“States of Mind” is a documentary about the idea of normality/abnormality in a mental hospital. It was shot inside several mental clinics in Italy in 2005. A small team of filmmakers spent several months inside the clinics with a camera and audio equipment. The team shared with patients and staff every moment and aspect of daily life, from breakfast till night shift. During this intense period patients and operators were constantly exposed to the camera's eye, while neutral observation and friendship quickly melt. Ideas of normality and abnormality, of surface and depth, of exposure and censorship started to blend into each other, creating interesting and unexpected effects. “States of Mind” had its world premiere at the prestigious IDFA (Amsterdam Documentary Film Festival) and has been released in USA and Europe.

Mood disorders can be considered as a pathology of Freedom in human being.

Manic patients feel under-responsible and depressives feel hyper-responsible. Both require from psychotherapist care for risk of suicide and innapropriate behaviour, but also empathy, support, and help from responsible others, relations and doctors. This responsibility is moral, juridic and penal.

We will discuss what Ethic for responsibility can be the right one for clinicians and therapists. We will also discuss which symptom or clinical features are the most hindering for responsibility in depressives. We will conclude that ethical basis is fundamental for right management in therapy.

The paper deals with the change in the attribution of responsibility in the care system during the 2nd half of the last century. The shift went from the rather parentalistic attribution of responsibility to the professional site (psychiatrist, psychiatric institution, its runner) with “de-powerment” of patients, to “em-powerment” and attribution of responsibility to patients and their social systems. This development was influenced by general societal movements (as the human rights), ethical teachings (Hans Strotzka in Austria and Hans Jonas internationally) and a growing awareness for the complex process in the illnes itself and the possibilities to behave under the condition of illness. Nowadays there should be a “topography” of responsibility in care processes with changing foci dependent on the respective capacities to cope with responsibility and the result of negotiating the respective coping power. A fair search for balanced results as fairness in the evaluation of outcomes as well is needed - but not allways reached dependent on the conflicting expectations toward professionals in our societies (as protection versus freedom).

Responsibility can be defined as an obligation or duty that something happens in a situation for which one can be praised or blamed. In this presentation, the constitutive elements of a moral account of responsibility such as whom a moral agent is, under what conditions moral responsibility applies, and the possible objects of responsibility ascriptions will be discussed. The contributions of Aristotle, Strawson, Carl Ginet, Hans Jonas, Daniel Wegner and others to our understanding of responsibility, causal determinism, and the illusion of conscious will be explored. The presentation will conclude by discussion the implications of these ideas for psychiatry particularly with regard to patient autonomy and responsibility.

This presentation aims to illustrate substance addiction from a point of view of the psychopathological responsibility. Substance abuse has been affecting modern society for more than forty years, and the sanitary, social, economic and the psychopathological impact of substance addictions are becoming more and more disastrous. At the moment there are no signs of any decrease in the number of addicts, on the contrary, the trend continues to spread to all social classes. In all these years a psychopathological perspective has never been sistematically applied to the addiction field. A psychopathological perspective is able to achieve a deeper insight into the problem of substances addiction and thus offer new and stimulating possibilities of treatment. From this point of view a psychopathological perspective implies precise responsibility, not only for the individual working within the Health Service, but for the hole organization of the Health System itself.

Aging is a process that affects bio-psycho-social functioning. When people reach upper age groups, the definition of normal and abnormal aging are confounded by the presence of multiple diseases, injuries and losses. As the people leave longer, physical, psychological and social losses may affect the quality of life. In geriatric population, one indicator of quality of life is the ability to perform required activities of daily living. The absence of that feature create negative efects on the psychology of the elderly.

In the consultation process, the geriatric psychiatrists must know the major events which influence elderly's quality of life in late life. Those events are pharmacology, end of life issues and suicides, and clinical syndromes such as delirium, dementia, depression, anxiety, etc. It can be said that life events are closely connected to quality of life and health.

To offer a high quality health and social care to the older patients, we need the knowledge about the conditions, the values and the quality of life of these people which influence their lives.

Good health is an important component of a good quality of life. The availability and the easy access to high quality of care contribute to a good mental health. WHO & WPA have defined the criteria to consider as good the quality of care delivered by services for old people with mental disorders. Services should be:

1. - comprehensive and take into account all aspects of the patient's physical, psychological and social needs and wishes;

2. - accessible, user-friendly and readily available, minimizing the geographical, cultural, financial, political and linguistic obstacles to obtaining care;

3. - responsive, that means to be ready to listen to and understand the problems brought to its attention and acts promptly and appropriately;

4. - individualized and should focus on each person with a mental health problem in her/his family and community context;

5. - transdisciplinary and should go beyond traditional professional boundaries to optimize the contributions of people with a range of personal and professional skills.

6. - accountable and should accept the responsibility for assuring the quality of the service it delivers and monitors this in partnership with patients and their families.

7. - systemic and should integrate all available services to ensure continuity of care and coordinates all levels of service providers including local, provincial and national governments and community organizations.

The challenge today is to extend these criteria to help the Primary Care team to develop strategies in order to promote mental health, to prevent mental disorders and to make their detection as early as possible.

Alzheimer's disease and related syndromes have heavy social and human consequences for the patient and his family. Beyond the neuropsychiatric effects of specific therapies for dementia, one of today's challenges is the Quality of Life(QOL) for both patients and especially their informal caregivers.

Caregivers often find themselves cutt off from friends and regular social activities. Caregivers of persons with dementia experience stressful demands, especially because of the length of time that care is required, the behavioral symptoms of patients, and the severity of decline of patients during the course of the illness.

Insufficient attention has been given to how end-of-life care affects caregivers or to caregivers responses to the death of the patient. A study conducted by some authors(eg. Schulz and al.2008) indicated that caregivers needed intervention and support services were needed most often immediately before the patient's death. Caregivers may need help in resuming their own livers after the patient's death. Psychiatrists who are called in as consultants or who have a long-term relationship with the patient or caregiver are uniquely positioned to assist the caregiver with his or her emotional needs that are associated with end-of-life care or the patient's demise.

According to literature, the caregiver's QOL is correlated to the QOL of the patient they cared for, the importance of behavioral disorders and the duration of dementia evolution. Assessment of parameters influencing caregiver's QOL and its possible link with patients QOL are very important because of necessary interventions to improve QOL.

After a conceptual definition of normal ageing and of active and successful ageing and their differentiation from morbid ageing, we try to consider not only the presence or absence of a disorder but also its impact in someone's quality of life. Impact of mental disorders on quality of life is one of the changes in criteria for public health priority. Nowadays, it is difficult enough to talk about quality of life of elderly with mental disorders. The psychiatrists and other health care providers have to face at serious medical and ethical challenges in caring the elderly mentally ill at the end-of-life, assuring them the best quality of life as it is possible. Knowledge of the persons’ past experiences and their current abilities could be used as a guide for making decisions affecting their QoL and also their end-of-life.

Following the principles of Declaration of Paris, 2005, we can discuss about the quality of end-of-life of elderly mentally ill and stigma against them, in term of: the right to live versus the right to die; the right to be treated versus the right to refuse the treatment; the right to know versus the right to refuse to know the diagnosis; the valid consent of the person with the capacity to consent and the patient without this capacity. Respect for the individual's expressed wishes and interest, should guide all end-of-life care decisions. The aim of any mental healthy intervention for older adults is to preserve the human rights and patient best interest.

In EU, the latest available data estimates that some 63,000 individuals die annually due to suicide, which translates to 1 suicidal death every 40 seconds. Europe comprises seven countries that are among the top 15 countries with the highest suicide mortality rates. Statistics illustrate that the highest mortality rates for suicide (≥ 25/100,000) comprises mostly former Soviet Union Republics. Suicide rates among the age-group 15-24 years have been steadily increasing over the past few decades with statistics reporting rates up to approximately 22/100,000 among males and 4.8/100,000 among females in Europe.

Epidemiological research has demonstrated that suicide is significantly correlated with suicidal and risk behaviors. Studies have identified suicidal ideation and deliberate self-harm to be significantly correlated to both suicide and attempted suicide. Furthermore, the strongest predictor of suicide is in fact a previous suicide attempt. In Europe, there are 10-20 suicide attempts for every completed suicide. In the US, it is even higher, with estimations reporting 100-200 suicide attempts for every completed suicide. However, suicidal behavior is not an isolated act, rather is a result of a process that co-occurs with psychiatric illnesses, which can range from depressive episodes to schizophrenia. Moreover, epidemiological evidence stipulates that suicidal behavior coincides with a multitude of risk-taking behaviors that are frequently established in adolescent years. Studies have linked suicidal behavior to various types of risk-taking behaviors that include peer victimization, sexual risk behavior, delinquency, and substance abuse. Future epidemiological studies in suicide are fundamental in monitoring, identifying risks and formulating preventive interventions.

Suicidal behavior runs in families and is prevalent in adolescence. Case-control and family-based studies in this age group failed to find a genetic association that survived replications. Gene-environment approach gave new hope for possible associations especially with the short allele of the serotonin transporter promoter polymorphism (5HTTLPR). However, a recent meta-analysis raised doubts about the consistency of these findings. Some new structural and functional imaging data may shade light on the age-related and gender-related development of the brain. This review suggests a new approach to Gene-by-Environment and timing interaction to understand the interplay that leads to suicidality in adolescents and young adults.

Disturbed sleep is an intrinsic symptom of depression and may precede or even initiate it. Thus, it is surprising that depriving a patient of sleep can induce improvement, often within hours - however usually with relapse following recovery sleep. Clinical trials of early and late partial sleep deprivation, or shifting sleep earlier, suggest a critical circadian phase where wakefulness is necessary for the antidepressant response. Combination with medication or light therapy can maintain improvement. There is now sufficient evidence for many chronotherapeutic combinations (Table) to support the use of “wake therapy” - the fastest antidepressant modality known - in general psychiatric practice (1).

It is now well established that CBT for chronic insomnia is as efficacious as hypnotic medication and is also likely to be better at maintaining improved sleep. Most studies have looked at the use of individual CBT; there have been only a few studies looking at CBT for insomnia given in a group format.

For nearly ten years the Bristol Insomnia Group has offered cognitive behavioural management and support for people with chronic insomnia.

The seven group sessions are led by up to three members of a team consisting of a doctor (sleep specialist), an occupational therapist and a research sleep scientist. Components of the group intervention include education about sleep science, information on insomnia medication, sleep hygiene, relaxation, and cognitive therapy. To assess efficacy participants complete sleep diaries, a quality of life scale (SF36) and the dysfunctional beliefs and attitudes scale (DBAS) pre and post group.

Sleep diaries (n=68) showed significant differences in Total Sleep Time (TST), Sleep Onset Latency (SOL) and Sleep Quality (SQ). Approximately half of the participants had clinically significant improvements in their TST (increased by 30 minutes) and about a third had a clinically significant decrease (by 30 minutes) in their SOL. SF36 scores showed statistically improved scores in all nine domains, DBAS scores showed statistically significant decreased scores post group.

These results demonstrate promising sleep parameter and quality of life improvements after attendance at the group. CBT for insomnia is a clinically and cost effective approach for the treatment of chronic insomnia.

Restless legs syndrome (RLS) as well as the periodic limb movement disorder (PLMD) are common primary disorders in the general population. They can also occur secondarily or exacerbate as a result of psychotropic medication. According to case reports or case series RLS or PLMD can aggravate due to treatment with antidepressants, antipsychotics or lithium. RLS can also occur during withdrawal from opioids. Especially the tricyclic antidepressants clomipramine and imipramine have been associated with elevated periodic limb movements as well as the tetracyclic antidepressants venlafaxine, SSRIs and SNRIs which also have been associated with RLS. RLS seems to occur mostly during treatment with mirtazapine. Amitriptyline, nortriptyline, doxepine and trazodone show neutral effects whereas bupropion has neutral to beneficial effects on PLMS/ RLS.

When withdrawn from opioid treatment, transient discontinuation effects could occur as well as an existing RLS could be unmasked.

When examining a maintaining or newly occurring insomnia, possible treatment side effects in form of RLS/ PLMS should be considered. If possible, substances should be replaced: antidepressants of other groups could be used; antipsychotic medication could be switched to antiepileptics or benzodiazepines. If the psychotropic medication cannot be changed, RLS and PLMD have to be treated on their own, if possible with dopaminergic substances which are the first-line treatment in RLS.