609 high school students and 270 college students were tested with M. Kovack Child Depression Inventory. 20% of adolescents and 15% of college students demonstrated increased scores in CDI. Desintegration of families, high prevalence of alcoholism and extreme growth of social orphanhood are among the major factors of depressive and anxiety disorders in population. About 50% of observed social orphans were at high risk for depression. Stratification of Russian society is another macrosocial factor of emotional disorders. Two opposing tendencies might be observed. From one side, significant part of population is on the impoverishment and degradation. From another side, well-to-do families are growing in numbers with special quest for elitist educational institutions with perfectionistic standards. Success and achievement orientation along with intensive training loads also generate threat to emotional health of children. 60% of observed students of these elitist schools were at high risk for depression. Parents of students with increased scores in CDI exhibited higher indices of perfectionism compared with parents of emotionally healthy students. Significant correlations between parental perfectionism and depression/anxiety symptoms in offspring have been registered.

Affecting 6-11% of the population, insomnia is the most common complaint in general practice. While insomnia is a major risk factor for health problems, its brain mechanisms have hardly been explored (Front Neurosci 2009;3:436). We applied brain imaging to find causes and consequences of insomnia. While some deviations recover after therapy, e.g. increased complexity cost in response times and attenuated prefrontal BOLD activation during word fluency (J Sleep Res 2008;17:335; Sleep 2008;31:1271), others don’t and may be heritable traits involved in the risk of developing insomnia. Using TMS, we found an abnormal intracortical excitability and facilitation (ICF) that did not recover after treatment (Biol Psychiatry 2010;68:950). This finding may be the first endophenotype allowing for genotyping, because ICF is among the most heritable human traits (J Neurosci 2009;29:8897). MRI voxel based morphometry (VBM) showed a lower volume of gray matter in areas that are part of the default mode network including the orbitofrontal cortex, where volume showed a strong negative correlation with insomnia severity (Biol Psychiatry 2010;67:182). This area seems involved in disturbed hedonic evaluation, which we indeed found to be disturbed (Sleep 2008;31:1301). Concertedly, we found new angles on mechanisms of vulnerability. We now look for research partners and volunteers for extensive web-based characterization of phenotypes of good and poor sleepers (www.sleepregistry.eu).

Little is known about the prevalence of nocturnal movement disorders in patients with insomnia or psychiatric disorders. However, it is well established that sleep-related motor disorders (movement disorders, parasomnias) are associated with psychopharmacological treatment. In a recent prospective study it has been shown that second-generation antidepressants may induce or worsen symptoms of restless legs syndrome (RLS) which is often associated with insomnia. While pure SSRIs and SNRIs carried an average risk of about 5% for triggering RLS, reboxetine did not seem to induce this syndrome. By contrast, mirtazapine caused or worsened RLS in almost 30% of the patients surveyed (Rottach et al., 2009). Other studies using polysomnography have reported an increased risk of periodic leg movement disorder with antidepressant treatment. It was reported that SSRIs and venlafaxine, but not bupropion, increased the risk of periodic leg movements during sleep (PLMS), suggesting that PLM activity seen in association with antidepressant administration might be serotonergically mediated (Yang et al., 2004). Sleep-related movement disorders may also occur under treatment with first- or second-generation neuroleptics (Cohrs et al., 2008). Administration of antidepressants may also induce the occurence of rapid eye movment (REM) sleep parasomnias such as REM sleep behaviour disorder (RBD) (Thomas et al., 2007). Own preliminary data of an ongoing study revealed that sleep-disordered patients with comorbid psychiatric disorders are more likely to report a variety of nocturnal movement disorders using the Munich Parasomnia Screening Questionnaire. However, whether this result is due to the psychopharmacological medication remains to be determined.

The DSM V will probably include four categories of eating disorders, anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified. The lifetime prevalence is about 5%. Cultural, social and interpersonal elements can trigger the onset and changes in neural networks can sustain the illness. Brain based explanatory models have been developed which include an imbalance between top down control and hedonic and homeostatic elements. The longer the duration of untreated illness the harder it is to reverse the illness as a variety of maintaining factors develop. CBT remains the treatment of choice for bulimia nervosa but there is more uncertainty about treatment for anorexia nervosa although treatment with a focus on the interpersonal elements is of value

The choice of an antidepressant is tailored according to patient factors (age, sex, severity, diagnostic subtype, comorbid disorders, past response) and to drug characteristics (efficacy, tolerability, safety, simplicity of use, discontinuation syndrome).

A wide range of antidepressants are available nowadays, with mode of action mainly based on the monoamine hypothesis of depression, but all have limitations: still too many nonresponding patients, late onset of action, and poor tolerability profile, resulting in low adherence. The challenges for a new antidepressant are first to provide all patients with rapid and sustained antidepressant efficacy in relieving all symptoms, second to lead patients out of depression by achieving complete remission, and third to ensure that patients are compliant throughout treatment.

Agomelatine is a new antidepressant with an innovative mode of action acting as an agonist of melatonergic MT1 and MT2 receptors as well as an antagonist of serotonergic 5-HT2C receptors. These receptors play a major role in circadian rhythms, which are dysregulated in depression. Recent data suggest that the distinctive antidepressant efficacy of agomelatine results from the potential synergy between these receptors.

Agomelatine rapidly improves depressive symptoms in most subtypes of depression, particularly in patients with anxiety symptoms, known as factor of resistance. Moreover, agomelatine shows greater antidepressant efficacy than fluoxetine in severely depressed patients (HAM-D total score difference over 8 weeks: 1.49; P = 0.024).

Thanks to its unique impact on mechanisms at the core of depressive dysregulation, agomelatine provides doctors and patients with an innovative approach to depression treatment.

Agomelatine is a completely new approach to the treatment of depression thanks to its innovative mode of action. Acting as melatonergic agonist and 5-HT2C antagonist, it provides depressed patients with a distinctive antidepressant efficacy that perfectly suits patients’ needs and addresses all symptoms at each step of depression. Two years after the first launch in Europe, now is the time for an update from doctors and patients alike.

The patient/doctor relation is key when initiating depression treatment, because patients are reluctant to start, fearing withdrawal symptoms, serious unwanted side effects, and “addiction”. It is important therefore that they understand that agomelatine has none of these effects.

The benefits perceived by patients right from the first days of treatment are influential, because patients are reluctant to continue with classic antidepressants (delayed onset of perceived benefit, early side effects). The early improvement reported by patients on agomelatine supplements data on clinical benefits seen in clinical trials from the first week versus venlafaxine (CGI-I, rate of response, daytime alertness, feeling good) and after two weeks versus sertraline (twice as many HAM-D responders to agomelatine as to sertraline).

Finally, patients are reluctant to maintain antidepressant treatment because of later side effects (weight gain, sexual dysfunction, emotional blunting). Patients on agomelatine confirm the absence of the classic side effects of antidepressants and are more likely to continue treatment than they are with other drugs. Both the antidepressant efficacy and the tolerability were confirmed in a large non-interventional study in a real-life setting in daily practice.

Most antidepressants acting through monoaminergic systems have limitations in efficacy and tolerability and this has led to other approaches to provide patients with adequate treatment.

Agomelatine is an innovative approach to depression as it resynchronizes circadian rhythms, which are disturbed in depressed patients, thanks to its action on the melatonergic MT1 and MT2 receptors, and the 5-HT2C receptors.

The efficacy of agomelatine in depressed patients has been shown in several multicenter, randomized, double-blind parallel-group studies either in comparison with placebo or in 4 head-to-head studies vs an SSRI (sertraline, escitalopram, or fluoxetine in patients with more severe depression) or vs an SNRI (venlafaxine) after 6-8 weeks of treatment.

Agomelatine produced a continuous improvement by significantly reducing all core symptoms of depression. Agomelatine significantly reduced the incidence of relapse in acute responders over a 6-month period (21.7% for agomelatine versus 46.6% for placebo, P = 0.0001), even in the severely depressed patients. Agomelatine was well tolerated in the short and long term.

The pooled analysis of 4 head-to-head comparison studies showed after 6-8 weeks a significant difference in favor of agomelatine vs SSRIs/SNRIs in the HAM-D total score 1.37 (P < 0.001) and for responders (7.21%, P = 0.005). In addition, fewer patients withdrew due to emergent adverse events with agomelatine (6.3%) than with SSRIs/SNRIs (10.5%, P = 0.0058).

Taken together these data indicate that agomelatine is an effective treatment of depression in the short and long term, with a distinctive efficacy and better tolerability than the main current treatments.

Anxiety disorders are considered to be the most prevalent of the psychiatric disorders, with generalized anxiety disorder (GAD) being one of the most common in primary care practice. GAD is a chronic and disabling disorder, which is frequently underdiagnosed and undertreated. It is characterized by both psychic symptoms (particularly worry) and somatic symptoms, and often complicated by comorbid conditions such as depression.

Agomelatine, the first melatonergic antidepressant, has been shown to be effective and well tolerated, not only in treating major depressive disorder, but also in treating the anxiety symptoms of depression. These findings give impetus to investigation of its potential anxiolytic properties in GAD.

Two randomized, double-blind, placebo-controlled studies assessed the efficacy of agomelatine in GAD. The first, a 12-week study, used the HAM-A total score as the primary outcome measure. In the second, a relapse prevention study, the responders to a 16-week open treatment period with agomelatine were randomized to maintenance treatment with either agomelatine or placebo for a 26-week period.

In the short-term treatment of GAD,1 agomelatine was superior to placebo with a HAM-A total score difference of 3.28 (P = 0.04). In the maintenance treatment of GAD, the incidence of relapse was significantly lower with agomelatine than with placebo. Agomelatine was well tolerated in both trials.

In summary, these studies showed that the novel antidepressant agomelatine is also efficacious in the treatment of GAD.

The extensive research into the treatment of bipolar disorder over the last 20 years means that we, as clinicians, have never been in a better position to treat patients with bipolar disorder. Yet despite the availability of modern, evidence-based treatment guidelines, bipolar disorder remains an everyday treatment challenge. Newly diagnosed patients requiring treatment for the first time are not always adequately controlled with single-agent therapy and, similarly, combination therapy is also frequently necessary as maintenance treatment. But with this recognition comes the new challenge of identifying when monotherapy is not enough, which agents to combine, when and for how long? How do we know?

Joined by an internationally respected faculty, Professor Siegfried Kasper chairs a discussion to help answer some of the key questions facing clinicians today:

What response can be anticipated from recommended first-line monotherapies for acute mania?

How do we know whether the response we observe when we prescribe a first-line treatment in a manic patient is adequate?

To what extent can a partial non-response to monotherapy be improved by the addition of a second agent?

What's the benefit of maintaining combination treatment once patients are stable and how long should I continue?

Does adding an antipsychotic to a mood stabiliser increase the risk of adverse events, in the short term or in the long term?

Drawing on latest guideline recommendations, recent clinical research, case studies and their extensive clinical experience, the panel will debate these interesting questions and shed light on how we can optimize both acute and maintenance treatment in this patient group.

Although the design of maintenance studies in bipolar disorder has significantly evolved in recent years, individual study designs continue to differ in important ways, with important implications. What may appear to be small differences between study designs, such as the type of most recent episode experienced by the patients or the stabilisation criteria used in the trial, can have big implications for study outcome. It is thus becoming increasingly important to be able to evaluate the results of trials within the context of the design and determine what they mean for treatment practice. Our panel will therefore also discuss the extent to which the design of bipolar maintenance studies can influence the results achieved and share their views on what this means for treatment now, and in the future.

Are we, and more importantly our patients, getting the most out of combination therapy for bipolar mania? Come and debate the issues with the panel, share your views and see what can be achieved.

The ideal anxiolytic drug would be effective in all anxiety disorders, with a rapid onset of action, across all symptom domains and the spectrum of severity, in achieving remission and minimising disability, in preventing relapse, and in treating comorbid depression. Ideally, the drug would be suitable for once-daily dosage, would have minimal adverse effects or cause minimal interference with everyday life, not lead to the development of tolerance, have no discontinuation symptoms, be suitable in physically ill patients and free from interactions, and be safe in overdose.

But there are no ideal anxiolytic drugs. Response rates to initial treatment can be disappointing, it is not possible to reliably predict likelihood of response; a substantial proportion of patients experience unwanted effects; many will relapse despite treatment adherence; comparatively little is known about further management after initial non-response; and discontinuation symptoms can be troublesome.

Hence there is much room for improvement in identifying those patients who are most likely to benefit from treatment; in choosing between drug and psychological treatments; in choosing the right drug for the right patient groups; in optimising medication dosage to achieve maximum effectiveness whilst minimising adverse effects; in combining drug treatments to enhance efficacy; and in treating over the long term to prevent relapse and recurrence.

Schizophrenia is a serious mental disorder which presents with both diagnostic and management challenges. In process of developing DSM5, the inclusion of a Psychosis Risk Syndrome is currently being discussed. This is also the focus of early intervention programs which should facilitate to diagnose the disorder as early as possible and to prevent long durations of untreated psychosis (DUP). As only about 20–40% of young people with At Risk Mental States (ARMS) develop a full blown psychotic disorder, the challenge is to identify people with ARMS who will eventually receive a diagnosis of schizophrenia. Various interventions have been evaluated in ARMS probands, yet it is still too early to make management recommendations.

Once the diagnosis of schizophrenia has been established, treatment must commence as early as possible, in order to prevent long DUP's. First episode patients show a very good chance of remission, 40–60% have been reported.

It is generally recommended to switch patients to clozapine after two or three different antipsychotics have been unsuccessfully tried. In the case of clozapine non-response, the evidence for further interventions becomes extremely weak.

Once improvement and/or remission has been achieved, maintenance treatment is the next big challenge. As most relapses are related to compliance problems, assuring a positive therapeutic relationship with an influence on compliance behavior becomes a key issue.

Managing schizophrenia patients requires expert skills, ideally provided by multiprofessional teams both in inpatient and outpatient settings. Sufficient attention must also be given to the somatic health of schizophrenia patients.

Bipolar disorder is rapidly becoming the primary diagnosis in adult psychiatry. It represents a wide spectrum of disorder all sharing common features of elated and depressed mood. The early descriptions of symptom-free euthymia have long been dismissed and the chronic and enduring deficits associated with the disorder are beginning to be better understood. The course of the disorder remains uncertain especially in light of the recently observed increases in children receiving the diagnosis. There is growing interest in the elated states seen as a common adolescent phenotype.

There is a simplified view of the illness as an episodic course interspersed with euthymia, short-term treatments being used in acute episodes and long-term treatments being indefinite and intended to prevent new episodes. However, subsyndromes, co-morbidities and a variety of chronic symptoms are common in bipolar disorder. In practice, they often drive treatment decisions. Chronic symptoms are usually related to anxiety, depression or cognition and are a disabling aspect of the long-term outcome. Unfortunately, there is little to guide the selection of treatment to reduce the impact of these symptoms since they have almost never been the subject of clinical trials.

The use of medication in combinations is the usual practice in bipolar disorder. The argument to favour this in guidelines is highly pragmatic, but there is a growing evidence base to support it. Lithium remains a key benchmark treatment for comparing alternatives in long term efficacy. Its effects against suicide are particularly important.

Depression is one of the thoroughly evaluated diseases in psychiatry with regard to diagnosis as well as treatment variables. Like in other medical conditions, early treatment should be aimed and watchful waiting which is for instance also not done in the treatment of high blood pressure or diabetes, has not been proven to be a sophisticated approach based on neurobiological considerations. Like in other diseases, it is apparent that days of untreated depression may result in brain damage like reduced volume size of the hypocampus. The course of illness of depression shows that life events are less important in later stages of the illness than in earlier. The introduction of the group of selective serotonin reuptake inhibitors (SSRI) marked a revolution in the treatment of depression, since it was possible to treat patient for the first time effectively with a more minor side effect profile with this approach. Substantially more patients could be reached and the association with this phenomenon and the reduction of the suicide rates in different countries like Sweden, Austria and Hungary has been discussed. Dual reuptake inhibitors effecting both the serotonergic as well as the noradrenergic pathways and the dopaminergic noradrenergic medication bupropion have been introduced in the filed with specific angles of treatment goals like pain or somatic symptoms. With the introduction of agomelatine, a unique mechanism of action with the combination of melatonergic agonistic as well as serotonergic antagonistic activities has been achieved. With this approach a more potent influence on the circadian rhythm has been shown compared to other, previously used antidepressant properties. Deep brain stimulation and vagus nerve stimulation for treatment refractory depressed patients yield promising results. More thorough characterisation of the underlying pathophysiology of depression including brain imaging results as well as molecular biological variables will yield further inside of the understanding and treatment of depression.

One of the recent initiatives inaugurated by the EPA European Platform of Psychiatrists aims at improving quality of mental health care in Europe by providing and implementing evidence-based information and advice and thereby minimizing mental health care gaps. To provide such guidance for schizophrenia, an overview will be given of existing treatment guidelines. This overview will focus firstly on methodological quality, since according to survey from 2005 the methodological quality of most guidelines was at best moderate (Gaebel et al. 2005). Secondly, the focus will be on treatment recommendations regarding core clinical questions like early recognition and intervention, acute and long-term treatment. Accordingly, respective recommendations from well established international guidelines will be presented. In addition, participants hopefully from all over Europe are encouraged to engage in the discussion and to provide information from their national/regional treatment guidelines, especially if not available in English language.

This talk will describe the methodology used for the development of the new NICE guideline on the treatment of schizophrenia for the UK, paying particular attention to meta-analytic and, where possible, economic methods or considerations used to develop recommendations on the use of Family therapy, CBT and the arts therapies. Some time will also be given to examining the evidence behind the first formal meta-analytic review of early intervention services for people with early schizophrenia, and a suggestion that these services may be beneficial as a result of them including evidence-based treatments rather than such services having a particular approach or service ideology. If time allows, we will also examine the evidence behind the choice of antipsychotic in the schizophrenia guideline, and speculate on the continuing usefulness, if any, of using terms such as ‘typical’, ‘atypical’, ‘first generation’ or ‘second generation’.

Metabolic and cardiovascular health problems have become a major focus for clinical care and research in schizophrenia. To evaluate the content and quality of screening guidelines for cardiovascular risk in schizophrenia we performed a systematic review and quality assessment of guidelines/recommendations published between 2000–2010, using the Appraisal of Guidelines for Research and Evaluation (AGREE). AGREE domain scores varied between 18 identified guidelines. Most guidelines scored best on the domains ‘Scope and Purpose’ and ‘Clarity of Presentation’. The domain ‘Rigour of Development’ was problematic in most guidelines, while the domains ‘Stakeholder Involvement’ and ‘Editorial Independence’ scored the lowest. The following parameters were recommended, in order of frequency: fasting glucose, BMI, fasting triglycerides, fasting cholesterol, waist, HDL/LDL, blood pressure, symptoms of diabetes. In terms of interventions most guidelines recommended advise on physical activity, advise on diet psycho-education of the patent, treatment of lipid abnormalities, treatment of diabetes, referral for advise and treatment, psycho-education of family and smoking cessation advice. Compared across all domains and content, 4 European guidelines could be recommended. Four of the evaluated guidelines are of good quality and should guide clinicians’ screening and monitoring practices. Future guideline development could be improved by increasing its rigour and assuring user and patient involvement. Although good guidelines are available research shows that the implementation in daily clinical practice remains poor.