Recent findings in 345 depressive patients and 89 healthy subjects from three international independent laboratories and hospitals offer clear and consistent information that possesses strong explanatory potentials for suicidal behaviour with death intent and for clinical use in suicide risk assessment and therapeutic intervention. Its extraordinary high sensitivity (97%) and specificity (93%) for suicide and the extraordinary highly significant relationship with operationally defined suicidal propensity (p= 8.3 x 10-17 and p= 6.1 x 10-20), its consistency over a row of published studies and its independence of serotonin, depression rating scores, antidepressive medication and other relevant variables makes the measurement of electrodermal hyporeactivity in an specifically designed acoustic habituation test a useful clinical tool for suicide risk detection as an important complement to the clinical suicide risk assessment.

Its theoretical links over specific brain structures to indifference towards everyday life (indifference vulnerability for suicide) and known cognitive dysfunctions like overgeneralized autobiographic memory offers a new psychobiological platform for theoretical work and support for cognitive therapeutic interventions in depressed and euthymic patients for preventive and possibly cure of suicidal propensity, beside known and possible biological treatment methods. Thorell's Hyporeactivity Theory is compared to other models and theories of suicide.

Some parts of the presentation are extracted from Thorell LH (2009): Valid electrodermal hyporeactivity for depressive suicidal propensity offers links to cognitive theory, Acta Psychiatrica Scandinavica, May;119(5):338-349.

Among the empirically supported psychiatric treatments, psychotherapy has produced a strong record of scientific evidence. This is especially so when looking at long-term, sustainable treatment gains. However, when performing psychotherapy, psychiatrists may encounter particular challenges regarding the following four basic ethical principles: respect for the patient's autonomy; beneficence; nonmaleficence; and justice. In balancing these principles, and applying them to an individual problem during psychotherapeutic treatment, the consequences to the patient and to others of different courses of action will have to be examined (utilitarian reasoning); comparing the problem with other, apparently similar problems may be another way of finding a solution; finally, in certain situations, absolute rules will be applied, e.g. the rule that therapists shall not exploit patients sexually or in other ways. A number of frequently occurring specific issues will be discussed: confidentiality and its possible exceptions, conflicts of interest, and consent to treatment. In addition, problems that arise specifically from the psychotherapeutic treatment setting will be addressed, such as imposing values in psychotherapy, sexual and non-sexual boundary violations. Ethical issues must be dealt with pro-actively and transparently throughout the psychiatrist's professional career. This can be done, e.g., in individual or group supervision and intervision. Awareness regarding ethical issues should be raised in psychiatric residents and psychotherapy trainees right from the beginning of their training.

I will examine a range of ‘treatment pressures’ in mental health care exerted on patients who are reluctant to accept treatment. Conceptual distinctions of moral relevance can be drawn between a number of interventions commonly termed 'coercive'. These include ‘compulsion’, ‘coercion’ (narrowly defined), ‘exploitation’, ‘deception’, ‘inducements’ (or offers), and ‘interpersonal leverage’. These pressures may be placed on a rough hierarchy of moral seriousness.

Justifications for coercive interventions will be briefly discussed and I will recommend a ‘capacity-best interests’ framework as applicable across the whole range of interventions.

Measures that may reduce the need for ‘coercion’ will be briefly discussed, the most promising being certain types of ‘advance statement’ which, among other effects, enhance patients' involvement in their treatment.

Prevention of severe mental disorders, and especially the indicated prevention, has become a main topic in psychiatric research and, consequently, a matter of ethical debates. Neuropsychiatric disorders, however, form a most heterogeneous group of disorders that, among others, strike first in different age groups, differ in outcome and in availability as well as safety of treatments, have more or less understood different aetiologies and are subject to different degrees of stigmatisation and discrimination. And, although the main focus and critic are on the accuracy of prediction and the safety of treatment, concerns and arguments vary with the different characteristics of the considered disorder.

Taking endogenous psychoses as an example, costs and benefits of an early detection, of an early intervention and of prevention research in the prodromal or premorbid phase will be reviewed. It will be argued that the best way to adhere to the major ethical principles in medicine - autonomy, nonmaleficence, beneficence and fairness - in research and clinical practice will have to be reassessed continuously against the background of the current state of knowledge as well as the public opinion. Thereby, great care has to be given to ensuring that the great expected ‘common good’ will not overcome an individual patient's right to his or her own good and that, especially in patients more vulnerable to misuse, i.e., minors and those already impaired in their decision-making capacity, autonomy is given priority.

Depression is a complex disorder characterized by a disruption of brain functions and altered intracellular mechanisms. However, it is evident that none of the current hypotheses of depression (monoamine, hypothalamo-pituitary adrenal, and neuroplasticity), can explain all the effects of antidepressants. On the other hand, there is no doubt that each of these hypotheses affords important insights into the pathophysiology of depression.

One hypothesis in particular is the object of an increasing body of evidence: the circadian rhythm hypothesis of depression is based on the fact that (i) depression is very often associated with a disruption of circadian rhythms, and (ii) the severity of depression is correlated with the disruption of circadian rhythms, suggesting that resetting the circadian rhythms may play a pivotal role in the treatment of depression.

Agomelatine is the first melatonergic antidepressant acting as an MT1/MT2 melatonergic agonist and as a 5-HT2C antagonist whose efficacy has been proven in several animal models of depression and in patients with major depressive disorder. These receptors are mainly present in the suprachiasmatic nuclei, but also in the hippocampus, prefrontal cortex, and hypothalamus.

Given the action of agomelatine through these receptors, it was important to establish to what extent agomelatine works through modulation or via synergic interaction between MT1/MT2 and 5-HT2C receptors. Recent data show that only agomelatine (not melatonin or a 5-HT2C antagonist) modulates the expression of neuroplastic genes (BDNF and Arc), suggesting that the intracellular events can be regulated through synergic activity between both melatonergic and 5-HT2C receptors.

Successful management of major depressive disorder (MDD) requires antidepressant efficacy at each stage of treatment: rapid improvement of the symptoms in the acute phase, good quality remission in the continuation phase, leading to complete recovery in the maintenance phase. The early improvement of symptoms during the acute phase is predictive of chances of remission, as well as better long-term compliance and reduced risk of suicide.

Agomelatine is the first melatonergic antidepressant acting as a melatonergic MT1 and MT2 receptor agonist and as a 5-HT2C receptor antagonist. Its efficacy in the acute phase of treatment was examined in 4 short-term studies: 1) two 6-week, randomized, double-blind studies comparing agomelatine (25-50 mg/d) with venlafaxine (75-150 mg/d), (2) a 6-week comparison study of agomelatine (25-50 mg/d) with sertraline (50-100 mg/d), and (3) an 8-week comparison with fluoxetine (20-40 mg/d) in patients with severe depression.

After 1 week of treatment, agomelatine was significantly more effective than venlafaxine on the following parameters: CGI-I (total score and response rate), daytime alertness, feeling good, getting to sleep, and quality of sleep. After 2 weeks, using HAM-D, there were twice as many responders to agomelatine as to sertraline. After 6 weeks of treatment, these differences in favor of agomelatine were maintained. After 8 weeks, agomelatine showed superior antidepressant efficacy on HAM-D total score and CGI-I over fluoxetine in treating patients with severe episodes. These convergent results make agomelatine a promising antidepressant for improving all stages of MDD and ultimately helping more patients to achieve complete and sustained remission.

After the initial response, the next goal is to ensure sustained remission with normal functioning and minimal residual depressive symptoms. During this phase, continued adherence to treatment is needed, which is easier if the patient perceives improvement and tolerates the treatment well. The efficacy of agomelatine, the first melatonergic antidepressant with an innovative mode of action, has been assessed in the long term in 4 studies:

1. (1) the 18-week extension phases of two short-term studies comparing agomelatine (25-50 mg/d) with venlafaxine (75-150 mg/d),

2. (2) a similar extension phase after 6 weeks of treatment versus sertraline 50-100 mg/d, and

3. (3) a specific 10-month placebo-controlled relapse prevention study.

At 6 months, more patients responded to treatment with agomelatine either in term of improvement in CGI-I scores as compared to venlafaxine (P< 0.05), or in terms of response rate on the HAM-D as compared to sertraline (P< 0.05). Agomelatine therefore appears to produce in more patients a relief of depressive symptoms than either SNRIs or SSRIs.

A meta-analysis showed that a higher percentage of agomelatine-treated patients completed the extension period of 6 months as compared with venlafaxine or sertraline suggesting that clinical improvement induced by agomelatine lead to a better compliance to treatment.

The antidepressant efficacy of agomelatine is maintained in the long term, as demonstrated by the prevention of risk of relapse by 56.3% versus placebo over a 10-month treatment period (p< 0.0001).

All these features make agomelatine, the option to consider for achieving a full recovery from major depressive disorder.

Agomelatine, the first melatonergic antidepressant, has been widely recognized as a true innovation since its launch in Europe one year ago. Agomelatine has a unique pharmacological profile: an agonist at MT1/MT2 melatonergic receptors and antagonist at 5-HT2C receptors, it resynchronizes altered circadian rhythms in depression.

Agomelatine has already become a first-line treatment option for patients with a first depressive episode, as well as those with recurrent depression. In daily practice, agomelatine can be used in all depressed patients, and is particularly indicated in patients complaining of sleep difficulties. Agomelatine ensures unimpaired daytime vigilance, cognition, gastrointestinal transit, and sexual functioning. Feedback to date from both inpatients and outpatients with major depression is positive: beyond the antidepressant effect, patients frequently report improvement in sleep-wake rhythms and daily functioning, as early as by the first week (mostly within the first 3 days), which differentiates agomelatine from other antidepressants. Most patients report improvement in mood and other symptoms after 2/3 weeks and satisfactory tolerability. The most frequently noted side effects are dizziness, headache, and nausea; liver function tests at initiation of treatment are not considered to be an issue. Because agomelatine, unlike conventional antidepressants, does not affect serotonin levels, in case of switch the initial antidepressant should be progressively downtitrated to avoid discontinuation symptoms, which risk masking the benefits of agomelatine.

In summary, the early effects of agomelatine shown in controlled studies are also experienced by the majority of patients in daily practice and reflect its ability to resynchronize circadian rhythms.

Treatment for alcohol dependent patients represents a largely unmet challenge in psychiatry and psychotherapy. Less than 10% of individuals in need are actually receiving treatment, fewer than in any other field of psychiatry (Kohn et al., 2004). Evidence-based psychotherapy and pharmacotherapy is available and will be reviewed (incl. the United Kingdom Alcohol Treatment Trial UKATT and the COMBINE Study). In general, effect sizes are low and lag behind success rates in fields such as smoking cessation. The main reason is the heterogeneity of patients being offered rather specific treatments in conventional RCTs. While some patients may clearly benefit others may not and some even get worse, making means of results rather meaningless.

Early attempts to introduce “personalised” treatment into the psychotherapy of alcoholism failed (Project MATCH). Current approaches use several domains for the sub-classification of patients such as psychopathology, genetics, neuroimaging, neuropsychology etc. (Mann et al., 2009). A new RCT (PREDICT Study) did not show a significant difference between naltrexone, acamprosate and placebo. However, by using f-MRI cue reactivity, genetics and psychopathology more homogeneous subgroups of patients could be defined. In these subgroups significant differences for naltrexone over placebo were found.

Personalized treatment seems to be a promising approach in alcoholism therapy. It may help to improve results considerable and thus create more motivation and hope in patients as well as in psychiatrists.

Huge geographical distances aside with language barriers are major obstacles in provision of mental health care in greenland. Dispersity of population and shortage of professional resources that speak inuit language were and still are major challenges in development of an effective mental healt care system. Telepsychiatry was developed in Greenland during last 10-15 years. The presentation will run through major aspects of historical facts as well as potential future impacts of telepsychiatry on development of modern health system in Greenland. Pioneer experiences with telepsychiatry via patients‘mother tongue will also be presented.

Having developed the first Forensic Tele-psychiatry Service in UK in 2005 the presenter would like to share this experience with the attendees of the symposia. Recommendations under Part III of the Mental Health Act 1983 have also been made. They have been accepted by both the Magistrates’ as well as Crown Courts. Assessments were primarily undertaken using the already existent video-link facilities within local Magistrates’/Crown courts and HM Prisons. The above experience supports the view that this saves time, cost and improves access to psychiatric services.

The presenter has also developed a Forensic Telepsychiatry Steering Group, with a research sub-committee, based in Nottingham. They are coordinating several research projects, exploring the use of teleconferencing facilities within forensic psychiatry. The session will discuss how the above is relevant to Forensic Psychiatrists and also address its importance to the training of forensic psychiatrists.

Tele-psychiatry has been used by other services in UK in Forensic settings albeit in a narrow remit not involving actual gate keeping assessments, preparation of Court Reports etc. The session will discuss how it is crucial for services across the UK and beyond to share experiences and promote innovative practices. It will aim to explore ways to succeed with regard to delivering timely, easily accessible and clinically sound psychiatric services, with the additional spotlight on cost-efficiency, saving valuable professional time and ‘going green’ with respect to health service delivery.

Today's use of internet technology brings with it “cost effectiveness” for Tele-psychiatry applications. Today, with a relatively current laptop computer, a web-cam, broadband connectivity (128 kbs or faster), and a free downloadable, secure video conference application, makes this technology available literally and virtually everywhere, anywhere, and at any time. We provide individual assessment, medication management, psychotherapy services and a unique “Co-Therapy” model in the treatment of Opoid Dependence. Study patients are located throughout the states of Arizona, and Alaska. Availability of broadband connectivity is the only limiting factor to access.We have compared the effectiveness of “Home-Telepsychiatry”, to more traditional “office based” Tele-Psychiatry over 8 years with 800 Home Telepsychiatry cases, and 1200 Office based cases. There is a clear patient preference for the Home-Telepsychiatry model. Compliance is dramatically improved as is the no-show statistic dramatically decreased. Outcome data clearly favors the Home-Telepsychiatry model.Mentally ill patients favor treatment provided in “their private space”. Providers learn more about their patients when we are a “guest” in the patient's home. Access to “patient support providers”, spouses, parents etc. is easy and more valuable using Home-Telepsychiatry.

International telepsychiatry service was established between Denmark and Sweden in order to increase access to cross-cultural expertise that was more readily available in Sweden. Video-conferencing equipment connected the Swedish department of the Little Prince Psychiatric Centre with two hospitals, one asylum seekers’ centre and one social institution, at four different places in Denmark. Over a period May 2006-October 2007, 30 patients were treated by telepsychiatry (21 men and 9 women). After the end of the telepsychiatry contact all patients were asked to complete a satisfaction questionnaire.

The patients reported a high level of acceptance and satisfaction with telepsychiatry, as well as a willingness to use it again or recommend it to others. Patients expressed a wish to use telepsychiatry via their mother tongue, rather than through an interpreter in the future.

Mental health services in Scandinavia face significant resource shortages that may result in functional gaps. There is no doubt that mentally ill asylum seekers, refugees and migrants are under-served in their mother tongue. Telepsychiatry can ease the access to scarce resources and improve the quality of care. Presented service is the first international telepsychiatry collaboration to be established in Europe. The results of the survey may contribute to changes in policy and routines within mental health services towards cross-cultural patient population not only in Denmark but also in the rest of the EU.