Schizophrenia is a chronic disorder with a high risk of poor outcome in terms of symptoms and social functioning and possibly also progressive brain alterations. The relapse rate is high and each relapse can induce further aggravations, both in psychosocial as well as in neurobiological terms. Thus, acute and long-term treatment with the highest degree of effectiveness should be provided to the patients in acute and long-term treatment.

Neuroleptic medication is the most important part of the treatment regimen for schizophrenic patients. The efficacy of neuroleptics in the acute and long-term treatment of schizophrenia is very well proven and the effect size is comparatively high. The second-generation antipsychotics (SGAs) have advantages over the neuroleptics of the first-generation (FGAs), and high expectations have therefore been put into them for the treatment of schizophrenia. Their better extrapyramidal-motor tolerability and efficacy in treating negative, depressive and cognitive symptoms, in addition to positive symptoms, supposedly result in a more favourable influencing of the overall course of the disease and in a higher quality of life for the patients, thus improving their acceptance by patients and leading to increased compliance. Differences in the pharmacological profile can be identified among others by receptor imaging approaches.

Evidence based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Applied to treatment in psychiatry, somatic, pharmacological and psychotherapeutic therapy as well as prevention and rehabilitation are to be assessed systematically. Evidence-based practice guidelines for the treatment of mental disorders are available in many countries and were developed based on the principles of EBM. This includes literature reviews, which are time-consuming and beyond the scope of everyday clinical psychiatrists' work capacity. Thus, evidence-based guidelines support the art of treatment in psychiatry by providing expertise.

Treatment algorithms published in treatment guidelines are often misunderstood as strict rules. In fact, guidelines cannot provide non-exceptional regulations. They imply the option to deviate from guideline recommendations. Guidelines and EBM will only be able to support clinical decision making. The “art” of making therapeutic decisions remains an essential competence of the practising psychiatrist.

Adhering to guideline recommendations in psychiatric treatment leads to optimized patient outcomes. EBM thus provides a firm basis for often complicated treatment decisions in psychiatry and critically supports the art of treatment in psychiatry. It will never kill this art but rather help it to survive as a highly specialized, scientifically based medical competence.

Prolongation or lifelong pharmacotherapy has emerged as the main therapeutic tool for preventing relapse in depression. However, outcome after discontinuation of antidepressants is unfavourably affected by the duration of their administration. Loss of clinical effects, despite adequate compliance, has also emerged as a vexing clinical problem. Use of intermittent pharmacotherapy with follow-up visits is another therapeutic option, that, however, entails the problems of resistance and of discontinuation syndromes.

In recent years, several controlled trials have suggested that a sequential use of pharmacotherapy in the treatment of the acute episode and psychotherapy in its residual phase may improve long-term outcome. Antidepressant drugs may be tapered and discontinued during the course of psychotherapy. The sequential treatment of depression not fall within the realm of maintenance strategies. It is an intensive, two-stage approach, which is based on the fact that one course of treatment with a specific tool (whether pharmacotherapy or psychotherapy) is unlikely to provide solution to the complex array of symptoms of patients with mood disorders.

The efficacy of antidepressants is clinically relevant. The highest effect size was demonstrated for severe depression. Based on responder rates and based on double-blind placebo-controlled studies, the number needed to treat (NNT) is 5–7 for acute treatment and 4 for maintenance treatment. Monotherapy with one drug is often not sufficient but has to be followed by other antidepressants or by comedication/augmentation therapy approaches.

Generally, antidepressants reduce suicidality, but under special conditions like young age or personality disorder, they can also increase suicidality. However, under the conditions of good clinical practice, the risk-benefit relationship of treatment with antidepressants can be judged as favourable also in this respect.

The capacity of psychiatrists to individualise and optimise treatment decisions in terms ofthe right drug/treatment for the right patient’ is still restricted since currently there are no sufficient powerful clinical or biological predictors which could help to achieve this goal. There is hope that in future pharmacogenetics will contribute significantly to a personalised treatment. With regard to plasma concentration, therapeutic drug monitoring (TDM) is a useful tool to optimize plasma levels therapeutic outcome.

Benzodiazepines have anxiolytic, hypnotic, muscle-relaxant and anticonvulsant properties. They also lessen agitation in the psychotic patient. They are much safer than previously available drugs such as the barbiturates. All sedative drugs have characteristic pharmacodynamic effects, causing sedation, psychomotor slowing and memory impairment.

The widespread use of benzodiazepines long-term is problematic. Even though some tolerance develops, long-term users are impaired in cognitive and psychomotor function compared to non-users. Tapering the drugs, even after several years of use, results in improvement in functioning. Newer anxiolytics such as SSRIs and pregabalin cause less impairment. Benzodiazepines are associated with dependence on prescribed doses with a clear-defined withdrawal syndrome lasting a few weeks; this is evident in 20–30% patients on benzodiazepines, and is severe in 10%. Benzodiazepines should never be withdrawn abruptly because fits paranoid or confusional psychoses may ensue. Secondary abuse of all sedative drugs is common and contributes to specific drug-related harms in abusers.

Few longterm studies have been performed so the longterm risk/benefit ratio is imprecise. The paucity of “gold standard” clinical trials means that the benzodiazepines seem no more effective than placebo in the longterm as anxiety-- and insomnia-reducing agents.

Alternative medications for the Anxiety Disorders have been developed and evaluated, principally SSRIs and pregabalin. Similarly, newer drugs are available for treating Sleep Disorders. Longterm use can be avoided by using non-pharmacological or non-dependence inducing medications. The fundamental problem which precludes routine longterm use is that it is impossible to identify those users who will develop dependence beyond 1–3 months prescription.

Benzodiazepines have anxiolytic, hypnotic, muscle-relaxant and anticonvulsant properties. They also lessen agitation in the psychotic patient. They are much safer than previously available drugs such as the barbiturates. All sedative drugs have characteristic pharmacodynamic effects, causing sedation, psychomotor slowing and memory impairment.

The widespread use of benzodiazepines long-term is problematic. Even though some tolerance develops, long-term users are impaired in cognitive and psychomotor function compared to non-users. Tapering the drugs, even after several years of use, results in improvement in functioning. Newer anxiolytics such as SSRIs and pregabalin cause less impairment. Benzodiazepines are associated with dependence on prescribed doses with a clear-defined withdrawal syndrome lasting a few weeks; this is evident in 20–30% patients on benzodiazepines, and is severe in 10%. Benzodiazepines should never be withdrawn abruptly because fits paranoid or confusional psychoses may ensue. Secondary abuse of all sedative drugs is common and contributes to specific drug-related harms in abusers.

Few longterm studies have been performed so the longterm risk/benefit ratio is imprecise. The paucity of “gold standard” clinical trials means that the benzodiazepines seem no more effective than placebo in the longterm as anxiety-- and insomnia-reducing agents.

Alternative medications for the Anxiety Disorders have been developed and evaluated, principally SSRIs and pregabalin. Similarly, newer drugs are available for treating Sleep Disorders. Longterm use can be avoided by using non-pharmacological or non-dependence inducing medications. The fundamental problem which precludes routine longterm use is that it is impossible to identify those users who will develop dependence beyond 1–3 months prescription.

Ethnic minority and immigrant patients are subject to what are termed “health disparities” wherein the quality of services received is not at the same level as that of majority group members. These disparities are a consequence of both erroneous diagnosis and, relatedly, inadequate treatment. Culture impacts both diagnosis and therapy by circumscribing how an individual understands distress. The experience, expression, and explanation of what psychiatry understands to be psychopathology are eminently “cultural”, for the clinician as well as for the patient. The very identification of a “symptom”, its relationship to psychopathology, and even what constitutes the specific diagnostic categories is in large part a function of the impact of these three “exes”. The therapeutic process and relationship is impacted in part by the fourth “ex”, the expectations of both clinician and patient, and, once again, when distinct can lead to early termination and/or poor outcome. Ethnicity, particularly in the context of ethnic minority status, can impact both diagnosis and treatment in the context of both overt and covert prejudice, particularly on the part of the clinician. Ethnocultural countertransference involves the unconscious projection of ethnic and racial prejudice onto the patient, which has a direct impact on diagnosis and the development of the therapeutic relationship. The presentation will review both barriers and suggest strategies for effective intercultural diagnosis and treatment.

During the last decades, the field of psychiatry has grown tremendously, but despite prevailing optimism we are faced with many challenges. A major challenge is that psychiatric services in many European countries are faced with increasing immigrant populations. Here there is a need to integrate knowledge hereof in the undergraduate, graduate and postgraduate training curriculum.

A main educational goal is to construct the core elements of a graduate training curriculum in psychiatry regarding cultural aspects to ensure high quality of psychiatric services via the creation of competent psychiatrists in all areas of Europe and promote the standard of training for cultural psychiatry by providing recommendations for training agreed upon by all stakeholders.

No explicit health policy has been formulated in many countries with respect to immigrants of which a large proportion has a traumatized background with a variety of problems linked to this.

Till now, the psychiatric curriculum in most areas comprises little training on cultural issues. On both under- and post-graduate level, the curriculum should comprise training in transcultural aspects of psychiatry.

With increased globalization there is a need to pay more attention to cultural aspects at all levels and develop strategies to increase the cultural competence of mental health professionals.

Consensus statements on psychiatric training and related issues related to cultural issues should be produced.

The paper will discuss the content of a culture sensitive curriculum and strategies to implement it.

Since the 1950s, political reforms have changed mental health care in most European countries. The political drivers, onset, pace, underpinning legislation and exact outcomes of reforms varied greatly among European countries, but there are also some common elements. Former large asylums have been closed or downsized, and different forms of services in the community have been established, particularly for patients with severe mental illnesses. Working in the community - in one form or another - is part of the job of many psychiatrists, and this aspect comes with specific challenges. These include working in a multidisciplinary team, establishing and maintaining positive relationships with patients in variable settings, combining different approaches in the treatment of often complex disorders, coordinating care across services, and taking responsibility for the quality of care in often difficult circumstances. This requires competence and skills that may be different from those of traditional psychiatrists working in hospitals. Psychiatrists should have appropriate skills in therapeutic communication, the management of small groups and the integration of different approaches of treatment and support. All these skills require appropriate training which most current curricula arguably do not provide. The stronger focus on the skills specifically required to work in the community is likely to change the traditional role of psychiatrists, but might increase the attractiveness and fascination of being a psychiatrist in the 21st century.

According to WHO estimates, 1.5 million people worldwide will complete suicide in the year 2020 and approximately 10-20 times this number will attempt suicide. Given that suicide still remains the most serious outcome of mental disease, it is essential that psychiatrists are specifically trained regarding legal and ethical aspects related to the treatment of suicidal psychiatric patients.

Clinical decisions guided by evidence based knowledge and ethical judgments according to the principles of beneficence, non-maleficence and autonomy intimately interact when a psychiatrist performs suicide risk assessment, recommends treatment and follow- up rehabilitation measures. Ethical dilemmas of respecting acute suicidal or chronic suicidal patient's autonomy when she/he is unable to control self-destructive impulses, confidentiality, Do Not Resuscitate (DNR) orders and involuntary confinement for the institutional ward will be discussed.

Existing research indicates that suicide risk is higher in the immediate aftermath of discharge from the hospital and when patients are transferred to outpatient care without securing the follow- up visit. Psychiatrists are sometimes under considerable pressure, due to economical downsizing of the psychiatric care, to discharge suicidal patients from inpatient care, which can lead to serious legal and ethical repercussions. Following evidence-based procedures is crucial, as well as maintaining a high standard of documentation for all processes and decisions taken.

Continuous education of health care staff, scrutiny of existing routines and knowledge about own attitudes towards suicidal patients are needed in order to prevent suicide.

Genome-wide association studies of psychiatric disorders have highlighted several novel susceptibility genes and taught us several importnat lessons.

1. 1) Psychiatric disorders are polygenic disorders. The contribution of each locus to risk of disease is modest and disease risk increases substantially with the total burden of risk alleles carried.

2. 2) The best findings from GWAS do not necessarily fall within those genes that have previously been widely studied.

3. 3) Pursuing a “top-hits-only” strategy may prevent us from understanding the genetic complexity of psychiatric disorders and polygenic disorders in general. A detailed consideration of the wider distribution of association signals across studies may prove to be a valuable strategy in complex genetics.

4. 4) Allelic heterogeneity may be an important factor in psychiatric disorders. Allelic heterogeneity means that a phenotype can be caused by different alleles within a gene; this phenomenon has been extensively observed in monogenic disorders such as cystic fibrosis as well as in BRCA1/2-associated breast cancer.

5. 5) Finally, as with other complex phenotypes, GWAS in psychiatric disorders demonstrate that the variants identified so far only account for a small fraction of genetic variability.

Future research will need to embark on several complementary approaches in order to fill the yet “unexplained” part of the variance. These will among others include sequencing projects, pharmacogenetic studies, detailed genotype-phenotype dissection approaches, and the study of prospectively assessed phenotypes.

The Cognitive Behavioral Analysis of Psychotherapy (CBASP) by James McCullough is the only psychotherapeutic intervention specifically designed for chronic forms of depression. CBASP integrates behavioural, cognitive, interpersonal, and psychodynamic theories and strategies.

The approach focuses on problems resulting from maltreatment and inhibition of maturation in early childhood by using the therapeutic relationship in a personal disciplined way. In addition, other interpersonal strategies such as the Significant Other History, the proactive Transference Hypothesis, and the Interpersonal Discrimination Exercise are used to overcome preoperational thinking. By means of another specific technique, the Situation Analysis, patients learn to focus on the negative consequences of their usual behaviour and to use efficient social problem-solving strategies.

In a large study involving over 600 patients with chronic Major Depression, CBASP proved to be effective. The combination of an antidepressant and CBASP was the most beneficial treatment condition. Particularly effective was CBASP for the subgroup of chronically depressives with an early childhood trauma.

In the workshop the theoretical basis will be taught, the specific techniques will be shown by live and video demonstrations, and they will be practised.

There are significant differences in psychiatric training across Europe. In the light of the current direction of Europe (without borders with free movement of workforce) it is inevitable to harmonize at least basic standards of psychiatric education across Europe. Ideally by working in partnership with relevant national and international bodies (European Union of Medical Specialists, Board of Psychiatry - UEMS, European Psychiatric Association - EPA and European Federation of Psychiatric Trainees - EFPT). A qualitative data analysis on the most important challenges of psychiatric trainees across Europe, carried out by the EFPT in 2009, revealed several interesting findings which might be of interest not only for trainees, but for all involved in the process of psychiatric education. As the most important issue trainees reported the imperfect structure of the training programs and problems with implementation of new ones. That is why new training programs based on a competency based framework are being developed lately in number of countries (e.g. United Kingdom, Ireland, Netherlands). However, not only the structure of the training and its implementation remains an issue, trainees are concerned also with topics related to working conditions, insufficient training opportunities, lack of supervision, funding and availability of psychotherapy courses, etc. Based on these findings EFPT will undertake specific actions which in cooperation with other organizations shall lead in the future to better postgraduate training opportunities in Europe.

Training schemes in psychiatry are developed and evaluated by national education policy makers in the majority of European countries. However, the requirements that a training program in psychiatry should meet are also defined on the European level in a form of recommendations by the Board of Psychiatry - European Union of Medical Specialists (UEMS).

Recently, the European Federation of Psychiatric Trainees (EFPT) which represent trainees from more then 30 European countries, reported data pertaining to the structure of training programs and to the evaluation of training programs in 30 European countries. Whereas in the majority of European countries the structure of training programs and methods of assessment of trainees' competencies are partially compatible with one another and with the existing recommendations at the European level, the quality assurance of training programs varies significantly among countries. Regular evaluations of training programs and mentors, however, contribute to the proper implementation of training programs and help that the theoretical training principles are followed through in practice. As quality assurance of training schemes is an important mechanism how to improve the delivery of training programs, it should gain more focus by responsible authorities who structure the psychiatric training on the national and international European level.

Even if technology and information are omnipresent, they rarely meet harmoniously. Either the lack of sufficient means prevents good information to reach its target or the technology is too complex to integrate flawlessly in the daily workflow.

The use and misuse of information technologies (internet, email, e-learning, social networks) has recently significantly increased among psychiatrists and patients and the changes in behavior of communication and seeking informations are real challenges.

Using the European Federation of Psychiatric Trainees network, the self-questionnaires concerning the usage of information technologies and the local patients-therapists communication were distributed among psychiatric trainees of 31 European countries.

A review of the results of this study, as well as recommendations about netiquette and useful websites for psychiatrists and scientists will be presented in detail.

There is no doubt that, in the modern era, psychiatry and the pharmaceutical industry have a relationship, though the nature of this is not universally well defined. Given that psychotropic medication is widely prescribed (ranking 3rd and 4th in US sales in 2007), and the role of the pharmaceutical industry in medical education has come under scrutiny, it is worth noting that the relationship between the industry and psychiatry trainees has not been studied in great depth.

Our Pan-European research group, composed exclusively of psychiatry trainees from at least 18 different countries, as part of the European Federation of Psychiatric Trainees (EFPT) has sought to study this in a systematic fashion. I will present preliminary findings of our survey, PRIRS (Psychiatric Residents-Industry Relationship Survey) which is currently taking place.

It is also hoped that this will facilitate a discussion amongst those attending the session, on the role of the pharmaceutical industry in psychiatric training, education and in general.