With a growing number of elderly persons, geriatric depression - associated with important morbidity and mortality- is becoming a significant health problem. Given the risk of polypharmacy and increased side effects, alternative non pharmaceutical treatments such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) may be solution. Recently, the FDA approved deep brain TMS (dTMS) for depression, not only stimulating deeper cortical areas but response and remission rates may be better, especially in elderly populations. Nevertheless, beneficial follow-up options following rTMS treatment remains to be determined. Therefore, one week after the last accelerated dTMS, all patients followed a 3 week open label tDCS with a home-use device. Study rationale and preliminary findings will be discussed.

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This study characterizes the real-world effectiveness and tolerability of transcranial direct current stimulation (tDCS) and aims to identify predictors of treatment outcome in patients with major depressive disorder (MDD). Treatment data was collected by the treating physician to a structured data collection form, from the patients who were treated with tDCS as part of routine clinical practice (F3 - F4 electrode montage, 2 mA, 30-mins sessions, 5 sessions per week, 2–3 weeks + maintenance treatment according to patient’s individual needs). Symptoms were scored according to common validated depression scales before and after the tDCS treatment. The study outcomes were clinical response (defined as >50% reduction from the baseline depression score) and remission. Furthermore, the data set allowed to investigate possible predictors of outcome, such as use of psychotropics and baseline depression severity. Overall, tDCS was found to be an effective and safe treatment for MDD in real-world patient population.

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A psychiatric facility represents a temporary home for its patients. Multiple studies have provided ample evidence that the built environment has the potential to support patients in their recovery process, in part by offering a homely surrounding. If their environment also succeeds in creating a therapeutic milieu in which the patients’ needs for protection, security, privacy, and orientation are met, the contribution of these surroundings can be even more significant. For example, clear, comprehensible building structures help patients to find their way around the new environment and further provide a feeling of security. To fulfill this goal, planners should pay special attention to the access zones and semi-public spaces in these types of buildings, as psychiatric patients often spend a lot of time there. Corridors should provide high spatial quality with daylight areas and places to sit down.

Based on an analysis of more than 30 psychiatric facilities in Germany, three spatial typologies were identified within which the factors listed above have been explored.

Firstly, the “Pavilion type”: square or slightly rectangular pavilion structures, generally with courtyards enclosed on four sides and multiple additions. This typology is found very often, especially on new build sites. The Pavilion type allows a useful combination of room functions and good lighting of all spaces. Secondly, the “L- or T-shaped type”: Linked L- or T-shaped, often appearing as comb-like buildings. These structures are particularly successful in integrating with the surrounding landscape. Thirdly, the “Block type”: Closed, block-like single-floor and two-floor typologies of different lengths. However, these building structures are increasingly rare as they often appear out of human scale and result in long, monotonous corridors.

In building design it is crucial to consider the triad of “architecture/interior design/ and landscape design” and to emphasize the specifics of the site. Each of these typologies offer different opportunities to achieve this goal; yet, only when a unique atmosphere is created – one in which everyone feels accepted and is seen as an individual – can patients, staff and visitors feel the comfort and support of a successful homely environment.

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Hospital built environment can affect patient clinical outcomes, patient satisfaction with care and treatment, staff performance and wellbeing, and carers/visitors’ engagement with services. Little is known about which urban planning, architecture and interior design characteristics can make environments therapeutic or detrimental for users.

We hope that the audience attending this presentation will i) get a good understanding of the impact of the hospital-built environment on patients, staff and visitors/carers and ii) understand which design elements can improve patient satisfaction with care.

As hospitals are among the most expensive facilities to build, their design should be guided by research evidence. In this presentation, we will review existing research evidence in this field and present our study of 18 psychiatric hospitals in Italy and the United Kingdom. Our findings indicate that out of several hospital built environment characteristics, two have the power to increase patient satisfaction with care.

These are (availability of) mixed-sex wards and rooms to meet family off wards.

We will show vignettes to further explore the role of mixed-sex wards and family rooms and discuss how to implement them when renovating, adapting or building mental health care facilities.

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Dr. Pereira-Sanchez will discuss how the climate change emergency apeals psychiatrists and demands both personal and organized responses. Such responses are in the domains of awareness, research, education, and action. Dr. Pereira-Sanchez will present specific examples from his collaborative work at the World Network of Psychiatric Trainees, where a global forum about the topic for trainees was organized, and the World Psychiatric Association, where he assists the coordination of a Tri-Sectional initiative on the topic.

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Sociopetal design methods can offer interesting means to support therapeutic concepts within ward environments. They can help to forge group identities through offering patients, staff and visitors opportunities to identify with the spaces they inhabit. “Sociopetal space” has been defined as “spaces which help bring people together"; but how does this actually work and what role can these types of spaces play in a hospital ward setting?

Some of these elements operate at a detail level and can be rather simple to deploy. Normalising the environment by making “regular” design decisions such as by using real rather then simulated materials (ie., actual wood rather then “wood patterned” furniture); or through offering a mix of lighting (ie., artificial and natural sources in variation) can create more homely spaces for patients and staff alike. Ultimately, design decisions at the detail scale can create phenomenal elements which can play a large role towards generating a favorable atmospheric experience on the ward.

It is also possible to explore how specific moments or places within a psychiatric ward might be designed to support patient agency, even on a closed ward. Sociopetal elements such as well-sited sitting spaces can offer moments of safety or retreat, leading to a greater sense of control. This can help patients feel more open to positive interactions with their colleagues and staff because they can safely observe or choose less committed ways of participation in daily or group activities.

Zooming out from these details, we will also look at the layout of a psychiatric ward (ie. accommodations) to help identify where opportunities such as those listed can be found. Simple gestures such as a slight widening of the corridor leading to important shared areas or better access to light or views of nature have been shown to improve outcomes for patients. What other design elements can be placed on or within wards to further this approach? Recent and ongoing projects within our practice will be shared to help workshop participants gather literacy in case they may be involved in future design projects.

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I will point out the important role of a thorough planning process in which all stakeholders work together starting in early phases of the design process („phase 0“) and engage in a truly interdisciplinary and iterative process throughout the entire planning phase as well as the building phase (where often ad hoc decisions have to be made in order to adjust to unforeseen circumstances).

I will examine the terms "Consensus Design" and "Evidence-Based Design" and relate them to lived reality by giving a number of examples from own experience. Here I will contrast different approaches in carrying out the planning process and demonstrate how only a truly interdisciplinary and iterative process can result in individualised and optimised therapeutic environments, strengthen identity and reduce stigmatisation.

As a support to future projects which workshop participants may be involved in, I will share some of the basic methods and tools which I have seen or used to help build and maintain this type of collaborative conversations throughout project phases.

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A new interpretation of the normalised “Wayfinding” design task offers the opportunity to become an important element of the larger clinical and architectural project for a new “core” expansion of a large regional psychiatric hospital in the South-East of the UK. We call this new approach Waymaking, as it goes beyond signage, leveraging our deep-set knowledge and understanding of the entire project at all scales.

Waymaking at the Rivers Centre for Mental Health (Rivers) begins with the exploration of movement narratives into and around its larger site. It turns a classic design task into a design opportunity on all scales, starting with an urban design and planning perspective, through to the architectural and landscape design decisions outside of the building and into the specific on-ward atmospheres in a manner integrated with the detail interior design decisions of colour, built-in-furniture and others.

Rivers has been carefully composed out of existing structures as well as smaller new-build and extension buildings. These are all set within a large, sloping site of noteworthy natural beauty. As such, Rivers can well be understood as a hillside village or campus of health - rather than as a traditional “hospital.” As a health village, Rivers provides spatial sequencing as the landscape design directly introduces a series of smaller, more human scale spaces built and natural all of which together aid in orientation and identity across the site. This will help support the daily use of the buildings by all stakeholders.

This strategy has been “baked-in“ to the architectural design as well, strategically distributed retreat/recovery spaces allow for space for de-escalation or relaxation. These can be found in the form of regular niches in the hallways and “porch” entrance spaces, usually with built-in benches and bespoke lighting elements. In addition to creating orientation affordances, these also provide opportunities for neurodivergent persons (ie. ASD, learning disabilities, etc.) to better understand and master independent movement around the Centre.

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Workshop War in Ukraine – a Big Challenge for the Mental Health Care

Abstract of presentation Mental health of internally and externally displaced persons in war period (Ukrainian experience)

Maruta

“Institute of Neurology, Psychiatry and Narcology of the National Academy of Medical Sciences of Ukraine” State Institution

The presentation is devoted to mental health problems of internally and externally displaced persons during the war. Issues of etiology, pathogenesis and clinic-psychopathological manifestations of mental disorders in displaced persons are considered.

The main focus is on risk, anti-risk factors and stress coping strategies that prevent the development of mental disorders.

The presentation also provided a system of therapy and rehabilitation for internally and externally displaced persons, as well as an evaluation of their effectiveness.

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After two years of pandemic with COVID-19 Europe is facing a war, which has already caused numerous death and injuries, mass displacement, and aggravated the economic and energy crisis and has left most countries completely unprepared and created a humanitarian crisis. The COVID-19 pandemics crisis pointed out the unpreparedness of the health (including mental health) sectors for the emergency situations. However, we also learnt some of the practices that proved effective – including the fast creation of collaborative networks on a larger scale that also allowed fast spread of good practices and practical organisation of help. The European Psychiatric Association as well as individual national psychiatric association have started an informal network of solidarity for Ukraine on February 28th, 2022 to respond to the needs of people in Ukraine as verbalized by the Ukrainian mental health professionals, but also to the need of surrounding countries where people from Ukraine fled to. Through this network several actions, including financial support, medical donations and education. The Croatian Psychiatric Association took the lead in the organisation of education for first line helpers and volunteers from Ukraine and countries surrounding Ukraine where displaced persons fled to, in collaboration with many partners.

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Europe is again confronted with a new dramatic emergency, a war which has already caused civil victims, mass displacement and even fear about a nuclear war and energy crisis. Again, Europe is facing new waves of war refugees, forcibly displaced people. There is increasing evidence that a large proportion of refugees or forcibly displaced persons suffer from the consequences of traumatic events and exhibit psychological problems or develop mental disorders, including post-traumatic stress disorder, depressive and anxiety disorders, and relapses in psychotic episodes. European countries are trying to face with an extraordinary surge of solidarity and generosity, but at the same time with the awareness that the needs are much beyond reaction capacity of individual people and states. The direct and indirect consequences of this humanitarian catastrophe cannot be estimated at present. Mental healthcare services are suddenly faced with major challenges and need to develop or expand strategies to address them. In this presentation, strategies from Germany will be presented and discussed.

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Armed conflicts produce a wide series of distressing consequences, including death, all of which impact negatively on the lives of survivors. This presentatiin focuses specifically on the mental health consequences of war on adults and child/adolescent refugees or those living in war zones basing upon review of all systematic reviews and/or meta-analyses published from 2005 up until the current time, that is Fifteen systematic reviews and/or meta-analyses conducted in adult populations, and seven relating to children and adolescents. Prevalence rates of Anxiety, Depression and Post-traumatic Stress Disorder (PTSD) were two-three-fold higher amongst people exposed to armed conflict compared to those who had not been exposed, with women and children being the most vulnerable sujects. A series of war-related, migratory and post-migratory stressors contribute to short- and long-term mental health issues in the internally displaced, asylum seekers and refugees. Based upon these evidences psychiatrists and psychiatric associations should take also the ethical responsibility for raising awareness of political decision-makers as to the mental health consequences caused by armed conflicts as a further reason for improving peace-keeping initiatives.

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In recent years, the state-funded side of the Hungarian psychiatric system has been struggling with a serious lack of resources. During the pandemic the level of organization, which was also not perfect, continued to deteriorate. Immediately after the breakout of Ukrainian war the civilians started to make significant efforts to support refugees. From the beginning our Association joined activities of Solidarity Network organized by EPA. We made efforts among other things to find Ukrainian-speaking psychiatrists to tackle the language barriers, connect the needs with the offers psychologists. When a refugee is admitted to a psychiatric unit as a patient, they receive all mental health care as any Hungarian citizen would. Overall however, mental care is insufficiently organized and the patient pathways for refugees - as those of the population - are not well-defined. The coordination between government services and civil organizations helping refugees is unsatisfactory. There is no steady support system that could provide regular, professional mental health care for those in need, thus a mental triage process is also missing to uncover the perhaps less severe mental problems, that nevertheless might require professional attention. Consequently there also seems to be a lack of assistance in trauma processing. There are some official civil organizations (e.g. Maltese Charity Service, Hungarian Red Cross) that are doing all they can for the refugees, but most of their staff is not professionally equipped to provide mental health care or to reliably identify when it is needed. When refugees show symptoms of a severe nature (psychosis, mania, severe depression, suicidal thoughts) they reach out to the professional mental health care system, but refugees struggling with less obvious mental health problems generally stay out of sight of professional psychiatric or psychological care.

civilian efforts, unmet needs, lack of human resource

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Immediately after Russia commenced aggression against Ukraine, the Polish Psychiatric Association publicly called for humanitarian support for Ukraine and initiated meetings with representatives of Psychiatric Societies operating in Ukraine in order to identify current needs in the war-stricken areas and coordinate aid.

The PPA allocated its financial resources to humanitarian aid and, through the EPA, appealed for condemnation of military operations as well as support for Ukraine by individual NPAs.

According to the UHNR data over 4 million displaced people, refugees, came to Poland so far and some of them benefited from such help.

The Polish Psychiatric Association supports the initiatives of non-governmental organizations supporting refugees and monitors and responds to the needs reported by the Ukrainian side on an ongoing basis. At present, the PPA activities focus on the following priorities:

1. Need-adapted-help: Provision of customized aid - not only medications but also power generators, technical equipment. And so, the PPA shipped to Ukraine some basic equipment, sleeping mats, bedding, mattresses, backpacks, cleaning products, personal hygiene products, as well as tools for renovation and construction.

2. Awareness - highlighting the consequences of Russia’s aggression on people with mental disorders in Ukraine and its impact on the entire population (PTSD, grief). Inviting and lobbying for dissemination of personal reports of Ukrainian health care workers and patients at international conventions, forums, events

3. Empowerment of personnel - strengthening competences required in provision of assistance in war-related disorders, training, projects of activities both across Poland and Ukraine

4. Supporting and responding to the needs reported by local psychiatric assistance centers facilitating and strengthening the competence of personnel in helping refugees

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Digital technologies and advances in computational methods have become key drivers of innovation in many medical fields. In precision psychiatry, accurate and reliable measures of mental health are critical for informing patient care and clinical research. There has been growing concern over the limitations of traditional mental health assessments that are typically grounded in nosology defined by the DSM and are based on interviewer-led assessments or patient self-report questionnaires. Whereas such gold-standard clinical assessments can be cost-prohibitive, insensitive to change, and prone to subjective biases, the use of digital technologies provides an opportunity to improve the practical feasibility as well as the inter-rater and test-retest reliability of repeated mental health assessments. The key promise of this approach is to unlock the clinical potential of digital technologies in ways that foster research of high clinical relevance and impact on clinical care. I will discuss these promises and challenges for the future use of machine learning approaches for predicting and monitoring post-traumatic stress and resilience.

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Psychiatry faces fundamental challenges with regard to mechanistically guided differential diagnosis, as well as prediction of clinical trajectories and treatment response. This has motivated novel approaches that aim to develop “computational assays” for inferring patient-specific disease processes from neuroimaging data, which can then be incorporated into decision making in everyday clinical practice. Such computational assays are often based on generative models, which describe how measured data may be caused by a particular mechanism. Combining generative models with machine learning allows translating the inferences from computational assays into patient-specific predictions, an approach referred to as generative embedding.

Here, I illustrate the clinical potential of generative embedding for the exemplary case of a generative model of whole-brain effective (directed) connectivity: regression DCM (rDCM). First, I introduce rDCM to the audience and highlight its relevance for understanding the pathophysiology of psychiatric disorders. I then provide an initial demonstration of the clinical utility of rDCM. Specifically, we assessed the ability of rDCM for predicting future episodes of depression in never-depressed adults, using a large dataset (N=906) of resting-state fMRI data from the UK Biobank. Over a 3-year period, half of the participants showed indications of at least one depressive episode, while the other half did not. Using nested cross-validation for training and a held-out test set (80/20 split), we found that a generative embedding procedure based on rDCM in combination with a support vector machine enables statistically significant predictions of future depressive episodes, both on the training (accuracy: 0.63, area under the curve (AUC): 0.66, p<0.001) and test set (accuracy: 0.62, AUC: 0.64, p<0.001). Interpreting model predictions based on SHAP (Shapley Additive exPlanations) values suggested that the most predictive connections were widely distributed and not confined to specific networks.

In summary, generative models of brain connectivity in general, and rDCM in particular, show initial promise to serve as computational assays for psychiatry. Our analyses suggest that (i) fMRI-based generative embedding approaches have some capacity for early detection of individuals at-risk for depression and (ii) achieving accuracies of clinical utility may require combination of fMRI with other data modalities.

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Despite extensive research, the cognitive processes mediating the impact of psychotherapeutic interventions remain poorly understood, and as a result difficult to quantify. Identifying such mechanisms is likely to be extremely helpful: it could help target interventions better, could support dosing therapy through monitoring, and could heighten the speed at which new interventions can be developed. Mechanisms research in psychotherapy has described a number of key difficulties to achieving this. In this and the next talk, we ask whether advances in cognitive computational neuroscience might provide some support. Specifically, the question is whether precise cognitive probes might identify specific mechanisms of interventions. In support of this, I will first describe a pilot study in participants undergoing an adapted behavioural activation therapy. I will then move to present results from two strands of experiments examining whether interventions derived from components of cognitive-behavioural therapy (CBT) are able to shift computationally-derived measures of their proposed psychological substrates. Findings from both strands will be discussed with respect to challenges in developing brief, reliable, engaging, and user-acceptable measures of cognition. Overall, this outlines some early new results in using computational methods to understand therapeutic processes in the psychotherapy for depression.

Q. Huys Grant / Research support from: Koa Health, Consultant of: Aya Technologies and Alto Neuroscience

The use of social networks is an integral part of our daily life as a means of communication. Patients manage information mostly from the internet, that strongly influence their beliefs and behaviors toward illness. Scientific dissemination through these kinds of platforms has expanded enormously in recent years, varying between them in style, contents and type of interaction with the users, that make necessary an individualized analysis. The use of Instagram goes beyond sharing photos and free comments, and it has been used extensively in different fields of medicine, such as mental health. This tool has enormous potential as a means of more effective communication and prevention and it is very valuable as a tool for psychoeducation and prevention in mental health. However, in the era where “information is easy to get but knowledge is difficult to find”, professionals of mental health should get involved and adapt to new scenarios of communication.

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In this first session of our motivational interviewing workshop, we address the basic principles of how every therapeutic relationship should be established and the main differences for the right environment in which we can develop motivational interviewing tactics that can be used to precipitate enduring change.

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In the field of health, social networks are increasingly used for research since they have demonstrated multiple uses. Proof of this is that more and more projects financed by public entities use this methodology, as well as scientific publications.

In the symposium, how to do this type of research will be explained in a practical and useful way for the listener. It will be explained with practical examples, and based on successful publications, how this type of work is designed, what type of people should integrate this research team, how to carry out the project, interpret the results and publish them.

We will also address the difficulties encountered and how to overcome them. Attendees will be able to ask all the questions they deem appropriate.

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