Patients with mood disorders frequently present with treatment resistant syndromes or develop tolerance to once effective first line medications. Refractory depressive, manic or mixed episodes challenge psychiatrists to find means of augmenting traditional therapies, despite the paucity of evidence based data that support this practice. The balance between risks and benefits in most cases seems acceptable, provided that the physician and the patients have a clear understanding of the possible adverse and therapeutic interactions and that treatment resistance is not the result of inadequate (dose/time) prescription of a first line monotherapy. The workshop will review the pharmacokinetic and pharmacodynamic interactions among the psychotropic drugs and the strategies to safely and successfully use a rational polypharmacy for the management of treatment resistant mood disorders.

Over the last few years, a new comprehensive program for acutely suicidal borderline patients has been developed in the Geneva area (careful description is provided in a distinct section of this workshop). The present work will report the results of a service research oriented study aimed at evaluating the impact of the implementation of such multidimensional intervention on a system of psychiatric services in a 500.000 inhabitant catchment area. Specifically, a pre-post design has been utilized to compare two distinct patient cohorts meeting criteria for borderline personality disorder who had bee referred to medical emergency room with suicidal attempt. Both cohorts had follow-up at 3-month and 1 year to assess treatment failure, repetition, hospitalization and direct costs. The results indicate that the program is feasible and may be associated with improved outcome and substantial costs savings among acutely suicidal borderline patients.

The following educational topics will be carefully addressed:

1. a. to establish a coherent model of the borderline syndrome as a complex, heterogeneous reaction resulting from the interaction of psychobiological vulnerabilities, psychosocial stressors and abnormal mental processes;

2. b. to teach how new data from recent investigations of the clinical course of the borderline crisis are changing our view of both the scopes and the limitations of mental health policies for borderline patients;

3. c. to review the several issues associated with adequate acute service provision for borderline patients in order to define a set of well structured recommendations for good quality, comprehensive emergency services organisation and acute treatment delivery;

4. d. to teach a well structured, simple, cost-effective, easy to implement psychodynamic crisis intervention program with specific accent on: case management, risk management, facilitating an alliance, inactivating pathological personality traits triggered from acute traumatic experiences, empathic exploration of distressing feelings, conveying insight on repetitive patterns of ego syntonic masochistic behaviour, active support for problem solving;

5. e. to teach the main aspects of an innovative brief psychodynamic psychotherapy program (mourning focused psychodynamic psychotherapy) model and its relevance to increased cost-effectiveness of psychiatric treatment among acute patients with borderline emotional crisis triggered from traumatic abandonment and other stressful life events.

The course is intended for people with an experience in the field of personality disorders and an interest in combining psychobiological science and psychotherapeutic wisdom to improve acute treatment and psychiatric services.

“Telepsychiatry” refers to video conferencing (interactive audio-video link in real-time where patient and doctor can both see and hear each other at the same time). Limited access to clinicians that have similar cultural and ethnic background decrease speed and accuracy of diagnosis and treatment (especially psychotherapeutic intervention). One solution to this problem is to give refugees, migrants and asylum seekers access to ethnic specialists by using Telepsychiatry.

4 stations have been established in Denmark during pilot project in periode 2005-2007. The equipment has been installed in two hospitals, one asylum seekers centre and one social rehabilitation institution.

Participants were mentally ill refugees, migrants and asylum seekers. 61 participants were involved in the assessment and/or treatment through 318 telepsychiatry provided remote consultations. They received mental health care by video-conferencing from providers who spoke participants ‘own language, i.e. without the assistance of interpreters.

All participants were asked to fulfil 10-items satisfaction questionnaire after the end of Telepsychiatry contact. The most of participants would prefer treatment via Telepsychiatry than via interpreter.

Aside from cross cultural patient population, Telepsychiatry can be used in order to provide mental health care towards domestic population in rural and remote areas with resource shortage.

In today's world of globalization and immigration, mental health workers are required to adapt their practice and develop new skills in order to treat immigrant populations. Ethnopsychiatry is a field created by Georges Devereux at the beginning of the 20th century. Devereux's unique psychoanalytic approach resides in reference to the relationship existing between psychic troubles and social norms in a given cultural context. During his multiple stays predominantly among North American Mohave Indians, Devereux structured knowledge and created concepts including anxiety observer counter-transference, schizophrenia as an “ethnic disorder”, the ethnic personality etc. Since the early 80's, the French psychologist and psychoanalyst Tobie Nathan, Devereux's student and follower, further developed his master's theories. He conceptualized a methodology with implementation in the French immigrant population. He thus shaped contemporary Ethnopsychiatry, as currently practiced in the Georges Devereux center, (Paris 8 University) in France and in many other clinics internationally. The ethnopsychiatric setting conceived by Tobie Nathan imparts a crucial and authentic role to cultural diversity. Tobie Nathan proposes to study with equal respect and seriousness theories and practices related to unhappiness and disease, irrespective of culture or civilization. Ethnopsychiatric setting helps to overcome the deleterious consequences of the split existing between the two cultural referents (host and origin) in which our patients live. During the presentation, principles of Ethnopsychiatric practice will be introduced accompanied by a case report of an Ethiopian patient from the Beer-Yaacov Mental Health Center Ethnopsychiatric clinic for illustrative purposes.

In the last decades a large number of co-morbidity studies were published indicating a strong relationship between affective disorders and alcohol addiction. Patients with affective disorders suffer also from dependence disorders at about 6 times more often than the rest of the population. In 30 to 60 percent of patients with alcohol addiction also affective disorders are present. In this context authors emphasized that depressive states observed in the course of alcohol addiction may be reactions to problems occurring in the frame of dependence disorders. In contrast to that depressive mood disorders in general (and above all states of anxiety and increased tension often connected with depressive states) can also be considered as starting points of addictive behaviour. Furthermore alcohol itself may induce and catalyze depressive mood. Less attention has been paid to the role of manic or hypomanic states in dependence disorders. The few studies indicate an increased co-morbidity rate between bipolar II disorders and alcohol addiction. In a psychopathological study carried out on 200 alcohol addicts in the Anton Proksch Institute Vienna we focused on the co-morbidity with bipolar II as well as on the pathogenetic role of hypomanic states in the frame of constellations of conditions of alcohol dependence using among other scales and a standardized interview, the Hypomania Self Rating Scale (HSRS, Angst). Preliminary results underline a strong relationship between Bipolar II Disorders and Alcohol Addiction: hypomanic states induce high risk behaviours which may become responsible for relapse and increased alcohol consumption.

In a pilot study with 55 inpatients, primarily admitted for cocaine addiction, the following hypotheses were found: Patients with cocaine addiction and comorbide core schizophrenia (according to Kreapelin, n=17) respond completely different on cocaine use than all other groups of patients including a schizophrenia spectrum group (without core schizophrenia according to Kraepelin). When using cocaine the schizophrenic patients do not experience new psychotic symptoms and existing symptoms do not get worse. Most of them are less bothered of negative symptoms and some of them are, even more, less bothered of positive symptoms. In all other patients with various comorbidity (n=28) and without comorbide psychiatric disorders (n=10) positive psychotic symptoms occur dependent on the dosage of cocaine. In some of them the positive symptoms are also triggered by stress alone. The symptoms occurred in a dosage dependent hierarchical structure: mistrust - delusions of reference with fear - delusions of persecution and illusions with anxiety or panic - threatening voices and noises - disorganized and catatonic behavior.

The psychopathology induced by cocaine prooved to be similar to one of the core symptoms of cycloid psychoses.

The hypothesis is raised that there is an individual genetically and/or environmentally caused liability to the developing of positive psychotic symptoms under various stress factors including drugs. These reactive psychoses have to be distinguished from schizophrenia. Their relationship to the spectrum of cycloid psychoses is discussed.

Frequent use of cannabis has been associated with poor outcome in patients with psychosis or schizophrenia, and research has become more and more interested in the question whether cannabis may actually cause psychosis or schizophrenia. Since only a minority of cannabis users eventually develops psychosis or schizophrenia, cannabis is suggested to be a component cause, potentially interacting with environmental as well as genetic factors. However, little is known about this putative interaction. Recent research in our group has therefore focused on differential sensitivity to cannabis and its psychosis-inducing effects. Experimental and observational work for instance showed that a functional polymorphism within the COMT gene moderates the acute effects of cannabis on psychosis outcome. In this presentation new evidence from epidemiological work is presented, showing gene-environment interactions within the cannabis-psychosis association. These results point to a moderating role for both age of onset of cannabis use and childhood trauma. Also a certain haplotype within the COMT gene was found to increase the risk of developing schizophrenia after adolescent cannabis use. Complex gene-environment interactions as well as interactions between cannabis and other environmental risk factors seem to underlie the cannabis-psychosis relationship. Possible biological mechanisms such as sensitization processes that may underlie these interactions will be discussed.

Cannabis contains a myriad of different chemicals, more than 60 of which are unique to the plant and called cannabinoids. The main psychoactive ingredient is delta9-tetrahydrocannabinol (THC) and this produces the effects that users seek (Curran et al., 2002 Psychopharmacology 164: 61-70). When given intravenously to healthy humans, THC produces psychotic-like and anxiogenic effects (D’Souza et al., 2004 Neuropsychopharmacology 29: 1558-1572). In contrast, cannabidiol (CBD), another major constituent of most strains of cannabis, appears to have anti-psychotic properties, is anxiolytic (Guimares et al., 1990 Psychopharmacology 100: 558-559)and may be neuroprotective in humans (Hermann et al., 2007 Biol. Psychiatry 61: 1281-1289). The relative THC/CBD ratio of cannabis varies greatly. Although high THC cannabis has become increasingly available over recent years, little is known on changes in levels of other cannabinoids as these are seldom measured. One study in the U.S. however found that the THC content of cannabis trebled in resin and doubled in leaf, whilst the average level of other cannabinoids, including CBD, remained unchanged. We recently found that users with high levels of THC in hair and little CBD demonstrated greater levels of schizophrenia like symptoms than users with higher levels of CBD (Morgan & Curran, 2008, Br J. Psychiatry, 192: 306-307). We are currently exploring the relationship between cannabinoids in naturalistically smoked cannabis and the acute and chronic effects of the drug. This presentation will focus on the implications of the increased ratio of THC/CBD and the different effects of CBD and THC in cannabis smokers.

Eating Disorders Not Otherwise Specified (EDNOS) represent the most common eating disorder diagnosed in specialized treatment settings. The purpose of the current presentation is to review epidemiological data on this residual diagnostic category. Namely we will present data on the prevalence of EDNOS in a nationwide community sample. In this study, participants were 2028 female students, aged 12 to 23, attending public schools in the 9th to 12th grades in Portugal. Participants completed the Eating Disorder Examination Questionnaire in Stage 1 of the study. In Stage 2, we selected all the participants who met any of these criteria:

1. 1. BMI ≤17.5,

2. 2. scores ≥4 on any of the four EDE-Q Subscales,

3. 3. a total EDE-Q score ≥4, or,

4. 4. the presence of dysfunctional eating behaviors.

In Stage 2, eating disorder experts interviewed 901 participants using the Eating Disorder Examination. The prevalence of all eating disorders was 3.06% among young females. Prevalence for anorexia nervosa was 0.39%, for bulimia nervosa 0.30%, EDNOS 2.37%. EDNOS was a very common eating disorder and accounts for three-quarters of all community cases with eating disorders. Implications for research and treatment will be presented.

This study aimed to analyse the course of eating disorders (ED) over thirty months emphasizing comorbidity and stability of the ED diagnoses. Particularly attention was given to the eating disorders not otherwise specified (EDNOS) subjects in comparison with anorexia nervosa (AN) and bulimia nervosa (BN) patients.

192 women with a DSM IV eating disorder diagnosis - 55 AN, 108 BN, 29 EDNOS - was assessed with the structured interview (SCID I) at the baseline, one year and thirty months after the first assessment.

83.3% of the total sample had in addition to the ED diagnosis one or more lifetime axis I diagnoses. We found no significant differences between the most common axis diagnoses - anxiety and affective disorders, or dependence disorders - in the three diagnostic groups, excepted for social phobia, in fact this disorder was significantly often present in AN. The distribution of the lifetime suicidal attempt was very similar in the three diagnostic groups.

The stability of the ED diagnoses was low, but EDNOS was the most instable ED diagnosis with a tendency to remission.

The axis I comorbidity of ED was very high, and the EDNOS subjects showed a very similar axis I comorbidity compared with subjects with AN and BN. The stability of the ED diagnoses was low and the EDNOS group showed the highest ED diagnosis instability and tendency to remission. The relationship between axis I comorbidity, and ED instability is unclear, further studies in these fields are needed.

The International classification of diseases - which includes a chapter dealing with mental disorders - will be revised and its 11th Revision will be published in 2014.

A special unit within the World Health Organization coordinates the process of revision and the numerous tasks that have to be undertaken to ensure full participation of the WHO member states in the process of revision as well as the consideration of evidence on which the classification is to be based.

The Department of Mental Health and Substance Abuse Control of the WHO has created a special advisory group that should help it in considering the evidence and proposals made by scientists, governments, organizations and interested individuals and in producing the draft of the classification of mental disorders for inclusion into the 11th Revision of the ICD: This group has, in turn, developed several structures that will deal with the tasks that will arise in the revision process. At the same time the American Psychiatric Association has created a DSM 5 Task Force that should develop proposals for the 5th Revision of the Diagnostic and Statistical Manual that will be published in 2012.

The lecture will describe the processes and structures that have been put in place by the two organizations and refer to the issues that have arisen or are likely to arise in the course of work that should lead to the proposals for the ICD 11 and the DSM 5.