Though care should be provided in patients’ homes for as long as possible, it must be recognised that care in an alternative residential setting may be the only way of meeting some patients’ needs effectively or avoiding intolerable carer burden. Such care will always be necessary, for people who have no relatives available. The residential care may be useful for respite care including a range of time limited services, to support the carers. Residential care should also be available for those patients whose physical, psychological, and/or social dependencies make living at home no longer possible. This provision includes a range from supported accommodations with low level supervision, medium level care facilities and full nursing facilities. There is a high prevalence of mental disorders in nursing homes and very often the staff is not adequately educated, trained and supported to care these individuals. Psychiatric consultation liaison services should be provided not only for residents but also to support the staff of these facilities. The most recent international documents point out the necessity to offer the best available care [1] for these vulnerable persons in the deep respect of their dignity [2]. It becomes urgent to launch a deep debate on this subject in order to recommend to authorities the best guidelines to support policies to be adopted in this field.

The increase of aging patients with schizophrenia becomes a public health issue. The exponential demography of the elderly, the improvement of cares associated with better physical follow-up directly impact the number of old patients with chronic psychiatric disease. Deinstitutionalization associated with a dramatic enhancement of ambulatory and community cares has led to a reduction of beds in psychiatric hospitals. When dependency occurs, due to physical comorbid illness or a worsening of the negative symptoms, psychiatric teams should find appropriate housing and no longer the psychiatric hospital. Nursing home and sheltered housing for the elderly dependent persons become a solution, but geriatric staffs are not always prepared to receive resident with schizophrenia and other psychotic disorders. They often are at a loss when faced with the expression of psychiatric symptoms or with the specificity of caring for often-younger patients whose behavior is different from older people with neurodegenerative disorders.

How psychiatric teams could long-term assist the sheltered housing and nursing home and bring a psychiatric know-how within staffs often reluctant to deal with psychotic patients who could burden caregivers. How could they be trained to cope with complex cognitive functions impairments of schizophrenia, far from cognitive impairments of Alzheimer dementia? How to change the representation of psychiatric illness, which often leads to a double stigmatization (old age and madness)? Improving the quality of life of aging patients with severe chronic mental illness in homes for seniors is a great challenge for psychiatric teams in collaboration with geriatric caregivers.

Evidence consistently demonstrates that people with long-term mental health conditions develop serious physical comorbidities at an earlier age than the average population. These physical comorbidities are often exacerbated because long-term psychiatric conditions reduce the patient's ability to manage somatic symptoms effectively, thus hindering treatment. This highlights the critical importance of continuous support by primary care physicians and nursing staff. People with persistent mental illnesses typically require long-term care significantly earlier than people without mental illness.

As a consequence, elderly patients with chronic mental illnesses who are essentially unable or unprepared to function in the outside world or are in need of constant medical attention are typically placed into long-term care facilities and nursing homes geared to serving physically disabled elderly.

These LTC institutions have no capacity to provide specific care for mentally ill patients. Difficulties in treating psychiatric patients in these LTC facilities often result in transfers to and repeated admissions in acute psychiatric hospitals.

In an effort to resolve the “revolving-door” situation of these patients and reduce the rates of re-admission to acute psychiatric hospitals, Modell Donaustadt was developed. In the talk, Modell Donaustadt will be presented as a best practice example for the treatment of mental and physical comorbidities in long-term care.

Ethical controversies in patients with intellectual disability who are sex offenders.

Patients with an intellectual disability (ID) have a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains (according to the DSM-5). These deficits in adaptive functioning result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life. Therefore, it is not surprising that these patients cross physical/sexual boundaries quite often. Above that, a proportion of all sex offenders have an intellectual disability.

The treatment of these sex offenders with an ID has to focus on protective factors, next to risk factors in order to decrease the risk of recidivism. Due to the chronicity of their disorder, quality of life is an important issue in these patients.

In this paper, we want to address some ethical controversies:

– hormonal treatment in patients with ID who are sex offenders;

– the right to have a ‘normal’ sexual life in these ID offenders, and the Dutch experience of the Stichting Alternatieve Relatiebemiddeling (SAR, that can be translated as foundation of alternative relationship mediation).

The SAR is an alternative dating service, giving information about the sexuality of physically or mentally disabled people and organizing sexual encounters for them.

This presentation will focus on the importance of psychiatrists understanding that they operate at an interface between two very different disciplines; medicine and law. There will be consideration of what and why psychiatrists need to understand the law, the way it operates and the likely implications of their opinions. There will be consideration of an example from England and Wales to illustrate the way in which psychiatry and law might interpret the same information. The aim is that psychiatrists will be better equipped to face the challenges the law presents.

A relatively high proportion of people detained in forensic psychiatric hospitals have intellectual disabilities (up to 3000 people in the UK; Royal College of Psychiatrists, 2013), and people with intellectual disability are significantly over-represented among those psychiatric patients with long lengths of hospital stay (CQC, 2013; Vollm, 2015). People with mild to borderline intellectual disabilities are also prevalent in the UK prison system.

Although the relationship between intelligence and offending is complex, lower intelligence is a known actuarial risk factor for offending behaviour. Studies, which have investigated the prediction of re-offending risk in populations with intellectual disability, have nevertheless found lower rates of recorded re-offending compared to those in mainstream forensic populations (e.g. Gray et al., 2010). The relatively high rate of ‘offending-like’ behaviour, which is not processed through the criminal justice system in people with intellectual disability makes risk prediction a more complex exercise with this group of people. It also makes outcomes measurement more difficult.

This paper will give an overview of the current research evidence and clinical practice in the field of risk assessment, risk management and outcome measurement with offenders with intellectual disability. It will summarise the findings of a recent NIHR funded systematic review by the author, which pertains to this area, and will point to future developments in the field.

There is an increasing interest in the Spanish prison to give the appropriate care when they are in prison. This situation has a special meaning in inmates with learning disabilities, as they are a vulnerable group inside prison. They are vulnerable in different areas as they have a high prevalence dual diagnosis (both with mental illness and drug misuse), they could suffer from abuse from other inmates, difficulties to understand prison regulations, etc. The prevalence of intellectual disability (ID) in the prison setting has been poorly evaluated. In Spain, despite various approximations or estimates regarding people with intellectual disabilities no reliable data is available.

In our presentation, we will give an overview of the care of this group of patients, presenting some data from an epidemiological study in Spain. The rate of learning disabilities was of 3.77% of the study population has an IQ below 70, and 7, 3% has borderline IQ rate. We also describe a new setting in one of wards of a prison of Barcelona where has a model of therapeutic community for treating offenders with intellectual disabilities. This resource open two years ago and is run between prison services and an organization “Accepta” (specialized in people with learning disability and penal law problems). This is an effort from the prison services to adapt to the needs of inmates and deliver a better service with a good post-release follow-up.

And finally, we present some data about learning disability in penitentiary psychiatric settings (the prevalence as a main diagnose is around 10%).

Polypharmacy is the rule in psychogeriatric patients, as they present frequently comorbidities such as depression, dementia [often including Behavioral and Psychological Symptoms of Dementia (BPSD)] and somatic diseases. Recommended treatments for geriatric depression are antidepressant medications, psychotherapy and psychosocial interventions [1]. Besides antidepressants, other psychotropic drugs are often co-prescribed, but somatic drugs are also needed for the treatment of other concomitant diseases. This situation increases the risk for adverse effects due to pharmacokinetic and pharmacodynamic interactions, especially since the organism of elderly patients displays a lowered homeostatic reserve and a decrease of functions, which allows resisting to xenobiotic influences.

On the other hand, there are also studies which suggest that in hospitalized psychogeriatric patients, the incidence of severe adverse reactions is lower in patients > 60 y than in those < 60 y [2]. This is one of the results of the AMSP-study group, which in German speaking countries has developed a pharmacovigilance program in psychiatric hospitals.

Old age depression is often difficult to discriminate from dementia (particularly of Alzheimer type) – particularly cross-sectionally. Incident dementia is frequently associated with depressed mood and agitation; depression in the elderly goes together with executive and memory dysfunctions; associated psychotic symptoms and activity-of-daily-life dysfunctions are shared by both conditions as well as major risk factors as vascular and metabolic factors. Frequently both syndromes are “masking” each other; depression may furthermore present as the first clinical sign of Alzheimers disease.

Yet, both clinical syndromes/disorders emerging from quite different are pathogenic neurobiological mechanisms with differentiating neuropsychological, – imaging and – chemical features. Clinical tools can be derived and enable accurate differential diagnosis. Thus, the distinction between both syndromes is a first instance for biomarker supported differential diagnoses in psychiatry.

The Convention on the Rights of Persons with Disabilities (CRPD) is the first highest international legally-binding standard which aims to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, including those with mental health conditions, and to promote respect for their inherent dignity. The CRPD embodies a ‘paradigm shift’, from the charitable and the medical approaches to disability to one, which is firmly rooted in human rights. It provides a clear path towards non-discrimination, full and effective participation and inclusion in society, respect for difference and acceptance of persons with disabilities as part of human diversity and humanity, equality of opportunity and accessibility just to name a few.

States which have signed the CRPD have an obligation to respect, protect and fulfil the internationally agreed upon set of standards guaranteed to all people included in the Convention. However, even in signatory states, violations often occur behind “closed or open doors” and go unreported and consequently unprevented. The growing number of people with mental health conditions in the world has further contributed to a level of attention paid to quality and human rights conditions in both outpatient and inpatient facilities, which has never been greater. Persons with mental health conditions need both de jure human rights protection and de facto human rights practices.

Seven years after the CRPD came into force the care available in many mental health facilities around Europe is still not only of poor quality but in many instances hinders recovery. The level of knowledge and understanding by staff of the rights of people with mental disabilities is very poor. It is still common for people to be locked away or to be chained to their beds, unable to move. Inhuman and degrading treatment is common, and people in facilities are often stripped of their dignity and treated with contempt. Violations are not restricted to inpatient and residential facilities; many people seeking care from outpatient and community care services are disempowered and also experience extensive restrictions to their basic human rights.

In the wider community, many people with mental disabilities are still denied many basic rights that most people take for granted. For example, they are denied opportunities to live where they choose, marry, have families, attend school and seek employment. There is a commonly held, yet false, assumption that people with mental health conditions lack the capacity to assume responsibility, manage their affairs and make decisions about their lives. These misconceptions contribute to the ongoing marginalization, disenfranchisement and invisibility of this group of people in their communities.

One of the underlying reasons it is difficult to move through the obstacles to fully embrace the CRPD, is that discrimination continues to affect people with mental health conditions on many levels. Changing laws is only a partial solution. We have to change the ways that we relate to each other at every level, and to offer people information and tools to make the transition to a more equitable social reality.

Since the first descriptions of anxiety, it has been related with temporality and in particular with the dimension of future. Thus, we already find anxiety defined as a general feeling of threatening (from the future) in the German mystic Jakob Boehme (1575–1634). He also used the image of “the wheel of anxiety”, with which he refers to its probable origin in a conflict between two forces which tend to separate themselves and are not able to do it, as a result from this centrifugal rotation movement of a wheel. This image also has a temporal character. In Kierkegaard, we read that “anxiety is always related with the future… and when we are disturbed by the past we are basically projecting toward the future…” In Heidegger's masterpiece, “Being and Time”, there is a chapter dedicated to the temporality of Befindlichkeit, and in particular to anxiety. Fear and anxiety have their roots, according to Heidegger, in the past, but their relation with the future makes them different: anxiety arises from the future as possibility, while fear arises from the lost present. In this paper, we try to make a contribution to the phenomenology of temporality (and of spatiality) of anxiety in relation with the analysis of a concrete anxiety experience: flight phobia. The analysis allows us to show both the desolation and narrowing of anxiety space, and with respect to temporality, the disappearance of every plan (the future), of every history (the past), and the reduction of the present to a succession of mere punctualities, behind which there arises, threatening, the nothingness itself.

The accurate identification of accelerated, agitated and anxious states is of paramount relevance for the correct diagnosis and the selection of a suitable psychopharmacological treatment. Choosing antidepressants, antipsychotics and/or mood stabilizers is presently contingent to the identification of specific phenotypic profiles in anxiety disorders, mixed and manic episodes and/or delirium states. Today, the anamnesis and psychopathological examination are hindered by the vagueness of the conceptualization of these experiences in diagnostic textbooks. We propose a selective review of literature of how these have been conceptualised aiming at increasing the segregation of specific phenomenological profiles across these phenomena.

This symposium analyses the psychopathological phenomenon “anxiety”, a classical concept, which has returned to be central in the recent psychiatric debate. Some of the most important international phenomenologists will discuss anxiety in the context of major psychopathological areas. Clinical and research insight will be presented in the context of a philosophically deep understanding of the fundamental qualitative features of the psychopathology of anxiety.

Schizophrenia is frequently associated with abnormal physical activity (PA) per se (e.g., hypokinesia, motor retardation, etc.) or related to antipsychotic medications (e.g., extrapyramidal symptoms including bradykinesia, tremor, etc.). Daily amounts of PA for subjects diagnosed with schizophrenia tend to decrease over the illness course and contribute to metabolic and cognitive disturbances. PA intervention for schizophrenia patients may result in increased well-being, improved cognitive functioning, fewer negative symptoms and increased self-efficacy, leading to improved management of psychosocial life domains. However, PA trials conducted among people suffering from schizophrenia show several methodological limits: small sample sizes, lack of randomized patients’ allocation, heterogeneity of interventions and inappropriate outcome measures.

Firth et al. (2015) have recently conducted a systematic review and meta-analysis of 11 trials on structured PA in schizophrenia (n = 659, median age of 33 years). The conclusions of this recent review are the following:

– aerobic exercise (for instance exercise bike) of moderate-to-vigorous intensity done at least 90 minutes per week is effective in improving cardiovascular fitness; studies (n = 7) using VO2max as an assessment of fitness have reported clinically significant increases in VO2max, “defined as sufficient to reduce cardiovascular disease risk by 15% and mortality by 20%”;

– several low-dose aerobic interventions did not shown any effect;

– there was a “strong effect of exercise on total psychiatric symptoms” (both positive and negative symptoms were reduced);

– total attrition rate was 32%. Group exercise showed a much lower attrition rate than solitary exercise;

– caregivers’ supervision increased compliance as compared to unsupervised intervention;

– in the only study that compared per-protocol and intention-to-treat analysis, a significant improvement in fitness, psychiatric symptoms and overall functioning only occurred in participants who attended > 50% of exercise sessions.

Schizophrenia is a severe brain disorder characterised by positive, negative, affective and cognitive symptoms and can be viewed as a disorder of impaired neural plasticity. Aerobic exercise has a profound impact on the plasticity of the brain of both rodents and humans such as inducing the proliferation and differentiation of neural progenitor cells of the hippocampus in mice and rats. Aerobic exercise enhances LTP and leads to a better performance in hippocampus related memory tasks, eventually by increasing metabolic and synaptic plasticity related proteins in the hippocampus. In healthy humans, regular aerobic exercise increases hippocampal volume and seems to diminish processes of ageing like brain atrophy and cognitive decline.

Patients with schizophrenia might benefit from exercise via multiple ways. It can be assumed that positive effects observed in healthy people counteract different pathological dimensions of schizophrenia or add to a better compensation. E.g. exercise may serve as a coping strategy, produces changes in brain structure and function and is already known to improve mood and cardiovascular health. First studies have shown beneficial effects of exercise in schizophrenia. These studies feature a multitude of exercise types and diagnostic tests and also lay emphasis on different research questions.

From the diverse information of the studies, heterogenic character conclusions for future therapy and research can be derived. From the point of view of sports science, feasibility and effectiveness of endurance training will be discussed on the basis of current literature and results from our own research. In a controlled trial 22 patients with schizophrenia participated in 12 weeks of endurance training using bicycle ergometers resulting, e. g., in improvements of endurance capacity and functioning. A special focus was laid on analyzing the differences between the adaptations of patients and healthy controls to test the transferability of methods and effects of endurance training. The exercise intervention was feasible and effective for both healthy controls and patients but some interesting differences could be found.

Additionally, ideas and special circumstances regarding the implementation of endurance training in clinical settings or for outpatients will be considered. From the current knowledge it can be concluded, that the implementation of endurance training in multimodal therapy strategies can be recommended to promote recovery.