLD and may constitute factors of poor prognosis. More recent MRI modalities, including fMRI and DTI, also show interesting results, notably to assess treatment response in LLD. Molecular Imaging also has the potential to improve our understanding of the pathophysiology of LLD, using imaging such as PET-FDG and Amyloid PET. Finally, there are emerging studies with novel neuroimaging modalities such as Ultrasound to measure subtle mechanical properties in the brain of patients with LLD. Finally, we contend that neuroimaging has the potential to provide markers for the identification of subcategories of LLD (vascular depression, amyloid depression, etc.) as well as prognostic values and markers for treatment response.

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Although ketamine can rapidly decrease suicidal ideation (SI), its neurobiological mechanism of action remains unclear. Several areas of the cingulate cortex have been implicated in SI; therefore, we aimed to explore the neural correlates of the anti-suicidal effect of ketamine with cingulate cortex functional connectivity (FC) in depression.

Forty patients with unipolar or bipolar depression with SI underwent six infusions of ketamine over 2 weeks. Clinical symptoms and resting-state functional magnetic resonance imaging data were obtained at baseline and on day 13. Remitters were defined as those with complete remission of SI on day 13. Four pairs of cingulate cortex subregions were selected: the subgenual anterior cingulate cortex (sgACC), pregenual anterior cingulate cortex (pgACC), anterior mid-cingulate cortex (aMCC), and posterior mid-cingulate cortex (pMCC), and whole-brain FC for each seed region was calculated.

Compared with non-remitters, remitters exhibited increased FC of the right pgACC–left middle occipital gyrus (MOG) and right aMCC–bilateral postcentral gyrus at baseline. A high area under the curve (0.91) indicated good accuracy of the combination of the above between-group differential FCs as a predictor of anti-suicidal effect. Moreover, the change of SI after ketamine infusion was positively correlated with altered right pgACC–left MOG FC in remitters (r = 0.66, p = 0.001).

Our findings suggest that the FC of some cingulate cortex subregions can predict the anti-suicidal effect of ketamine and that the anti-suicidal mechanism of action of ketamine may involve alteration of FC between the right pgACC and left MOG.

A paradox of the modern world is represented by the increasing rate of comorbidities, although the life expectancy is increasing worldwide, the number of disease-free years is not improving consequently. Physical comorbidities are often overlooked in people with severe mental disorders, although this problem needs to be adequately managed since it is associated with a worse quality of life and a poorer personal and social functioning. In particular, in people with severe mental disorders is very common the contemporary presence of infectious diseases (mainly TBC and HIV) and other physical conditions, which worsen the long-term prognosis.

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Genetic approaches are increasingly advantageous in characterizing treatment-resistant schizophrenia (TRS). We aimed to identify TRS-associated functional brain proteins, providing a potential pathway for improving psychiatric classification and developing better-tailored therapeutic targets.

TRS-related proteome-wide association studies (PWAS) were conducted on genome-wide association studies (GWAS) from CLOZUK and the Psychiatric Genomics Consortium (PGC), which provided TRS individuals (n = 10,501) and non-TRS individuals (n = 20,325), respectively. The reference datasets for the human brain proteome were obtained from ROS/MAP and Banner, with 8,356 and 11,518 proteins collected, respectively. We then performed colocalization analysis and functional enrichment analysis to further explore the biological functions of the proteins identified by PWAS.

In PWAS, two statistically significant proteins were identified using the ROS/MAP and then replicated using the Banner reference dataset, including CPT2 (PPWAS-ROS/MAP = 4.15 × 10−2 and PPWAS-Banner = 3.38 × 10−3) and APOL2 (PPWAS-ROS/MAP = 4.49 × 10−3 and PPWAS-Banner = 8.26 × 10−3). Colocalization analysis identified three variants that were causally related to protein expression in the human brain, including CCDC91 (PP4 = 0.981), PRDX1 (PP4 = 0.894), and WARS2 (PP4 = 0.757). We extended PWAS results from gene-based analysis to pathway-based analysis, identifying 14 gene ontology (GO) terms and the only candidate pathway for TRS, metabolic pathways (all P < 0.05).

Our results identified two protein biomarkers, and cautiously support that the pathological mechanism of TRS is linked to lipid oxidation and inflammation, where mitochondria-related functions may play a role.

The current scientific literature has increased our understanding of how medication could be beneficial for patients with eating disorders (EDs) on a molecular, functional, and behavioural level. Based on theoretical considerations about neurotransmitters, hormones and neural circuits, possible drug targets for the treatment of EDs may include signal molecules and receptors of the self-regulatory system such as serotonin, norepinephrine and glutamate; the hedonic system including opioids, cannabinoids and dopamine; and the hypothalamic homeostatic system including histamine, ghrelin, leptin, and insulin.

The currently approved pharmacological treatments for EDs are limited to fluoxetine for bulimia nervosa (BN) and - in some countries – lisdexamfetamine (LDX) for binge eating disorder (BED). Topiramate might be an additional option for people with BN and BED.

There are no approved pharmacological options for anorexia nervosa (AN), even though study results for olanzapine and dronabinol are promising. Psilocybin, ketamine, and metreleptin have recently been considered and tried in AN.

Case reports and studies regarding the drug treatment of the new DSM-5 EDs include the use of mirtazapine for avoidant restrictive food intake disorder (ARFID); fluoxetine for pica; and levosulpiride and baclofen for rumination disorder.

This talk is based on a comprehensive review of the scientific literature regarding the pharmacological treatment for EDs and will include a preview of the 2023 update of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders.

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Andrea Gmeiner1, Melanie Trimmel1, Amy Gaglia1,2, Beate Schrank3, Stefanie Süßenbacher-Kessler1, Michaela Amering1

1Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria 2Division of Psychology, Bangor University Wales,UK 3Department of Psychiatry, Karl Landsteiner University for Health Sciences, Austria

Gender parity, authorship, geographic and subject matter diversity are declared goals in the academic publishing world. Recent data on the progress towards these goals suggest that changes and a shift towards diversity have been happening over the last decades. Examples include significantly increasing numbers of female first and senior authors between 2008 and 2018 (Hart et al, 2019) over a wide range of journals. Our own data on trends in three high-impact psychiatric journals over a 25-year time period from 1994 until 2019 suggest that female first, female senior, and female overall authorship have increased significantly over the quarter of a century covered. Results do indicate that gender parity in first authorship was reached in the category of original research articles for the first time in 2019 (Gmeiner et al, 2022). However, data also showed the remaining underrepresentation of women in senior authorship positions in line with the leaky pipeline phenomenon. Gender differences in publication trends with regards to subject matters and topics in the 2004/14/19 part of this sample showed the percentage of female first authors exceeding 50% in the two most frequent subject matters ‘basic biological research’ and ‘psychosocial epidemiology’ in 2019 (Trimmel et al, submitted for publication). Although the percentage of female first authors in the three most common target populations under study (mood disorders, schizophrenia, general mental health) increased from 2004 to 2019, gender equality has not yet been achieved in these fields. Consistent monitoring of publication trends and gender distribution by researchers and academic journals needs to identify and counteract the areas of underrepresentation of women.

Hart, K. L., Frangou, S., & Perlis, R. H. (2019). Gender Trends in Authorship in Psychiatry Journals From 2008 to 2018. Biological psychiatry, 86(8), 639–646.; Gmeiner A, Trimmel M, Gaglia-Essletzbichler A, Schrank B, Süßenbacher-Kessler S, Amering M, (2022). Diversity in high-impact psychiatric publishing: gender parity within reach? Archives of women’s mental health, 25(2), 327–333.

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Fifty years after its introduction, the American Psychiatric Association’s (APA) Goldwater Rule remains contentious, prohibiting member-psychiatrists from providing mental health commentary on individuals they have not treated and where they lack consent. Whilst its resonance extends beyond the United States, there is limited awareness about the Goldwater Rule’s applicability elsewhere, notably within Europe.

In 2022, we investigated whether the European Psychiatric Association’s (EPA) forty-four National Psychiatric Association Members (NPAs) had similar guidelines to the Goldwater Rule or comparable ethical positions around media and public commentary. We initially searched NPA websites and subsequently contacted NPAs via email and phone. Findings were coded to four categories: “NPA-level rules or position”, “No NPA-level rules orposition but noted country-level rules”, “No NPA-level rules or position and did not note country-level rules”, and “No response”.

n=27 NPAs had relevant web materials or replied to our correspondence (61.3% of total NPAs). From these 27, based on our interpretation, n=6 (22.2%) had rules or positions, n=6 (22.2%) indicated that country-level rules existed, and n=15 (55.5%) did not have applicable NPA-level or country-level regulations.

A sizeable proportion of NPAs included in our study have not yet formally developed or considered ethical issues addressed by the Goldwater Rule and psychiatric commentary on an individual’s psychopathology. Accordingly, the EPA could consider broader discussions about this, accounting for national traditions and sociocultural aspects of clinical practice. These could integrate the advantages and disadvantages of the APA’s rubric towards an evolved ethical debate.

The leaky pipeline is a visual metaphor for the under-representation of women in leadership positions in Academic Psychiatry despite their over-representation in medical schools, residency programs, and junior academic positions. The presentation focuses on the key obstacles that pertain to personal and societal attitudes and institutional barriers and proposes empirically tested and pragmatic solutions.

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Treatment-resistant depression (TRD) is an important clinical challenge and may present differently between age groups.

A total of 893 depressed patients recruited within the framework of the European research consortium “Group for the Studies of Resistant Depression” were assessed by generalized linear models regarding age effects (both as numerical and factorial predictors) on treatment outcome, number of lifetime depressive episodes, hospitalization time, and duration of the current episode. Effects of age as numerical predictor on the severity of common depressive symptoms, measured with Montgomery–Åsberg Depression Rating Scale (MADRS) for two-time points, were assessed by linear mixed models, respectively, for patients showing TRD and treatment response. A corrected p threshold of 0.001 was applied.

Overall symptom load reflected by MADRS (p < 0.0001) and lifetime hospitalization time (p < 0.0001) increased with age in TRD patients but not treatment responders. In TRD, higher age was predicting symptom severity of inner tension, reduced appetite, concentrations difficulties, and lassitude (all p ≤ 0.001). Regarding clinical significance, older TRD patients were more likely to report severe symptoms (item score > 4) for these items both before and after treatment (all p ≤ 0.001).

In this naturalistic sample of severely ill depressed patients, antidepressant treatment protocols were equally effective in addressing TRD in old age. However, specific symptoms such as sadness, appetite, and concentration showed an age-dependent presentation, impacting residual symptoms in severely affected TRD patients and calling for a precision approach by a better integration of age profiles in treatment recommendations.

The aim of this study was to assess barriers and facilitators in the pathways toward specialist care for eating disorders (EDs).

Eleven ED services located in seven European countries recruited patients with an ED. Clinicians administered an adapted version of the World Health Organization “Encounter Form,” a standardized tool to assess the pathways to care. The unadjusted overall time needed to access the ED unit was described using the Kaplan–Meier curve.

Four-hundred-nine patients were recruited. The median time between the onset of the current ED episode and the access to a specialized ED care was 2 years. Most of the participants did not directly access the specialist ED unit: primary “points of access” to care were mental health professionals and general practitioners. The involvement of different health professionals in the pathway, seeking help for general psychiatric symptoms, and lack of support from family members were associated with delayed access to ED units.

Educational programs aiming to promote early diagnosis and treatment for EDs should pay particular attention to general practitioners, in addition to mental health professionals, and family members to increase awareness of these illnesses and of their treatment initiation process.

This presentation is titled " Case scenarios 1: Trauma based approach: from instability to stability". You will be given a case based oriented insight into the relationship between substance use disorder and forced displacement and treatment options that are based upon the trauma some has been experienced. A focus will be on factors that contribute on psychological stability in extreme situations. Thus you will be presented preliminary results of our ongoing study funded by the Heidelberg Academy of Sciences and Humanities that dedicated to the question of how mental stability and health-related quality of life of individuals change over time.

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Although in many countries in the meantime more women than men choose medicine and later psychiatry for their training, key positions in hospitals and research are still mainly held by men. The professional career of women is impeded not only by institutional, but also by psychological barriers such as gender role behavior and gender role stereotypes. Mentoring can help young women to overcome these barriers.

But usually mentoring starts too late. As studies have shown, important decisions about future career steps are taken already towards the end of medical studies. Therefore, gender sensitive teaching and mentoring should start already at university and should not only address young women, but also young men as potential partners and future colleagues - especially regarding their gender role behavior and stereotypes. Mentoring programs considering gender-specific needs should be implemented in the regular teaching during medical studies and in psychiatric training.

Furthermore, women should be coached during their further career steps since there is not only a “glass ceiling” that excludes young women from achieving leadership roles. When they finally have achieved such a role, women often face further difficulties stemming from gender stereotypes and traditional gender roles.

University teachers and employers should be addressed, as well as politicians. Otherwise, psychiatry not only loses a great potential of talents, but might also miss the chance of reforms towards a more gender-sensitive psychiatry and psychotherapy.

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The aim of the present study is to evaluate the role of individual affective temperaments as clinical predictors of bipolarity in the clinical setting.

The affective temperaments of 1723 consecutive adult outpatients presenting for various symptoms to a university-based mental health clinical setting were assessed. Patients were administered the Hypomania Checklist-32 and the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego – Auto-questionnaire (TEMPS-A) and were diagnosed by psychiatrists according to the DSM-5 criteria. TEMPS-A scores were studied as both continuous and normalized categorical z-scores from a previously established nationwide study on the general population of Lebanon. Simple and multiple binary logistic regressions were done on patients who have any of the DSM-5 defined bipolar types, as a combined group or separately, versus patients without any bipolar diagnosis.

At the multivariable level and taking into account all temperaments, the irritable temperament is a consistent predictor of bipolar I and bipolar II disorders. Cyclothymic temperament also played a strong role in bipolarity but more decisively so in bipolar II and substance-induced bipolarity. The hyperthymic temperament had no role in bipolar I or bipolar II disorder.

Recent genetic evidence implicates glutamatergic-receptor variations in schizophrenia. Glutamatergic excess during early life in people with schizophrenia may cause excitotoxicity and produce structural deficits in the brain. Cortical thickness and gyrification are reduced in schizophrenia, but only a subgroup of patients exhibits such structural deficits. We delineate the structural variations among unaffected siblings and patients with schizophrenia and study the role of key glutamate-receptor polymorphisms on these variations.

Gaussian Mixture Model clustering was applied to the cortical thickness and gyrification data of 114 patients, 112 healthy controls, and 42 unaffected siblings to identify subgroups. The distribution of glutamate-receptor (GRM3, GRIN2A, and GRIA1) and voltage-gated calcium channel (CACNA1C) variations across the MRI-based subgroups was studied. The comparisons in clinical symptoms and cognition between patient subgroups were conducted.

We observed a “hypogyric,” “impoverished-thickness,” and “supra-normal” subgroups of patients, with higher negative symptom burden and poorer verbal fluency in the hypogyric subgroup and notable functional deterioration in the impoverished-thickness subgroup. Compared to healthy subjects, the hypogyric subgroup had significant GRIN2A and GRM3 variations, the impoverished-thickness subgroup had CACNA1C variations while the supra-normal group had no differences.

Disrupted gyrification and thickness can be traced to the glutamatergic receptor and voltage-gated calcium channel dysfunction respectively in schizophrenia. This raises the question of whether MRI-based multimetric subtyping may be relevant for clinical trials of agents affecting the glutamatergic system.

Syndemics are synergistically interacting epidemics (for example, the epidemics of substance use disorders and forced displacement) in a particular context with shared drivers such as pre-existing political, structural, social and health conditions. Policymakers may ask what the risks of and needs are for forcibly displaced people with regards to substance use disorder (SUD). Working from a syndemics framework, we would argue that multiple risk and resiliency factors relating to both forced displacement and SUD work synergistically, and impact more significantly upon some populations than others. These risk factors include structural inequality and racism, social deprivation, violence, homelessness, trauma, childhood adversity, and co-morbid physical and mental health disorders. Individuals may become vulnerable while experiencing displacement, during transition, settlement or resettlement, and also through their life across and across generations. In this perspective, our answers to policymakers becomes more nuanced. We may argue for integrated, multi-modal interventions, cross-disciplinary collaborations, cross-pollination of ideas and knowledge and embedding lived experience to bridge gaps and make use of limited resources in sustainable ways. This presentation will detail aspects of the application of a syndemic lens to the evidence base on SUD among forcibly displaced people and generate discussion on what scientists, clinicians and policymakers can and may do with these insights.

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Journal editors can promote gender equality in various ways. The main ones are consideration of gender when inviting editorial board members, peer reviewers, and authors of solicited opinion pieces or reviews. As in many areas, the problem can be that the pool of suitable women is perceived to be small and the same women are asked to perform multiple tasks in addition to their academic and clinical duties. Journal editors need to seek women who are less well known but competent for the task required. To increase the pool of qualified candidates, editors should promote training using existing resources, such as online peer reviewer courses, or develop in-house initiatives, such as The Lancet Psychiatry’s Editorial Board Development Programme. It is important to make public commitments to gender balance, for example as part of a diversity pledge, with specific targets, and to collect and report data with regular updates. Gender balance should be an integral part of information templates in manuscript handling systems, such as asking authors and peer reviewers to consider women when recommending alternative peer reviewers. Where relevant, journal editors can also consider gender balance in their use of images, cover art, podcast or interview subjects, profiles, news and features, and social media content.

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Major depressive disorder (MDD) is a leading cause of disability worldwide, and yet delivery of care for this illness is rife with gaps. The COVID-19 pandemic has had far reaching implications for every facet of healthcare, and MDD is no exception. This scoping review aimed to ascertain the impacts of COVID-19 on the delivery of MDD care in Europe, as well as to evaluate any novel MDD care strategies trialled in this period.

We searched the PubMed and PsycINFO databases up to January 2022 with a strategy centred around COVID-19 and MDD. Full texts of eligible studies examining working-age adults and conducted in Europe were evaluated against several criteria. All outcomes were then extracted and a narrative synthesis was constructed to summarise identified themes.

Of 1,744 records identified in our search, 11 articles were eligible for inclusion in the review. In general, these studies reported a decrease in treatment rates, access to care, and perceived access to care during the COVID-19 pandemic. In addition, digital interventions trialled during the pandemic were broadly well-received by users, though their efficacy in improving MDD care was ambiguous.

Despite a limited number of pertinent studies, this scoping review identified a trend of exacerbated treatment gaps in MDD care during the pandemic. Several of our pre-specified gaps, including delays to detection or treatment of depression and rates of follow-up contacts, remained unexplored in the context of COVID-19. This highlights the need for further investigation to obtain a full understanding of the relationship between COVID-19 and MDD care in Europe.

Psychopathology and side effects of antipsychotic drugs contribute to worsening physical health and long-term disability, and increasing the risk of mortality in these patients. The efficacy of exercise on these factors is not fully understood, and this lack of knowledge may hamper the routine application of physical activity as part of the clinical care of schizophrenia.

To determine the effect of exercise on psychopathology and other clinical markers in patients with schizophrenia. We also looked at several moderators.

MEDLINE, Web of Science, Scopus, CINAHL, SPORTDiscus, PsycINFO, and Cochrane Library databases were systematically searched from inception to October 2022. Randomized controlled trials of exercise interventions in patients 18–65 years old diagnosed with schizophrenia disorder were included. A multilevel random-effects meta-analysis was conducted to pool the data. Heterogeneity at each level of the meta-analysis was estimated via Cochran’s Q, I2, and R2.

Pooled effect estimates from 28 included studies (1,460 patients) showed that exercise is effective to improve schizophrenia psychopathology (Hedges’ g = 0.28, [95% CI 0.14, 0.42]). Exercise presented stronger effects in outpatients than inpatients. We also found exercise is effective to improve muscle strength and self-reported disability.

Our meta-analysis demonstrated that exercise could be an important part in the management and treatment of schizophrenia. Considering the current evidence, aerobic and high-intensity interval training exercises may provide superior benefits over other modalities. However, more studies are warranted to determine the optimal type and dose of exercise to improve clinical outcomes in people with schizophrenia.

This presentation will share data from a new meta-analysis of RCT studies using cognitive remediation to treat children and adolescents with ADHD. For this matter, 25 studies were accessed, and results will focus on outcomes immediately after the end of the program and in follow-up. Outcomes include subjective measures of functioning (through validated scales), neuropsychological measurements and academic performance. Comparisons regarding length of training, intensity, concomitant use of pharmacological treatments will also be provided. These findings will build on previous meta-analysis on the issue that were performed in the past.

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