Physical pain and psychological pain are risk factors for suicidal behaviour, and understanding of the neural pathways linking pain and suicide may contribute to suicide prevention. Neuroimaging studies have shown changes in association with physical and psychological pain and with suicidal behaviour. Psychological stressors such as social exclusion may trigger emotional pain that is associated with functional changes in the prefontal cortex, cingulate cortex, thalamus, and parahippocampal gyrus. This functional network shows considerable overlap with brain areas involved in physical pain and suicidal behaviour. Changes in the brain motivation-valuation circuitry may predict pain persistence and thus contribute to the development of suicidal thoughts and behaviours.

Maladaptive social interaction and its related-psychopathology have been highlighted in psychiatry especially among younger generations. “Hikikomori” defined as a syndrome with six months or longer of severe social withdrawal was initially reported in Japan, and the prevalence rate has been reported as 1.2% in Japanese population. The majority of hikikomori patients are adolescents and young adults who become recluses in their parents’ homes for months or years. They withdraw from contact with family, rarely have friends, and do not attend school or hold a job. An international vignette-used questionnaire survey indicates the spread of hikikomori in many other countries (Kato et al. Lancet, 2011; Kato et al. Soc Psychiatry Psychiatr Epidemiol, 2012). In addition, our international clinical studies have revealed the prevalence of hikikomori outside Japan (Teo et al., 2015). On the other hand, a novel form of maladaptive psychopathology, called modern-type depression has emerged in Japan (Kato et al. J Affect Disord, 2011; Kato et al. Psychiatry Clin Neurosci, 2016).

In this presentation, I will introduce “Hikikomori” and “modern-type depression” in Japan, and also propose novel diagnostic/therapeutic approach against them.

Diagnostic systems and methods must respond to patients’ diversity in expressions of mental distress, social and cultural context and the meanings given to illness. Due to increasing migration and globalisation the challenge of considering diagnosis in the context of culture has become increasingly significant in Europe. And globalization has further led to changes in value systems and our awareness of patients with ethnic minority background.

Over recent decades, there has been an increasing development of psychiatric diagnosing with nosological categorisation combined with multi-axial schemas. Diagnosis, besides identifying a disorder and distinguishing one disorder from another disorder - differential diagnosis, has also an aim to include an overall understanding of the patient's situation.

We witness an upsurge in the attention paid to the cultural limitations to psychiatric diagnostic practice and treatment modalities. Guidelines for the psychiatric profession are in critical focus from a transcultural perspective. Some claim their universality independent of cultural context; others find cultural adaptation useful and necessary.

Do the diagnoses and clinical and ethical guidelines give meaning in the cultural setting? Are they compatible with the cultural values of the therapist and those of the patient and the family? Several sources claim the biomedical paradigm for being Western with insufficient consideration of the socio-political context.

The cultural formulation developed as part of DSM-IV and now DSM-5 is one model to support a systematic review of culture and context in psychiatric diagnosing.

The paper will discuss the advantages and shortcomings of current diagnostic categories and guidelines vis-à-vis the universe of traumatized refugees with other ethnic backgrounds.

URL: http://www.mariannekastrup.dk/

Diagnostic assessment in psychiatry, as a formulation and as a joint re-construction process between the clinician and the patient, is essential in clinical care. Clinical interview is the crucial tool of the clinician in this process. Accordingly, a two-fold task is faced. On one hand, the clinician is in need of making a comprehensive diagnostic assessment to construct a valid and working formulation of the patient's situation and a treatment plan.

On the other hand, the bases for a psychotherapeutic alliance and rapport should be established. A comprehensive diagnostic assessment aims to bridge the current scientific evidence and knowledge with the uniqueness of the specific person who presents for care. The clinician facing the complexities of the human existence in health and ill mental health constructs working hypotheses in the context of the interview, to understand and formulate the psychopathological state. Clinical interview serving as a practical channel in constructing these hypotheses, also serves as the main tool in establishing a therapeutic alliance. The theory and practice of different schools of psychotherapies offer considerable contributions to the clinician in managing these tasks.

Understanding the meaning of the human suffering through empathy in a judgment free milieu is essential in the establishment of rapport, compliance and a better clinical outcome. This presentation will discuss the complexity of diagnostic process in psychiatry and emphasize the contributions of psychotherapeutic theory and skills and humanistic approaches in this process. Brief clinical vignettes from the authors’ clinical practice will be used to broaden the scope of discussion.

Depression is a complex, heterogeneous psychiatric disorder with multifactorial aetiology. Substantial evidence indicates that depressive episodes are associated not only with changes in neurotransmission in the central nervous system (CNS), but also may lead to structural changes in the brain through neuroendocrine, inflammatory, and immunological mechanisms. Among the factors deserving special attention connected with developing systematic inflammation are altered intestinal permeability, IgG food intolerance, and changes in gut microbiota.

We present a possible scenario of the development of depression, linking elevated zonulin production, loosening of the tight junction barrier, an increase in permeability of the gut wall, and the passage of macromolecules, normally staying the gut, into the bloodstream, with the immuno-inflammatory cascade and induction of IgG-dependent food sensitivity. Alterations in bidirectional signaling between the gastrointestinal tract and the brain, so called “microbiota–gut–brain axis”, may be normalized by dietary immunomodulating factors, including prebiotics and probiotics. In the case of increased IgG concentrations, the implementation of an elimination–rotation diet may prove to be an effective method of reducing inflammation and, in this way, alleviating depressive symptoms.

Given complexity and variety of mood disorders, it is necessary to develop improved integration models. Preliminary study results raise hope that the new methods mentioned above, i.e. psychobiotics, prebiotics, an elimination-rotation diet, may be an important addition to the psychiatrist's armamentarium as therapeutic agents improving the efficacy of the treatment for affective disorders [1–3].

Numerous risk factors for schizophrenia can be reconciled through a common enteric source. These risk factors include systemic and localized inflammation, compromised endothelial barriers, IgG sensitivities to food antigens, exposure to viral and parasitic pathogens, and autoimmunity. The gut in a homeostatic state equates with a functional digestive system, cellular barrier stability and properly regulated recognition of self and non-self antigens, as managed by a complex community of resident microbes. Our studies address how environmental and genetic factors relate to GI dysfunction, impact the resident gut microbiota and result in dysregulation of processes in the host central nervous system. We hypothesize that disturbance to GI equilibria activates peripheral immune factors including complement pathway components that function in synaptic pruning. We evaluate these issues with peripheral immune biomarkers and deep sequencing in a number of case-control psychiatric cohorts that include antipsychotic-naïve individuals. Although certain medications and lifestyle factors might affect GI functioning, our findings support a GI pathology inherent to the schizophrenia disease process and a role for the gut-brain axis in complex brain disorders. The identification of those individuals affected by GI-related risk factors will enable appropriate and individualized treatments to be designed and tested for efficacy of both gut and brain-related symptoms.

The patient-centered care features quality, affordable, and timely care in a variety of settings – technology is a key part of that – particularly among younger generations and child and adolescent patients. The consumer movement related to new technologies is nearly passing clinicians by, as new ways of communicating with others (text, email, Twitter, Facebook) revolutionizes how we experience life and access healthcare. This paper explores a continuum with healthy, innovative behavior on one end (e.g., social media) and pathological Internet use on the other end–and the range of self-help and e-mental healthcare options being used. Specifically, it focuses on how social media adds to, yet may complicate healthcare delivery, such that clinicians may need to adjust our approach to maintain therapeutic relationships, interpersonal/clinical boundaries, and privacy/confidentiality. We suggest planning ahead to discuss expectations about online communication between doctors and patients as part of the informed consent process, offer other do's and don’ts for patients and clinicians, and review applicable guidelines. More research is needed on consumer and patient use of technology related to healthcare, as is an approach to basic and advanced measurement of outcomes.

Only a very small percentage of adolescents and young adults with mental challenges is able to access specialized care. Access is limited due to a lack of capacity but also internal hurdles and stigma especially among young males. The web creates a new environment for them, which is defining a new culture of communication and interaction. The majority is using smart phones to access the Internet and make that their main communication device.

Walkalong is a web-based platform, which aims to provide a range of opportunities and tools for youth with especially mood challenges. These tools include screening and assessment, online resources and all kind of orientation and interaction for informed decision-making.

We are working on that to develop a framework for better online-based mental health care including useful tools beyond crisis based on the principles of empowerment and strength based approaches.

Relapses, deterioration of cognitive functioning, negative symptoms, neuroleptic resistance are the examples of many consequences of noncompliance in schizophrenia. In order to improve the compliance, schizophrenic patients treated in an outpatient department in a traditional way have been given an additional possibility of contacting their doctors with the use of a special application on a portable electronic device. Other functions of this application are possibilities of PANSS, Calgary and CGI measurements and cognitive trainings for the patients. This type of a remote contact with patients can be an effective tool in the work in an outpatient setting. The compliance was assessed using a telepsychiatric system, sending reminders: 1 hour before the planned dose to remind them that drug intake is approaching, and at the moment of intake to check if they took the drug. In general the compliance in the group of schizophrenic patients in remission is very low, however the telemedicine system improves the compliance in this group of patients, in which the compliance is the worst.

Our current healthcare system in the United States is characterized by problems with access to timely and evidence-based care, particularly for mental disorders. Telemental health improves access to care regardless of the point-of-service or barriers involved. Its effectiveness across age, population and disorders is as good as in-person care, though adjustments for some populations in the approach is necessary. Early intervention is an example of “Cadillac” care or a best evidence-based approach that is easier to distribute via telemedicine. Cadillac care delivered via TMH has the potential to bring evidence-based early intervention modalities to very young children and their families. However, early access to care is also critical for all populations, particularly those with cultural or medical disadvantages. It appears that telemental health may be preferable or better than in-person care in some instances.

Digital healthcare is the use of technology to deliver healthcare. There are many facets of it. The paradigm of care at a distance e.g. a live interface is the most understood, whether it is the old fashioned analog phone call or that of todays Millenial who ‘get’ Skype or see video calling as a day to day reality.

This has moved to non-live uses, asynchronous, the modern version of written communication, email, videomessage, Instagram, twitter or any one of a multitude of social media.

It has progressed beyond that though to a plethora of devices, apps and cross breeds that promise to maximise your patients health, and often your practice income! Grand claims, if not ones supported by the evidence.

They have broadened the range of providers from the plain vanilla (group) therapist to the Cyber support groups; from patient information sheets, to sophisticated hyperlinked, video embedded ‘hope box’, or manual on your phone. They have changed in vivo exposure from what was limited by travel time, to what is limited by the programmers imagination.

Telemdecine can connect patients and providers worldwide – how can that not be an amazing promise, today's truly outstanding goal – tomorrow commonplace event.

The promise of near infinite data; if only we can measure enough, we can treat better, may hold true for a physical paradigm such as mobile ECG or BP monitoring, but is it true for mental health?

Science is not a door to infinite wisdom, but a rescue from unending ignorance. The evidence is that technological innovations are not a magic solution but tools widening access, they are to travel what the motorway is to the dust track. They are an equaliser in that more people can be reached than ever before–but they do not replace human skill and ability.

By December 2015, 500 million smartphone users worldwide will be estimated to be using a health care application. Yet, there is no evidence of a systematic evaluation of a fraction of these apps. They may not be snake oil salesman, but has the placebo effect graduated from molecules to ones and zero's?

We will explore the evidence to understand some of the promises and the realities of what was once Tomorrows World, here today.

The appeal of psychiatry as a speciality varies around the globe for a number of reasons. In a majority of countries, medical students are reluctant to choose psychiatry and this has become a much more evident matter of concern in the past three decades. The factors, which affect the choice of psychiatry as a specialty by medical students include external and internal stigma, quality of teaching of the subject as well as research exposure and clinical experience during placements. In many countries, a placement may last only two weeks and the exposure is to patients in asylums, whereas a majority of psychiatric conditions are treated in primary care. In addition, personal factors such as the ability to deal with openness and ambiguity play a role in the choice of speciality. A study in 19 countries to explore factors prior to entering medical school, experiences in medical school and postgraduate in the choice of the subject showed that those medical students who are likely to choose psychiatry fall into three major categories:

– those who had decided prior to joining medical school that they wanted to choose psychiatry;

– those who decide during medical school placements and, finally;

– those who select the specialty after having finished their medical school training.

The latter group has two further subgroups: one, which falls passively into psychiatry and another who make an active choice to take it up. Among 2198 students who participated, 4.5% of the sample planned to become psychiatrists, with a further 15% considering it as a possible career. Women (21%) were more likely to consider psychiatry than men (16%). Key factors associated with choosing psychiatry were personal as well as based on teaching/learning experiences. In order to recruit into psychiatry, better teaching, exposure to common mental disorders and small research projects may prove to be helpful.

Media coverage of suicide has been repeatedly shown to influence suicide rates. The Werther Effect (WE) qualifies the propensity of suicide stories to prompt imitative behaviors. By contrast, the Papageno effect (PE) was more recently identified as a way for journalists to contribute to suicide prevention through their productions. Crucially, both WE and PE depend on the quantitative (audience, redundancies, size of articles, etc.) and qualitative (type of story, editorial style, content, etc.) properties of the coverage.

In order to promote the PE and limit the WE, the World Health Organization (WHO) have edited a guideline for media professionals. For instance, journalists are advised to prohibit sensationalism, avoid pictures or details about the suicide method, and show due respect to the bereaved relatives. However, it is now clear that the only chance for these recommendations to be applied is to integrate their diffusion into a more general effort toward collaboration with journalists.

Papageno is a French national suicide prevention program that fully relies on learners to rise awareness about suicide and its coverage. It mainly consists in pair-meetings between psychiatry trainees and journalism students. Such an innovative formula breaks with the old top-down knowledge transmission model in order to foster personalized and sustainable sensitization. It aims at growing up a new generation of journalists who would be more aware of their responsibility concerning suicide and would more spontaneously resort to the WHO guidelines. Ultimately, the Papageno program strives for the creation of a new culture where journalists and psychiatrist would collaborate for a safer media coverage of suicide.

The world today is more challenging than ever before. Discrimination, stigma, and ever-changing lifestyles are just a few examples of elements that have a profound impact on the mental health status of our global population. Even though the burden of mental illness is well documented and increasing, mental health remains a neglected area of health worldwide.

Youth Associations, like the International Federation of Medical Students’ Associations (IFMSA) and the European Federation of Psychiatric Trainees (EFPT) recognize the importance of tackling this problem, taking an active role on promoting education in our communities, tackling stigma and advocating for more action. Medical students worldwide, from Slovenia, Australia, Lebanon, Brazil, Quebec and Grenada – among at least 42 other countries, organise expansive, creative and engaging mental health projects.

With particular interest we can mention the winner of the last Rex Crossley Award, attributed to a Slovenian project ‘in Reflection’: a suicide prevention project, which tackles the different factors associated with vulnerable groups through a series of workshops and campaigns that seek to destigmatize the mental health problems and offer the opportunity to high school students to get the help they need.

This talk will give an insight into strengths, weaknesses and challenges faced by youth in tackling mental health, specially in the role of the IFMSA, displaying some of our most interesting and innovative projects from future mental health leaders around the world, together with the initiatives of EFPT.

At Guy's King's and St Thomas’ School of Medicine, a unique initiative is the Psychiatry Early Experience Programme (PEEP), which allows students to shadow psychiatry trainees at work several times a year. The students’ attitudes towards psychiatry and the scheme are regularly assessed and initial results are already available.