Cognitive impairment is a core deficits in schizophrenia and in bipolar disorders. The cognitive dysfunctions are related to the abnormal brain activation in these illnesses. Working memory and executive dysfunctions associated with prefrontal cortex abnormalities in these illnesses are known as an neuropsychological marker of vulnerability to the diseases.

The most important methods used in assessment of abnormal brain activation are neuroimaging methods and neuropsychologial tests. Current data show high coincidence between the level of performance on cognitive tests and activation of the brain. The data obtained in patients with schizophrenia and bipolar disorder show the significant association between level of hypofrontality (decrease of blood flow and intensity of glucose metabolism) and the level of impairment of the performance of prefrontal tests.

The Cogtest Battery it the novel computerized neuropsychological battery used for cognitive screening in different mental and neurological diseases. This battery consisted with tests for evaluation different domains of cognition, such as frontal functions (working memory and executive functions), verbal abilities (connected mostly with left hemisphere activation), attention, psychomotor speed, spatial and motor performance, memory and learning (associated with temporal lobe activation). Based on gold standard paper and pencil tests. The computer version of the tests and touch screen make possible to examine patients with motor disabilities - such as patients with Parkinson's Disease. The specific data management system make possible to eliminate data with artifacts.

Selected tests from the system are used as a cognitive stimulation during neurophysilogical assessment (EEG, EMG, EOG) and during neuroimaging, especially with F-MRI.

Cognitive dysfunction such as impairment of memory, attention, spatial and verbal functions plays important role in etiopathogenesis and clinical picture in neurodegenerative disorders. There are related with structural and functional abnormalities of different region of the brain connected with these cognitive processes. Cognitive dysfunctions caused severe functional and social disabilities of the patients. The neuroimaging methods such as F-MRI, or PET scan are very useful in diagnosis of structural and functional changes in the brain in neurodegeneration diseases, e.g. Parkinson's or Alzheimer's diseases. Neuroimaging during cognitive stimulations show different brain activation in patients with schizophrenia or neurodegenerative disorders in comparison to healthy subjects. F-MRI show increase of prefrontal cortex activation during n-Back test performance in healthy controls, while in patients with schizophrenia and Alzheimer disease this effect was not noted. In schizophrenia patients after treatment with risperidone (but not with haloperidol) the normalization of activation in different brain area was observed.

F-MRI assessment during N-back test (0 - back and 1-back tasks), encoding and recognition, visual discrimination performed in 9 patients with Alzheimer's Disease (AD) and 9 healthy subjects show abnormal activation in patients with AD. Among 9 patients with AD 5 were treated with rivastigmine, 4 received placebo. Cognitive improvement was observed after 3 months of treatment with rivastigmine - the same time fMRI showed an increase in brain activity in regions involved in attentional processes. This indicate that neuroimaging methods during cognitive stimulation may be useful in cognitive assessment in CNS disorders and in assessment of drug effect on cognition.

Prefrontal functions impairment in schizophrenia and bipolar disorder are are markers of vulnerability to the diseases. Our previous data showed association between Wisconsin Card Sorting Test (WCST) performance in schizophrenia with the polymorphism of dopaminergic genes)COMT, DRD 1) and with polymorphism of Brain-derived neurotrophic factor (BDNF) in bipolar disorders. The Src-family tyrosine kinase Fyn plays important role in the interaction between BDNF and glutamatergic receptor NMDA in prefrontal cortex. The possible association between the polymorphisms of BDNF and Fyn genes and performance on WCST and N-back tests in healthy subjects were assessed in 200 healthy persons, genotyped for the two polymorphism of BDNF gene (C/T, Val66Met) and three polymorphisms of the Fyn gene (-93 A/G, IVS10+37T/C, Ex12+894T/G). In the whole group, the T/T genotype of C-270T BDNF polymorphism was associated with higher percentage of conceptual responses on WCST. Male subjects with C/T genotype obtained better results on percentage of correct reactions in N-back test. No significant differences between any of Fyn gene polymorphisms and WCST performance were found. Better results on percentage of correct reactions in N-back test were obtained by subjects with G/G genotype of 93A/G polymorphism and with G/G genotype of FYN T/G polymorphism. Female subjects having T/T polymorphism of T/C polymorphism performed better as to percentage of correct reactions in N-back test. The results obtained may suggest a contribution of BDNF and glutamatergic system genes to working memory efficiency in healthy subjects and bipolar disorder, while in schizophrenia with dopaminergic system genes.

Pathological obesity may be related with impairment of impulse control and cognitive disturbances. In this study the cognitive frontal functions in relation to the polymorphism of candidate genes in patients with pathological obesity were assessed. The prefrontal functions were evaluatedmusing Wisconsin Card Sorting Test. The polymorphisms of genes connected with serotoninergic and dopaminergic system : 5HT2A, 5HT2C, 5HTT, DAT1, and COMT, and also the polymorphism of BDNF - involved with modulation of nervous system development and neuroplasticity were assessed. Polymorphisms of the genes were detected by RFLP and VNTR PCR methods.

The 100 subjects with pathological obesity, BMI>40 operated with Mason method were enrolled. The results of WCST were compared with the results of healthy sex, age and education matched controls.

Subjects with pathological obesity show significant worse results on all domains of WCST, compared to controls. The frequencies of the polymorphisms in the obese group were: 5HT2A -1438A->G - A/A - 11%, A/G - 50%, G/G - 39%; DAT1 VNTR in 15th exon - short/short - 13%, short/long - 34%, long/long - 53%; BDNF Val66Met (G->A) - A/A - 3%, A/G - 24%, G/G - 73%. Interesting results were obtained in the case of 5HT2C: a known polymorphism (-759C->T) could not explain the banding pattern observed. It is possible that we have found a novel polymorphism that strongly correlates with obesity. The results obtained show significant prefrontal dysfunctions in patients with pathological obesity which may be related to the polymorphisms of serotonin and dopaminergic system genes and possible association of the obesity with the new polymorphism of 5HT2C gene.

Symposium “ Family burden: dimensions, determinants and intervention”

Title of presentation: Determinants of the caregiving appraisal

Appraisal of caregiving and its relationship to family burden and experienced mental health problems in the relatives were investigated as part of a multi-centre study of the quality of mental health services in Sweden. The sample was drawn from relatives of involuntarily and voluntarily admitted patients to acute psychiatric wards. The instrument used was a semi-structured questionnaire, interviewing relatives about the burden, experience of mental health problems and appraisal of the caregiving situation.

The results showed a high proportion of relatives engaged in caregiving activities on a daily basis the month before the patient's admission to hospital and a high proportion of relatives appraising the caregiving activities negatively. The burden was more extensive if the relative and the patient were living together, had a longer duration of their relationship, if the relative was rendering caregiving on a daily basis and if the relative appraised caregiving negatively.

The relatives’ psychological distress was not related to their negative appraisal of caregiving, nor was patient characteristics, such as diagnosis and level of psychosocial functioning. The only factor found to influence the relatives’ psychological distress was the duration of relationship to the patient.

Interventions reducing psychological distress for relatives who have known the patients for more than 20 years, who live with the patient, who give care on a daily basis and who appraise their caregiving negatively are suggested.

In the past 30 years, research on Expressed Emotions and family burden, and the adoption of the stress-vulnerability model of schizophrenia, have led to the development of integrated treatments for this mental disorder combining pharmacological and family cognitive-behavioural interventions. The latter, called Psychoeducational Family Interventions (PFI), aim to: a) provide the family with information about the patient's disorder and its treatments; b) improve family communication patterns; c) enhance family's problem solving skills; d) encourage relatives’ involvement in social activities.

Since the 1980s, a number of RCT and several meta-analyses have demonstrated the efficacy of PFI on relapse and hospitalisation rates in schizophrenia.

In recent years, there has been a shift from efficacy to effectiveness studies and great attention by the researchers in developing training programmes in PFI for ordinary staff.

In this presentation, we will provide an overview of the studies on PFI for schizophrenia which have been carried out in the last decade in routine clinical settings or with at least partial involvement of ordinary staff. These studies have been grouped into: a) studies comparing PFI with standard care; b) studies comparing PFI with individual integrated interventions; c) studies comparing different PFI strategies; d) implementation studies.

The results of these studies reveal that, when provided in clinical settings, PFI have positive middle-term effects on patients’ clinical status and disability, and limited impact on family burden.

Future studies are needed to identify the “best dose” at which PFI can be provided in routine conditions at the most convenient cost-benefit ratio.

Sixty years ago, the concept of custodial inpatient treatment began to gradually change into that of an activating outpatient concept. Through this process, the number of in-patient beds today in all psychiatric hospitals in the western part of the world has been reduced to 10-20% of those at the beginning of the 20th century. Though outpatient services had expanded to a high degree, the main burden of the psychosocial treatment still fell upon relatives. Most of these nursing families were poorly informed regarding their new duties. Thus many families were overstrained and not able to fulfill their function as "co-therapists". Because of the prevalence of overstrained families with dysfunctional behaviour, the EE-concept was developed in the sixties (Brown et al 1964). With the introduction of family therapy and the emergence of self help groups for relatives, families obtained substantial support. Through family therapeutic interventions, relatives were systematically integrated into long term rehabilitation concepts. In this way, the stigma of the "HEE"- relatives was changed (Bebbington et al 1994; Schulze-Mönking 1994; Möller-Leimkühler 2008). In the meantime, the engagement of family members can be viewed as an important resource and not merely as a stress factor which is to be reduced (Pitschel-Walz, Bäuml et al 2001). According to the therapeutic guidelines it is now part of standard therapy to integrate relatives already in the beginning of the treatment. In this context, psychoeducation is a very effective measure to inform family members of the background of the illness and the most important treatment elements. During the course of time, many concepts have been developed, particularly concerning schizophrenic psychosis, to train relatives and their patients to have better communication with less stress and more helpful interactions. Through the establishment of a worldwide network, relatives are encouraged to use their knowhow not only alone at home but also in their interaction with professionals and politicians to improve the living conditions of their patients. In this lecture, the historical background and actual findings concerning the empowerment of the relatives will be presented.

The study was conducted in a tertiary care facility in Rawalpindi, Pakistan. The objective was establishment of a service delivery system in a tertiary care facility of Rawalpindi for screening, early diagnosis and prompt management of women with post natal depression. It also evaluated the effectiveness of the service and determined the frequency of Postnatal Depression cases presenting in the postnatal clinic of Rawalpindi General Hospital. This interventional study involved screening and confirmation of diagnosis for Postnatal depression of 908 mothers presenting in the postnatal clinic. The scales used were Edinburgh Postnatal Depression Scale (EPDS) and Hamilton Rating Scale. EPDS showed scores above cutoff of 10 for 318 (35%) mothers. When Hamilton scale was applied, 05 (1.57%) mothers had no confirmed diagnosis of Depression, however, all the remaining 313 mothers (98.42%) had Depression. The prevalence of the post natal depression was found to be 313 per 1000 or 31%. Statistically significant associations were observed on Chi Squared test, between PND and variables like mothers educational status, their working status, number of previous children, mode of last delivery, obstetrical complications during last pregnancy, age group, monthly family income, Effectiveness of the services rendered were evaluated by applying t-test by comparing the mean weekly turn over of PND patients over 35 wks study period and showed statistically significant difference in favor of interventional services with t-statistic of 16.263, p-value of 0.000.

Risk for emotional and behavioural problems are known to be high among children of depressed mothers, but little is known about the impact of antenatal and postnatal depression on the physical health of the infant. Our one-year prospective follow-up study of 320 mothers and their infants in rural Rawalpindi, Pakistan, shows that infants of antenatally depressed mothers have poorer growth than controls. The relative risk for being underweight (weight-for-age z-score < -2SD) is 4.0 (95%CI 2.1-7.7) at 6 months and 2.6 (95% CI 1.7-4.1) at 12 months, while the risks for stunting (length-for-age z-score < –2SD) is 4.4 (95%CI 1.7-11.4) at 6 months and 2.5 (95% CI 1.6-4.0) at 12 months. Relative risk for ≥5 diarrhoeal episodes per year is 2.4 (95% CI 1.7-3.3). Chronic depression carries a greater risk for poor outcome than episodic depression. The associations remain significant after adjustment for confounders by multivariate analyses. It is concluded that preventive and treatment strategies for maternal depression could benefit not only the mother's well-being but also the infant's physical health and development.

Previous studies have found maternal depression to be a major risk factor for poor growth in infants in Pakistan and south Asia. The mediating mechanisms between maternal depression and infant malnutrition are an important area for research.Studies have shown that maternal depression maybe associated with shorter duration of feeding however the evidence is equivocal. The quantity of breast milk could be another factor which has only been tested with relatively inaccurate methods of clinical scoring and test weighing till date. We aim to study the relationship of maternal depression with duration of breastfeeding and infant feeding practices. Moreover, we would also estimate the breast milk production and intake by the infant in depressed versus normal mothers, using the new technology of isotope dilution, in a rural community in Rawalpindi, Pakistan.

A random sample of 100 depressed and 100 non-depressed women will be recruited for the proposed prospective cohort study. The depressive disorder will be diagnosed antenatlly and 6 months postnatally using validated instruments. The duration of exclusive breastfeeding will be assessed prospectively and infant feeding practices will be assessed at 6 months with appropriate tools. Breast-milk intake will be measured in 30 mothers from each group, using the dose-to-the-mother deuterium oxide method also validated in Pakistan by the investigators. Differences in the two groups of mothers will be estimated using appropriate statistical techniques, while controlling for possible confounders.

The aim of study is to determine the maternal perception of inadequate breast feed and compare possible augmentation of breast milk with lactogouges (metclopromide) and structured counseling of mothers, using the new technology of isotope labeling in a community in Rawalpindi, Pakistan.A random sample of 200 lactating mothers having complaints of reduced breast milk production is being recruited from well baby clinic of participating hospitals. All should be practicing exclusive breastfeeding with infants from 2-3 months of age. Their perceptions regarding their breast milk production is assessed. They are randomized into four groups. Group one will be given oral metclopromide, groups 2 will be given structured counseling by trained health workers and group 3 will receive placebo whereas group 4 will receive CBT. Breast-milk production will be measured at completion of 4 weeks of intervention by using the dose-to-the-mother deuterium oxide method also validated in Pakistan by the investigators to a limited sample. Differences in the groups of mothers will be estimated using appropriate statistical techniques, while controlling for possible confounders. Outcome of the study would be able to demonstrate that lactogouges, or simple counselling may have an effect on increasing the breast milk quantity of mothers and also effect of interventions on their perceptions. The results of the study could have a major impact on the breastfeeding teachings and practices in our society which in turn has a potential to improve and have a significant impact on one of the main Millennium Development Goals i.e. child mortality and morbidity.

The aim of the TREAT-study (Treatment-systems Research on European Addiction Treatment) is the comparison of the course of predominantly opiate dependent patients from six European regions concerning severity of illness, health service use and heroin-use.

Over the last several years diagnostic research made significant conceptual and methodological advances but acute mental disorders still remain almost neglected from international classifications. This is becoming, however, an area of growing concern with considerable relevance to mental health policies: an increasing number of patients seek for acute/emergency treatment with atypical symptoms yet classic diagnostic categories do not adequately describe the multiple co-morbidities and unpredictable course of these disorders. To capture a number of exquisite clinical characteristics that may be a putative target of innovative treatment programs on the changing scene of emergency psychiatry and acute psychiatric treatment, this report will introduce the concept of “new acute mental patient” a condition at the crossroad of dissociative disorders, mood disorders and personality disorders among patients exposed to traumatic life events. The validity of this diagnostic construct and its relevance to outcome research will be further investigated utilizing the data basis from longitudinal studies.