One of the major challenges in clinical psychiatry remains the absence of well established objective measures of symptoms’ severity. Clinical insights are mainly provided through keen behavioral observation and subjective questionnaires and scales.

The aim of this paper is to predict depression severity through speech using the features extracted from the speech as provided by participants during a semi-structured dialogue with a virtual avatar.

We use data from a subset of the DAICWOZ dataset consisting in 142 dialogues between participants and a virtual avatar during which the avatar uses several prompts to maintain a conversation with the participant. The avatar uses prompts involving the topics of travel, dream jobs, and memorable experiences. From the speech generated from the dialogue, we extract participant utterances separated by prompt and extract features from the three sets of transcripts. We extract content features from the transcript and acoustic features from the excerpt corresponding to the speech from the participant for the prompt in question.We perform regression experiments on the PHQ8 items using the features extracted from each set of transcripts. Furthermore, we combine the features extracted from each set of transcripts and compute partial spearman correlations between them and the PHQ8 items using gender as a covariate.

With our best regression model we obtain an R2 of 0.1, explaining 10% of the variance in the PHQ total score. Additionally, we obtain a mean absolute error of 1.25, suggesting that the regressor can detect with more or less precision clinically meaningful differences in depression severity between participants. Partial correlations between the total score and the features show significant correlations between features dependent on the amount of speech generated by each participant, along with the complexity of syntactic structures used.

Automatic analysis of spontaneous speech could help with the detection and monitoring of signs of depression. By combining the use of this technology with timely intervention strategies for instance provided by a virtual agent it could contribute to timely prevention.

A. König: None Declared, M. Mina Employee of: ki:elements GmbH, S. Schäfer Employee of: ki:elements GmbH, N. Linz Shareolder of: ki:elements GmbH, Employee of: ki:elements GmbH, J. Tröger Shareolder of: ki:elements GmbH, Employee of: ki:elements GmbH

Major depressive disorder (MDD) is a highly prevalent mental illness that often first occurs or persists into adulthood and is considered the leading cause of disability and disease burden worldwide. Unfortunately, individuals diagnosed with MDD who seek treatment often experience limited symptom relief and may not achieve long-term remission, which is due in part to our limited understanding of its underlying pathophysiology. Many studies that use task-based functional magnetic resonance imaging (fMRI) have found abnormal activation in brain regions in adults diagnosed with MDD, but those findings are often inconsistent; in addition, previous meta-analyses that quantitatively integrate this large body literature have found conflicting results.

This meta-analysis aims to advance our understanding of the neural basis of MDD in adults, as measured by fMRI activation studies, and address inconsistencies and discrepancies in the empirical literature.

We employed multilevel kernel density analysis (MKDA) with ensemble thresholding, a well-established method for voxel-wise, whole-brain meta-analyses, to conduct a quantitative comparison of all relevant primary fMRI activation studies of adult patients with MDD compared to age-matched healthy controls.

We found that adults with MDD exhibited a reliable pattern of statistically significant (p<0.05; FWE-corrected) hyperactivation and hypoactivation in several brain regions compared to age-matched healthy controls across a variety of experimental tasks.

This study supports previous findings that there is reliable neural basis of MDD that can be detected across heterogenous fMRI studies. These results can be used to inform development of promising treatments for MDD, including protocols for personalized interventions. They also provide the opportunity for additional studies to examine the specificity of these effects among various populations-of-interest, including youth vs. adults with depression as well as other related mood and anxiety disorders.

None Declared

Repetitive Transcranial Magnetic Stimulation (rTMS) is a new emerging neuromodulation treatment that has been tried for multiple psychiatric conditions [1, 2]. Its major approved application is treatment-resistant depression (TRD) [1]. At the same time there is a perceived potential for its use for other clinical conditions, primarily other mood and anxiety disorders [2]. At Homewood Health Centre we have been using rTMS as an adjunct treatment for patients with TRD and multiple comorbidities.

To evaluate the effectiveness and feasibility of rTMS in complex clinical populations.

Observational study. Quick Inventory of Depressive Symptomatology (QIDS). Generalized Anxiety Disorder Questionnaire (GAD-7). Descriptive statistics.

We have treated 30 patients, 12 women (40%) and 18 men (60%), with average age of 42.0±15.6 years. All patients had a primary diagnosis of major depressive disorder. The standard questionnaires were used to quantify the severity of depressive symptoms (QIDS) and anxiety (GAD-7). The average baseline scores for depression and anxiety were 16.1±4.9 and 15.0±4.4, respectively. The patients received an average of 28.1±5.1 treatments. All patients but one received the full course of treatment as planned. The average end-of-treatment (EoT) scores for severity of depressive symptoms and anxiety were 9.6±6.5 and 7.3±5.3, respectively. The rates of improvement and remission for depressive symptoms were 66.7% and 36.7%, respectively. The rates of improvement and remission for anxiety symptoms were 76.9% and 30.8%, respectively.

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Our data indicate that rTMS provides significant improvement and recovery rates in complex clinical populations and is well-tolerated. While further research is required, we recommend wider implementation of rTMS for treatment of mood and anxiety disorders.

1. Brunoni AR, Chaimani A, Moffa AH, Razza LB, Gattaz WF, Daskalakis ZJ, Carvalho AF: Repetitive Transcranial Magnetic Stimulation for the Acute Treatment of Major Depressive Episodes. JAMA Psychiatry 2017, 74(2):143.

2. Somani A, Kar SK: Efficacy of repetitive transcranial magnetic stimulation in treatment-resistant depression: the evidence thus far. Gen Psychiatr 2019, 32(4):e100074.

None Declared

Depression can be understood as a complex dynamic system, where depressive symptoms can directly affect each other. Knowledge on this symptom-symptom interaction is still scarce and is likely to differ between individuals. The hypothalamic-pituitary-adrenal (HPA) axis is often implicated in depression, with hypercortisolism and impaired glucocorticoid receptor-mediated feedback inhibition being commonly reported. High salivary cortisol levels may reflect a reaction to symptoms, or may rather be a cause, effectively ‘binding’ symptoms.

We aimed to analyze the temporal interplay between salivary cortisol and emotions in depressed patients and controls by using the novel Dynamic Time Warp analysis (DTW) approach.

The ‘Mood and movement in daily life’ (MOOVD) study consisted of 30 pair-matched (15 depressed and 15 control) participants. Salivary cortisol was collected three times a day for 30 days, resulting in 90 measurements per individual. At the same moments, participants completed questionnaires on an electronic diary, which included different momentary positive (PA) and negative (NA) affect items. The dynamic interplay between salivary cortisol and affect were analyzed by DTW, which extends momentarily associations to include one earlier and one later time point, in both undirected and directed analyses.

Individual networks differed substantially within groups. At the group level, undirected and directed network analyses showed differences between depressed patients and controls. In undirected analysis, connectivity of PA items was comparable between depressed patients and controls, but the NA items showed a less dense network in depressed patients. Directed DTW analyses indicated (p = 0.07) that increases in salivary cortisol preceded that of some NA items (e.g., tiredness) in controls, but tended to follow upon NA item increase (e.g., not feeling appreciated) in depressed patients.

At the group level, connectiveness between NA items was substantially weaker in depressed patients compared to controls. As in complex systems strong internal connectivity facilitates “critical transitions” to different states, this may reflect (or explain) the persistence of a chronically depressed state. We preliminary conclude that high salivary cortisol in depression may be a consequence of NA, rather than a cause. Replication of these first exploratory findings are needed.

None Declared

Depressive disorder is one of the most typical psychiatric disorder that occurs after a traumatic event. However, there has been minimal research regarding the prevalence and associated factors of depression after a traumatic event.

Therefore, this study aims to investigate the prevalence of depressive symptoms and associated factors in the residents of the Gangjeong village, who have been exposed to a traumatic event recently for a prolonged period.

The subjects of this study were the residents of the Gangjeong village, who have been exposed to a traumatic event related to the construction of the Jeju Civilian-Military Complex Port. The questionnaires were used to assess the participants` general characteristics (sex, age, marital status, occupation, self-perceived health, etc.); in addition, for the clinical evaluation, overall stress was assessed through the Global Assessment of Recent Stress Scale (GARS), social support through Functional Social Support Questionnaire (FSSQ) and suicide risk through Mini-International Neuropsychiatric Interview-Plus (M.I.N.I-Plus). In order to evaluate the depressive symtpoms, CES-D (Center for Epidemiologic Studies Depression Scale) was used.

In 713 subjects, the prevalence of depressive symptoms was 18.5% (95% CI=15.66-21.36) (Table 1). Multivariate logistic regression analysis identified the length of residence and marital status as factors associated with depressive symptoms (Table 2). Furthermore, the depression group has a significantly higher score of overall stress (GARS), suicide risk and the lack of social support (FSSQ), in comparison with the non-depression group (Figure 1) group (depression gr. vs non-depression gr. : 28.8±15.0 vs 12.8±10.1, 4.9±8.0 vs 1.1±3.6, 44.8±13.2 vs 34.0±13.9, respectively).

The prevalence of depressive symptoms was higher among the study population compared to the general population. People exposed to the traumatic event, especially after prolonged exposure, should be assessed environment factors, the status of overall stress, social support and the suicidal risk.

None Declared

Depression is predicted to become one of the major sources of disease burden worldwide, leading to numerous adverse consequences that complicate the daily rhythm of life. Non-adherence is a serious issue in patients suffering from depression. Premature discontinuation of treatment is repeatedly encountered in depression, bringing on to increased disease severity, greater number of relapses, more hospitalizations and decreased remission rates. Given the impact of medication non-adherence among patients with depressive disorders, it is important to recognize factors associated with non-adherence and find ways to influence them.

Our objective was to find out the frequency, as well as potential differences in self-reported psychological distress of medical adherence in patients diagnosed with major depressive disorder.

Sample consisted 83 patients (Mage = 45.4, SD = 14.8, 76% were female, 24% were male) with major depressive disorder (MDD) hospitalized at the Clinical Department of Crisis and Affective Disorders. After the informed consent of patients, the following assessment tools were administered: A socio-demographic questionnaire, Mini International Neuropsychiatric Interview (M.I.N.I.-6), Depression Anxiety Stress Scales (DASS-21), and The Morisky Medication Adherence Scale (MMAS-8).

Thirty-three (39.8%) patients were considered non-adherent (MMAS-8 adherence score < 6) while 45 (54.2%) had moderate adherence (MMAS-8 adherence score < 8) and 5 (6%) high adherence (MMAS-8 adherence score = 8) to their medication respectively. Negative associations were found between medication adherence and self-reported levels of depression (r = -0.30, p < 0.01), anxiety (r = -0.29. p < 0.01) and stress (r = -0.31, p < 0.01). One-way ANOVA yielded significant variation on the self-reported anxiety subscale of the DASS-21 questionnaire among adherence groups of patients with MMD (F (2,80) = 3.73, p < 0.05, η2 = 0.26). A post hoc Tuckey test showed that the non-adherent and moderate adherent groups of patients significantly differ on the level of experienced anxiety; the high adherence group was not significantly different from other two groups. Results indicate that the non-adherent group generally experiences more symptoms of anxiety than the moderate adherent group.

Patients with major depressive disorder show significant non-adherence to medical treatment. More research is needed in this direction, as well as the development of recommendations and strategies to improve the level of adherence in this group of patients.

None Declared

Work stress, anxiety and depression have an enormous impact on the well-being of employees, their employers, and society. Due to the loss of productivity, common mental disorders have a substantial economic impact. Major depression alone has been attributed to 50% of long-term absences from work, and depressive symptoms are related to lowered productivity while at work. Anxiety also contributes to loss of productivity and sickness absence. Treatment of common mental disorders in a work setting may improve symptoms, however, that does not automatically lead to improved work productivity. Addressing mental well-being at the workplace might improve work functioning, and digital interventions have been introduced with that objective. However, their evaluation in research has been limited.

The European Intervention to Promote Wellbeing and Health in the Workplace (EMPOWER) digital intervention is designed to provide and evaluate an integrative user programme that meets the needs of employees and employers in addressing work stress.

This work was supported by the European Union Horizon 2020 Research and Innovation Programme Health (grant number APP1195937, 848180). The EMPOWER project started 1.1.2020 and is currently ongoing.

We aim to

1) describe the design and development of the digital intervention.

2) culturally validate the intervention in three countries

3) test the prototype and beta version for its usability in the RCT to evaluate its effect in four countries that is currently ongoing.

A user-centred design process was followed from January 2020 until November 2021 to create a beta version for usability testing. A tailored algorithm was developed to provide support at the individual employee level and the company level. Each element of the digital intervention was translated and culturally validated in four languages in Spain, the United Kingdom, Poland, and Finland. Usability testing was conducted in each country (n=31) to explore validity, usability, and user experience.

The digital intervention consists of a website and a mobile application (app). The website has a public section and an employer portal that provides recommendations to reduce psychosocial risks in their company based upon clustered input from employees. The app provides algorithm-based personalised content after assessing a user’s physical and psychological symptoms, work functioning, and psychosocial risk factors for work stress. The usability testing improved the flow through the app and high ease of use and completion of tasks by participants.

The EMPOWER digital intervention is a tailored multimodal intervention addressing wellbeing, work stress, mental and physical health problems, and work productivity. Usability testing provided validation of the app as version to be evaluated in the EMPOWER RCT.

None Declared

Prevention of perinatal depression beginning from the antenatal period is essential.

This study aimed to investigate the effectiveness of recently developed internet-delivered cognitive behavioral therapy (iCBT) for preventing the onset of a major depressive episode (MDE) in the third trimester and at 3 months postpartum.

This is a two-arm, parallel-group, general-information controlled, randomized controlled trial. Participants were 5,017 pregnant women at 16–20 weeks’ gestation without MDE at baseline. They were randomly assigned to an iCBT (intervention; n = 2,509) or general-information (control; n = 2,508) group, stratified by psychological distress at baseline. The primary outcomes were the numbers of new MDE onsets, measured using the World Health Organization Composite International Diagnostic Interview 3.0, at 32 weeks’ gestation and at 3 months postpartum.

New MDE onset was reported by 59 participants (2.35%) in the intervention group and 73 (2.91%) in the control group during follow-up. Compared with the control group, the hazard ratio (HR) of MDE in the intervention group was 0.85 (95% CI 0.61–1.20). Among participants who scored between 5 and 8 on K6 at baseline, 10 (1.37%) in the intervention group reported new onset of MDE, compared with 28 (3.81%) in the control group, and the HR of MDE was 0.38 (95%CI 0.19–0.79).

No intervention effect was found for iCBT in preventing new onset of perinatal MDE. iCBT might prevent perinatal depression only among pregnant women with subthreshold depressive symptoms.

None Declared

Excessive stress at work is a problem that leads to numerous complications, including the development of depression and burnout. A very important factor contributing to coping is a change in attitude to the situation at work. A helpful tool is Cognitive Behavioral Therapy. However, access to CBT is limited due to cost and lack of time. Mobile therapeutic application based on CBT may be the answer to these barriers.

The aim of the study was to test the effectiveness of mobile CBT in comparison with CBT in the face to face formula and in comparison with the control group, not receiving any intervention.

The face-to-face (ftfCBT) CBT intervention included 12 hour treatment sessions. Mobile CBT (mCBT; UpBalance smartphone application) included a therapeutic program analogous to the protocol used in the ftfCBT group. The content of the application was divided into short educational parts (in the form of videos, animations, articles and podcasts) and exercise parts available to the subject throughout the duration of the study. The study involved 90 subjects randomly assigned to three groups: ftfCBT, mCBT and control (randomization 1: 1: 1). Two measurements were made - baseline and after 12 weeks. The following questionnaire methods were used: the Thermometer of Distress, the Occupational Stress Questionnaire and the LBQ to measure burnout.

In the initial measurement, no differences were observed between the ftfCBT, mCBT and control groups. After 12 weeks in the control group, there were no differences between the t0 and t1 measurements. In the ftfCBT and mCBT groups, an improvement was observed in both the reduction of the level of distress and the reduction of burnout symptoms. There were no differences in t1 between the ftfCBT and mCBT groups. A higher level of compliance was observed in the mCBT group than in the ftfCBT group.

A mobile therapeutic application focused on coping with occupational stress is an effective intervention improving the mental state of employees. Mobila digital cognitive behavioral therapy can also be a helpful alternative to classic psychotherapy and can respond to the unmet needs of employees in terms of access to therapy at a suitable time.

E. Wojtyna Grant / Research support from: National Centre for Reaserch and Development, A. Mucha: None Declared

Conventional healthcare records are generally inaccessible to service-users. ‘Beth’ is a digital tool in South London and Maudsley NHS Foundation Trust which allows service-users to self-monitor symptoms, set therapeutic goals, access aspects of clinical records and communicate with care teams.

To explore service-user and clinician perspectives of Beth, and to understand how Beth might impact clinical care.

Service-user and clinician users completed an online questionnaire. Likert-scale and free-text response questions covered user experience, impact on clinical care and suggested improvements. N=26 service-users and 43 clinicians completed the questionnaire. Quantitative and qualitative analyses are presented.

Service-users reported the most useful features were tracking sleep and mood, messaging their care team, logging coping strategies and viewing care plans, goals and upcoming appointments. A majority reported Beth improved clinical assessments and they would recommend it to others. Barriers to using Beth included navigational difficulties, lack of access to internet or hardware, needing to register for an account and forgetting to use it. Clinicians reported booking appointments, messaging service-users, sharing care plans and accessing mood diaries were the most useful features. However, many clinicians did not use Beth regularly. Barriers included difficulties using Beth, finding it time-consuming and reportedly poor service-user adherence.

Our findings highlight potential benefits of digital tools in mental health care, alongside numerous barriers and suggested improvements. Limitations include a small sample size and lack of objective user data. Future work may involve qualitative interviews, analysis of objective usage data and trialing improvements in service design.

None Declared

Problematic substance use is rising, and other mental health conditions like anxiety and depression correlate with substance abuse. Diverse interventions to reduce this effect are emerging. Supportive text messages offer the prospect of improving symptoms of drug misuse and other associated comorbidities.

The study aims to evaluate the impact of the Text4Hope-Addiction program in mitigating craving, anxiety, and depression symptoms in subscribers.

Individuals self-subscribe to Text4Hope Addiction program by texting “Open2Change” to 393939 to receive daily addiction-related text messages for three months. Subscribers are invited via text message to complete online questionnaires which assess cravings, anxiety, and depressive symptoms using the Brief Substance Craving Scale, Generalized Anxiety Disorder-7 Scale, and Patient Health Questionnaire-9 on subscription (baseline), six weeks and three months. Data were analyzed using SPSS version 25 with descriptive and inferential statistics. Satisfaction responses were used to assess various aspects of the Text4Hope- Addiction program.

There was a significant difference in the mean baseline and three-month BSCS scores ( -2.17, 95% CI of -0.62 to -3.72), PHQ-9 scores (-5.08, 95% CI of -1.65 to -8.51), and the GAD-7 scores (-2.93, 95% CI of -0.48 to -5.56). Participants agreed that the supportive text messages helped them cope with addiction-related stress (89%), anxiety (81%) and depression (69%).

The Text4Hope-Addiction program effectively reduced cravings, anxiety, and depression among subscribers, with high satisfaction rates for the program. Healthcare practitioners and policymakers should consider implementing supportive text-based strategies to complement conventional treatments for addiction.

None Declared

With the rapid advancement of modern technology, many countries have adopted mental health care systems supplemented by digital means of communication. Are Tunisian patients “ready” for the “digital revolution”?

The aim of our study was to assess perceptions of people living with mental illness on digital mental health.

We developed a cross-sectional study where we randomly included patients who were treated for a psychiatric disorder in a public or a private practice. Inclusion criteria were: subject 18 years old or older, clinical remission for at least three months. We developed a questionnaire on sociodemographic and clinical variables. We also included questions on patients’ level of interest in using digital mental health services such as teleconsultation and mental health smartphone apps. Perceived obstacles in using digital mental health by patients were also evaluated.

Our sample size was 260 patients. The mean age of our population was 36,4 years old with. The mean distance from the household to the mental health care provider was 17,3 km.

Two thirds of the sample had access to a wifi connection at home (172 patients). When asked about the content of internet searches, 66% have already looked for information on their mental health or mental disorders on web pages. Patients were very interested in video teleconsultation with their therapists (72%), psychoeducation apps (68%) and online mood journals (61%). They expressed little to no interest in online exchanges with other patients and medication reminder apps. The most reported obstacles in implementing digital mental health as noted by patients were : lack of perceived effectiveness, virtual communication with their therapist and confidentiality issues.

Mental health patients in Tunisia expressed a great interest in teleconsultations and online psychoeducation programs. Further research on the willingness of mental health professionals to adopt digital mental health services are needed.

None Declared

The fact that nurses do not have a voice in the treatment decision of patients and that there is no framework about futile treatments can cause some psychological problems such as depression, burnout and moral distress (Yildirim et al., 2018). If not managed properly, moral distress leads to decreased job satisfaction, increased nurse turnover rates and intent to change the working area or leave the profession (Vieira & Doedato & Mendes, 2021).

This study aimed to explore the nurses’ attitudes towards futile treatments and its relationship with the moral distress, intention to leave the job and the other personal factors.

This study has a descriptive and correlational design, carried out with 425 nurses, between April-May 2021 in Istanbul. The data were collected using a Personal Information Form, The Nurses’ Attitudes Towards Futile Treatment Scale(NATFTS), Moral Distress Scale(MDS) and Intention to Leave Scale (ILS). Personal Information Form: The form consists of 22 questions including the socio-demographics and professional characteristics. The Nurses’ Attitudes Towards Futile Treatment Scale (NATFTS): The scale was developed by Yildirim et al. in 2019, consisting of 18 items and uses a 5-point likert type scale.Moral Distress Scale(MDS):The scale, developed by Hamric (2012), adapted to Turkish by Karagözoğlu et al. (2017), consisting of 21 expressions, was designed to measure the level of moral distress in nurses. Intention to Leave Scale (ILS):The scale was developed by Wayne et al. (1997), and adapted to Turkish by Avcı ve Küçükusta(2008) in the form of 5 items. The data were analyzed by using descriptives, Kruskal Wallis test, Independent Samples t- test and ANOVA, Pearson Correlation analysis on SPSS 25.0 for Windows. For significance, p < .05 and 95% CI were assumed in the data analysis.

A moderate negative correlation was found between NATFTS score and the ILS score (r=-0.356, p<0.001). Nurses who think that futile treatments should be applied under the strict rules have less tendency to leave their jobs. On the other hand, there was a lower positive level of correlation between NATFTS score and the MDS score (r=0.295, p<0.001). That is, nurses who think that futile treatments should be applied under the strict rules have a higher level of moral distress. A low-level negative of relationship was found between the MDS score and the ILS score (r=-0,260, p<0,001). As the level of moral distress increases, the tendency to leave work decreases.

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It is believed that educating nurses and strengthening them psychologically will prevent them from experiencing moral distress, increase job satisfaction and reduce intention to leave (Cicolini et al., 2014). Considering the negative effects of ethical dilemmas about futile treatments on health professionals, it is recommended that legal regulations be made on the subject and institutions determine their own protocol.

None Declared

Coercion is a general term used to refer to a series of actions, ranging from involuntary treatments to forced interventions, which can be ethically, legally and clinically challenging for both professionals and service-users. Perception of healthcare professionals on restraint practices is in important factor determining the clinical outcomes.

The aim of this study was to determine i) the differences between the estimates of healthcare professionals working in the Emergency Unit of Erenköy Psychiatric and Neurological Training and Research Hospital (Erenköy RSHEAH) regarding physical restraint practices and the real use and outcome values ii) the knowledge, attitudes and opinions of healthcare professionals on such procedures.

The study was designed as a descriptive cross-sectional online survey. All healthcare professionals working in the Emergency Unit of Erenköy RSHEAH (with a catchment area of 5 million people) who agreed to participate in the study and who were not part of the research team were included. Sociodemographic information, information about working experience, and estimates of physical restraint practices in the last month were questioned. Attitudes and opinions towards these practices were evaluated with 5-point Likert-type questions. Ethical approval was obtained from Erenköy RSHEAH Clinical Ethics Committee (Decision No: 40, 18.07.2022).

A total of 55 healthcare workers (31 trainees, 10 specialist psychiatrists, 6 nurses, 8 security personnel) participated in the study. The mean age of the participants was 32±6.4 years (24-50, min-max) and 52.7% were female. The mean duration of employment in the health sector and current institution were 6.6±5.7 (1-22, min-max), and 4.1±4.1 (1-17, min-max) years, respectively. The estimated mean rate of physical restriction was 13.5±13% (2-60, min-max). However, the actual median rate was 4% (0 - 8.8% min-max) in the same month. The estimated mean duration of physical restraint was reported as 87.8±54.1 (20-300, min-max) minutes, whereas the median actual duration of physical restraint was 60 minutes. No significant relationship was found between the estimates of duration, rates and complication rates of of physical restraint and the duration of professional experience (p>0.05). A significant difference was found between professional groups in terms of restraint duration and complication rate (p<0.05), as well as their opinions regarding the appropriateness of restraint practices with the legal framework (Table 1).

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It was observed that healthcare workers had a misperception regarding the rate and duration of physical restraints, which were perceived as higher than the actual values. Thus, the restraint interventions were perceived to be more negative than they actually are. Correction of such misperceptions should become part of the continous educational processes of all professional groups.

None Declared

Assistance to people suffering serious mental illnesses has undergone large variations in the last twocenturies. After World War II, The community became a new destination for them.But hardly anyone knew how to cope with mental illness in thecommunity. Thus, several initiatives arose in the US. Both social work and psychiatry,moved towards a pragmatic point of view by the rising tide of patients seeking help: initiatives trying to providesolutions to themost basic needs of patients: accommodation, food,medical care, takingof medication, etc. By the 1970s, Mary Ann Test and LeonardStein had proven the effectiveness of theirLife Coaching in Madison, Wisconsin. In 1981 his program is disseminated by several states under the name of Assertive TreatmentCommunity and thus spread throughout the United Statesand Canada, Australia and Europe. Psychiatry has recognized it as the program that got the most for supporting the community model. 50 years later the basics of the TAC model remain more or less thesame. But home interventions caused a continuous conflict in the ethical field notwell addressed…

WHY IS AN ACT team a fertile ground for ethicalconflicts?This approach is coercive or assertive?There are several reasons. There is a specific ETHICAL ENVIRONMENT in THE ACT team

1.“Diffusion of Responsibility”-

2. Mutual confirmation bias:

3. There is a tendency to think that professionals areethical by nature.

4. Biased search for information when problems arise.

Sources are sought to confirm us before clarifying whathappened

5. A special tendency to conformism.

6.Repetitive responses.

We will analyze the main ethical conflicts arising in ACT teams:

1. CONFLICTS OF AUTONOMY

2. PRIVACY AND CONFIDENTIALITY ISSUES

3. CONFLICTS OF DUTIES

4. ASSERTIVENESS VERSUS COERCION

The great challenge is knowing how and when to intervenewith patients with variable decision-making capacity orwithout any insight, as well as the impact on theirautonomy. It is an exercise both in art and inphenomenological training: Because there are subtledeficits, difficult to appreciate, but there are otherdeficits that are obvious.

The challenge: balancing the needs and safety of thecommunity with the needs and safety of the individual.ACT teams staff must juggle both perspectives, whilemaintaining a therapeutic alliance.

The continuous contact with the patient in an ACT teamgives, especially to clinicians, a privileged place ofobservation to act correctly in those situations and to be asupport so that whoever arrives lacking in affectivity orwith relational problems could grow until reaching a moreprudent and competent judgment.

WHAT COULD HAPPEN IF WE TRAIN PROFESSIONAL IN BIOETHICS MORE IN PATIENT´S RIGHTS, A FIELD FOR LAWYERS??

None Declared

Assisted dying (AD) is a general term in the literature to incorporate both physician-assisted suicide (PAS) and voluntary active euthanasia. In 2002 Belgium became the first country in the world to specifically acknowledge mental suffering in law as a valid basis for AD, specifically euthanasia, with other countries passing similar AD legislation more recently. Local legislation stipulates both substantive and procedural criteria that must be met for AD in jurisdictions, with only minor differences in procedural criteria noted accross sites.

In countries without AD legislation it remains a criminal offence for a physician to partake in AD, the offence prosecutable under local laws as manslaughter. It is a fiercely contentious issue within the medical, legal, political, religious and ethical fields with lack of consensus and on-going deliberation.

The author examines literature regarding the ethical issues raised by medical assistance in dying in psychiatry.

A non-systematized review of the literature, using literature available on PubMed, PsychINFO and Medline.

Findings from this review indicate that Beauchamp & Childress’ biomedical approach of equilibrating the ethical principles of ‘respect for autonomy’, ‘beneficience’, ‘nonmaleficence’ and ‘justice’, to act in the best interests of their patients are those most used in contemporary psychiatric practice. There is a fundamental theme suggested in the literature that ‘respect for autonomy’ is both the prevailing and challenging ethical principle to soundly navigate in AD cases. Within this principle, the task of objectively assessing capacity remains dominant.

Psychiatry remains unique in its pathology, biological and social entanglement hence the literature suggests a limit to autonomous decisions be considered, due to the extreme vulnerability and vast potential for abuse of this patient cohort.

Ultimately, the literature suggests physicians adhere to available professional medical ethical guidelines (should they be available), using an objective scale for undertaking capacity assessments, and seeking advice from the courts rather than bearing any outstanding ethical burden in these most complex of cases.

Infinite complexities and dissensus surrounding practice of psychiatric AD. The ethical principle of autonomy retains a significant role in both AD and psychiatric debates, with specific attention drawn the quandary of psychiatric capacity assessment. In addition to the moral question of whether it is appropriate to assist psychiatric patients to end their lives, the appropriateness of this role for psychiatrists is yet to be determined in light of professional disdain. Further analysis of cases are required, as they are published over time, to further reform the ethical and legal arguments.

None Declared

Penal coercive measures (e.g., detention) seriously interfere with the individual’s fundamental rights (especially the right to liberty). It is necessary to have proper guarantee mechanisms to protect an individual against the arbitrariness of decisions made in this regard. It is especially significant in the case of people with mental disorders (MD). This group of entities may not be able to take intended legal actions to protect their rights and, thus, requires enhanced legal protection. The effectiveness of legal solutions depends on the appropriate terminology. Vague, ambiguous, or archaic terms pose a risk of over-interpretation and create an area for abuse. An example of such solution is art. 5(1)(e) of the European Convention on Human Rights (ECHR) allows deprivation of liberty for “the person of unsound mind.”

The study aims to analyze the concept of “person of unsound mind” appearing in the ECHR and to define its semantic scope in relation to mental disorders. This procedure aims to determine whether the status of a person of unsound mind is the same as the status of a person with MD - both in legal and medical contexts.

The study consists of two stages. The first stage included the narrative review of the literature by searching the PubMed and Google Scholar databases with the keywords “unsound mind” and “person of unsound mind”. The second stage included the analysis of the European Court of Human Rights judgments relating to art. 5(1)(e) of ECHR, collected in the HUDOC database. Forty-four articles and 128 judgments met inclusion criteria and were included for further analysis.

The study shows that the concept of a “person of unsound mind” is primarily indefinite. The term does not correspond to the current standards of medical terminology. It relates to mental disorders but has a narrower scope. The term “unsound mind” refers only to “true mental disorder”, which is of that kind or degree that warrants compulsory confinement. To be considered a “true” mental disorder has to be of a certain severity. This term should be interpreted narrowly, but there are no grounds to limit its scope to psychotic disorders only. However, including some non-psychotic disorders in its scope may be questionable (e.g., antisocial personality disorder).

The structure of art. 5(1)(e) ECHR does not comply with the current medical terminology standards. This inconsistency in terminology and primary indefinite character of the “unsound mind” may implicate a lot of difficulties in precisely defining its meaning and scope of use in individual cases. It is dangerous from the perspective of the personal liberty of people with MD. This term should be replaced with the term “mental disorders,” the meaning of which is well-established in medicine.

None Declared

A legal definition for EAS describes this procedure as “intentionally terminating life by someone other than the person concerned, at the latter’s request”. The number of requests for EAS has been progressively increasing in countries where this procedure is allowed, including concerning psychiatric patients (2% of all requests). EAS for reasons of unbearable suffering raises ethical concerns due to lack of criteria for psychiatric patients.

To discuss the avaliable data about EAS and its controversial value in psychiatric patients.

Non-systematic review of literature on current knowledge about EAS, particularly in patients with mental disorder.

In terms of sociodemographic and clinical characteristics, these patients were mostly women, with at least two psychiatric conditions; the main diagnosis is a (treatment-resistant) mood disorder, with some medical comorbidity. Psychological suffering was the main motivation, in patients with severe symptomatology associated with psychiatric and physical conditions (26% reported both psychological and physical suffering). These patients tend to be empowered and value self-determination. There is to highlight a high percentage of patients still alive after a not granted pEAS request (69%) and a high rate of pEAS requests withdrawals (37%).

Suicide prevention remains a priority in terms of public health. Thus, there is a need to ensure that EAS isn`t a way to increase suicide mortality by giving access to lethal methods to suicidal patients. In some cases, EAS request has a paradoxical value to regain control of life and it`s related to the transient nature of unbearable mental suffering.

The actual process provides a continued recovery-oriented care in parallel with the EAS evaluation, and a thorough evaluation which requires a multi-expert panel with the envolvement of mental health professionals. Ethical concerns remains about its paradox: unbearable psychological suffering is a target for suicide prevention and also a required criterion for EAS.

None Declared

Healthcare delivery in prisons depends on the national Ministry of Interior in 14 of 17 autonomous regions in Spain. A traditional model for health and mental health care provision prevails.

To increase understanding of the mental health care process of imprisoned persons with a serious mental illness (SMI) in Spanish prisons with a traditional model of health care provision.

10 healthcare professionals (6 physicians, 3 nurses, 1 pharmacist) working in small (<450 imprisoners), middle size (450-1,000) and big (>1,000) prisons took part in 3 online focus groups between 31st May and 2nd June 2022. The moderator used open-ended questions to research into the healthcare process (diagnosis, treatment, follow up, prevention) of imprisoners with SMI. Focus groups lasted 2 hours, and were audiotape recorded and transcribed. Transcripts were analysed applying constant comparative method and theoretical saturation.

Mental healthcare provision varies across prisons, but commonalities exist. Healthcare professionals reported that about 60% of SMI are diagnosed by the correctional general practice physician (GP) at incarceration. Severe cases are assessed by an external psychiatrist. Once a week (average) the psychiatrist visits the prison to either confirm diagnoses or adjust treatments. One third of imprisoners who would benefit from a psychiatric assessment has it. Follow up occurs in the prison infirmary for close supervision. If addiction concurs, referral to therapeutic modules happen. Polypharmacy and overmedication are common. Simplification of therapies and slow-release injectable formulations of antipsychotics are desirable. Everyday mental health care and rehabilitation take place throughout a specific, little equipped, psycho-social support programme implemented in most prisons but restricted to the most disabled SMI persons. Acute psychiatric episodes occur due to treatment interruptions or deviations and are managed by the correctional GP. Hospital referrals are problematic without protocols. Prevention of relapses relies on imprisoners supervision and staff observation. Healthcare records are only available to healthcare professionals working in prisons. Outside prisons, continued care needs of mental health and social support in the community. Due to healthcare services modest readiness to respond to needs and poor social networks, SMI persons are prone to relapse and recidivism.

Focus groups found that working in isolation from the public healthcare system, shortage of psychiatrists, poorly implemented therapeutic and rehabilitation programmes, and lack of mental health and social care services in the community negatively affect the care of imprisoners with SMI in Spain.

None Declared

Intensive home treatment (IHT) for people experiencing a mental health crisis has been progressively established in many western countries as an alternative to in-ward admission. But is this a real alternative? We previously reported that patients treated in our IHT unit only differ from those voluntarily admitted to hospital in suicidal risk and severe behaviour disorders (not in other factors such as clinical severity) (Martín-Blanco et al., Rev Psiquiatr Salud Ment 2022;15:213-5). Now we are interested in disentangle if those patients who used to require inward management can be successfully treated at home.

To describe subsequent treatment trajectories of the first 1000 admissions to our IHT unit and to compare clinical characteristics among the different groups of trajectories.

Retrospective cohort study. Subsequent treatment trajectories were collected from December 2016 to October 2022 and classified: absence, hospital, IHT, and mixed (hospital and IHT). Statistical significance was tested by means of ANOVA or Kruskal-Wallis test for quantitative variables (corrected for multiple comparisons) and chi-square tests for qualitative variables.

Tables 1 shows the characteristics of the whole sample. Of the 1000 IHT admissions, 12.1% needed subsequent hospital admission(s), 12.7% IHT admission(s), and 9.3% mixed admission(s). There were no differences among these groups in median severity at IHT admission, but there were differences in the number of previous admissions (p=0.0001): the group with no subsequent admissions had less previous admissions than the other groups (pBonf<0.0001), and the group with subsequent IHT admissions had less than the group with mixed admissions (pBonf=0.0123). There were differences between groups regarding distribution of diagnoses (p<0.0001) (Fig. 1). When considering subsequent admissions by diagnosis, there were differences in severity at IHT admission (p=0.0068) and in number of previous hospitalizations (p<0.0001) (Fig. 2).Table 1.Clinical characteristics of the whole sample (N=1000)

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Patients that used to require inward management can now be treated at home when suffering an acute episode. Therefore, IHT has changed treatment trajectories for some patients with psychiatric disorders.

None Declared