Film wields an extraordinary power and can both influence and be influenced by society. Given that 1/4 people suffer from a mental illness at some point in their lives, mental health issues play huge roles in our society and on our screens.

The medical film festival Medfest operates under the auspices of the RCPsych and the aim of the festival in 2012 was,’To stimulate debate of the social and political implications of portrayals of health and illness on our screens’.

Waltz with Bashir is a film that vividly depicts the 1982 Lebanon War through the lens of an Israeli veteran.

The former Prime Minister of Lebanon stated,’…that Lebanon would be the last Arab state to have peace with Israel…’

To demonstrate how the power and synergy of film can be utilised to deliver the peaceful message of co-existence.

The WPA announced that it would be holding the 2012 Cultural Psychiatry Conference in Tel Aviv. I submitted an abstract on Medfest and the portrayal of PTSD in Waltz with Bashir.

I received an invitation from the Scientific Committee to deliver a Keynote Lecture in Israel.

RCPsych initiatives like Medfest inspired me to challenge preconceptions and prejudices. Most importantly, however, whilst I have no misgivings that it will take more than a lecture to resolve the on-going Arab-Israeli conflict this experience has given me, a Lebanese early-trainee psychiatrist, and others that glimmer of hope that one day the two people may live in peaceful co-existence.

Adequate pathways to care are a prerequisite for early detection and intervention in First Episode Psychosis (FEP). Two systematic reviews examined the influence of ethnicity, social and clinical factors on psychosis care pathways. Accessibility to health services differs for under 18s, yet differences in care pathways between age groups and the impact of family factors have not been investigated.

To investigate the influence of family factors in help-seeking pathways for adolescents with FEP.

Naturalistic crossectional study of 1351 FEP (14-35 years) referred to Early Intervention Psychosis teams (London, UK; 2003-2009). Care pathways included accounts on who initiated help-seeking process, initial contact points (GP, emergency services, education, social services, police and court/prison), and family factors (social support, living arrangements and family load of mental illness).

For the majority of adolescents (n=118) and adults (n=1232), first and second contact points were GP (30% vs 42%) and emergency services (18% vs 23%). However, these two services accounted for less than half of the adolescents’ sample. Adolescents made higher use of education (p<0.001). Family factors, such as good social support (p=0.036), living with carers (p<0.001) and family load of mental illness (p=0.018), were associated with family taking a leading role in problem recognition.

Adolescents with psychosis differ from adults in their contact points when seeking help. Problem recognition is a complex process which involves identifying and legitimizing mental health concerns. Parental awareness and perception of problems revealed as a key step in seeking help for adolescents.

Gender Incongruence (GI) is a rare condition in adolescence characterized by a marked incongruence between one's experienced gender and the assigned sex. It presents as a combination of: a strong discomfort and/or intense rejection of the behavior/attributes of the born gender, a strong desire to live (and be treated) of the experienced gender, and/or a determination to follow the process of transition (i.e. hormonal therapy, sex reassignment surgery). Psychological functioning and treatment outcome has shown significant variation across transgender individuals.

This study aimed to investigate the diagnostic stability of GI in adolescents across ICD-10, DSM-IV-TR, DSM-5, and ICD-11.

Case series of four adolescents aged 16-17 (3 female-born and 1 male-born) with GI seen at Child and Adolescent Mental Health Services (London, UK) in 2012, who completed clinical assessments and questionnaires (Utrecht Gender Dysphoria Scale and Gender identity/GD questionnaire for adolescents and adults).

GI diagnostic criteria varied across diagnostic systems regarding: (1) number of indicators required, (2) symptoms duration, and (3) presence of clinical distress/impairment. In our case series, the latter led to diagnostic instability: two adolescents did not fulfill DMS-IV-TR and DSM-5 criteria. Nonetheless, the dimensional approach supported the GI diagnosis for the four adolescents.

Classification systems evolved in their conceptualization of GI over time evidenced by a shift in the condition name and diagnostic criteria. Diagnostic instability across classification systems may have an impact on their clinical utility. Evidenced-based investigations are required to further assess the clinical utility of the new classification systems.

Everyday clinical routine is frequently challenged by difficulty to choose among differential diagnostic options, since many psychiatric disorders share similar phenotypes. E.g., borderline personality disorder (BPD) and schizophrenia (SZ) can both be associated with psychotic syndromes.

Our objective was to evaluate the effectiveness of combining sMRI data and pattern classification methods to differentiate between BPD and SZ.

We aim to introduce objective diagnostic measures to improve the reliability of clinical evaluations.

sMRI data of 114 female patients were used to train a multivariate disease classifier.

MR images were processed using voxel-based morphometry and high-dimensional registration to the MNI template. Grey matter volume maps were fed into a machine learning pipeline consisting of adjustment for possible age effects, PCA for dimensionality reduction and linear ν-support vector classification. Diagnostic performance of the classifier was determined by repeated nested 10-fold cross-validation.

We were able to correctly classify unseen test subjects’ diagnosis with 74% accuracy. Classification sensitivity and specificity was 74%. Volume reductions in SZ vs. BPD were predominantly located in the left peri- and intrasylvian regions, orbitofrontal regions, the nucleus caudatus and the right cerebellum. Volume reductions in BPD compared to SZ were found predominantly in the left cerebellum, in limbic areas and the left inferior occipital gyrus.

Our results suggest that SZ can be differentiated from BPD at the single-subject level using sMRI and pattern classification methods. In future, this method might enhance clinical evaluations and improve accuracy and reliability of differential diagnosis.

Cannabis use has demonstrated an association with earlier onset of psychosis. Investigation of sociodemographic and clinical characteristics in association with cannabis use in adults with first-episode psychosis (FEP) has resulted in inconsistent findings. The clinical profile of cannabis users amongst adolescents with FEP remain widely understudied.

To investigate the frequency of cannabis use, and its association with sociodemographic and clinical characteristics in adolescent-versus adult-onset FEP.

Naturalistic cross-sectional study of 1363 FEP cases aged 14-35 (136 with adolescent-onset psychosis) referred to Early Intervention Services for psychosis in London (UK) (2003-2009). Sociodemographic and clinical data (age of psychosis onset, symptom domains, substance misuse, insight, violence, global functioning, and duration of untreated psychosis [DUP]) were collected at entry to EIS.

Cannabis users were more likely to be male (78.2%), White (43.0%) and unemployed (72.0%). No significant difference was found in cannabis abuse/dependence frequencies between adolescents (28.4%) and adults (24.7%). Cannabis abuse/dependence was associated with an earlier onset of psychosis by 2 years (p<0.001), greater manic and positive symptoms (p<0.001), increased violence (p=0.011), and poorer functioning (p=0.013) and insight (p=0.003). For adolescents, cannabis abuse/dependence was associated with greater positive symptoms, poorer functioning and longer DUP.

Cannabis use shapes the clinical presentation of FEP individuals. Similar frequencies of cannabis use between age groups suggest that substance misuse services should be provided to all, aiming to reducing consumption. Greater vigilance amongst clinicians would enable earlier detection of psychosis in substance misusing adolescents, to reduce DUP and minimise associated poor outcomes.

In Tunisia, the number of suicide attempts (SA) leading to a psychiatric follow-up seems to increase.

To describe the clinical and environmental profile of suicidal patients addressed to the outpatient psychiatry department.

It was a retrospective and descriptive study. Data were collected from the files of 29 suicidal attempters referred in 2012 to the outpatient psychiatry department at the Hedi Chaker University Hospital of Sfax in Tunisia, after one or more SA.

SA accounted for 2.4% of new patients referred to the outpatient unit during the year 2012. The sex ratio (M / F) was 0.7 and the mean age was 28.8 years. They were single in 51.7% of cases. Their school level didn’t exceed the primary education in 62% of cases and they didn’t have any occupation in 51.7% of cases. Some relational problems, especially family ones were identified in 69% of cases and the quality of family and / or social support was considered poor in 41.4% of cases. The SA was reactional in 24.1% of the cases; 34.5% of suicidal attempters presented a personality disorder and 17,2% presented a major depressive episode.

A young single person with no profession, a limited educational attainment and low social support, such is the profile most frequently encountered among suicidal attempters. The presence of underlying mental disorders and socio-familial dysfunction seems to be important risk factors for suicide and should be considered in the prevention of recurrence.

Valproic acid is a broad-spectrum drug used in neurological disorders but also in psychiatric disorders such as mood stabilizer in bipolar or schizoaffective disorders.

Despite being a usually well tolerated drug, valproic acid may be associated with some adverse effects. Most of which are mild and transient, however some adverse reactions may be serious like encephalopathy. In fact, valproic acid induced encephalopathy is an unusual but serious complication, characterized by decreasing level of consciousness, focal neurological deficits, cognitive slowing, vomiting, drowsiness and lethargy, with or without hyperammonemia.

The aim of this work is to describe a case report of a woman who developed valproic acid induced encephalopathy during her hospitalization in the Coimbra's Psychiatric Department.

This is a woman, 46 years old, diagnosed with a bipolar disorder who was hospitalized for stabilization of their depressive symptoms.

At the entrance, a confusional state was found with fluctuating state of consciousness, psychomotor slowing and incoherent speech.

An analytical study was conducted which showed a hyperammonemia of 70μg/ dL.

Immediately the valproic acid was suspended on suspicion of encephalopathy induced by this drug.

Gradually, in about 2 or 3 weeks, confusional state disappeared, and the patient discharged from the hospital oriented in time and space, with coherent speech, euthymic mood and regularized sleep.

Valproic acid induced encephalopathy, is a reversible but potentially fatal adverse reaction that requires a high index of suspicion. Organic brain damage and polytherapy appear to be important risk factors for its occurrence.

A 23 year old woman with an established diagnosis of eating disorder was analysed for multiple personality traits in the background of a multifactorial etiology.

1. 1) Establishing secondary complications in the case

2. 2) Diagramatically representing the findings

1. 1) Identifying the personality traits

2. 2) Etilogical analysis

1. 1) Retrospective analysis of all medical and psychiatric events.

2. 2) Interviewing the patient and relatives.

3. 3) Research

4. 4) Analysis of all medical investigations carried out.

5. 5) Response to multidisciplinary management.

It was confirmed that multiple factors played their roles in the development of the condition including both familial and environmental agents.

53 patients and 47 matched controls were studied using a new questionnaire (SEXSAM Scale) measuring relevance of sexual and emotional relationships in patients’ daily life. A specific Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX Montejo 2001-2008), Sexual Activity Assessment Scale modified from Kinsey (Montejo 2006) and the HONOS Scale measuring bio-psychosocial functioning were also applied.

Sexuality (physic and emotional) was scored as high valuable and the main motivation for sexual activity was looking for love and fondness in both groups. No differences were found in the value of more affective behaviours such as kissing, caressing, hugging or massaging. Global satisfaction in sexual and emotional life was significantly superior in control group and linked to the higher frequency of sexual relations. Many patients suffered for sexual dysfunction related to the treatment use and many of then were dissatisfied with their sexual life. Just a few numbers of patients had regular sexual intercourses. Patients describe an improvement in the self-perception of mood, appetite, sleep, anxiety level, humour sense and self-esteem when they have sexual relations. Predominant sexual activity for patients was masturbation. Prostitution use was higher in patient group. All these findings are negatively influencing personal satisfaction and quality of life.

Relevance of sexual and emotional life in patients is as high as in normal population. These patients are more concerned about affection and companionship than about physical pleasure.

Depression is very common among institutionalized elders. Because of the increased risk of cognitive impairment/dementia, and mortality we want to describe the evolution of depression and analyze predictive factors.

In the Aging Trajectories Study (Instituto Superior Miguel Torga - Coimbra), we followed up a sample of 83 nondemented persons (M ± SD baseline age = 79.51 ± 6.58; men: 17; women: 66). In a 2-year prospective cohort analysis (2010-2011, and 2013), we assessed depression using the Geriatric Depressive Scale/GDS as screening tool and the Mini International Neuropsychiatric Interview to diagnose depression. We also used the UCLA Loneliness Scale, the Geriatric Anxiety Inventory/GAI, the Positive and Negative Affect Scale/PANAS. Sociodemographics, and health were control variables. We performed a multinomial logistic regression to identify predicitive factors.

Fifty participants had depression at baseline, nine developed, 49 maintained, nine remitted, and 16 maintained without depression.

Having depression was associated with worse scores in UCLA, GAI, and PANAS. Not having depression was correlated with higher positive affect.

Baseline higher GAI and UCLA, and lower positive affect and satisfaction predicted recurrent depression.

Improvement in GDS, GAI, and positive affect predicted depression remission.

Results show that depression is a concern issue for professionals working with institutionalized elderly. Anxiety, loneliness, low positive affect and satisfaction constitute a risk factor for maintaing depression in institutionalized elderly and low anxiety and depressive symptoms are a protective factors for depression. These results could be used in depression prevention programs.

In this study, the impact of quetiapine fumarate extended release (QXR) and escitalopram (ESC) on HPA axis activity was investigated in depressed patients in relationship to antidepressant efficacy.

In a randomized, open-label 5-week trial 60 inpatients suffering from major depression (DSM-IV criteria) were treated for 5 weeks with either QXR (300 mg/day) or ESC (10 mg/day). The dexamethasone/CRH (DEX/CRH) test was performed before treatment, after 1, and after 5 weeks of treatment. Cortisol (COR) AUC values were used to assess HPA axis function. The Hamilton Depression Rating Scale was used weekly to estimate antidepressant efficacy.

QXR and ESC showed comparable antidepressant effects but strongly differed in their impact on HPA axis activity. In the QXR group, a marked inhibition of COR AUC levels was observed which was most pronounced after one week of treatment but showed a partial re-increase after 5 weeks of treatment. In contrast, ESC transiently stimulated COR AUC values (week 1) whereas COR AUC levels at week 0 and week 5 were comparable. COR improvement at week 1 (defined as COR peak value reduction between DEX/CRH test 1 and 2) was significantly associated with better clinical outcome.

Apparently, different effects on HPA axis activity reflect distinct pharmacoendocrinological properties of psychotropic drugs.

Cognitive rehabilitation techniques, reminiscence therapy, and reality orientation therapy, have shown an impact on cognition, life satisfaction, mood, and on the progression of cognitive decline in elderly.

To test the effectiveness of a NRGP on the cognitive and emotional functioning of institutionalized elderly.

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single blind randomized controlled study with paired groups.

Coimbra institutionalized elderly, aged between 64-92 (N = 88) with cognitive impairment no dementia, mostly women (75.0%).

randomization of participants to the rehabilitation group/RG (n = 41) and to the comparison/waiting-list group/CG (n = 23). NRGP involved groups of five elders, and took 90 min. per day, once a week, for 10 weeks.

Mini-Mental State Examination/MMSE, Frontal Evaluation Battery/FAB, Geriatric Depression Scale/GDS.

We used general linear model with repeated measures analysis of variance.

RG improved significantly on cognitive, and executive function (p < 0.001), and CG worsened on cognitive, executive function, and mood (p < 0.01). There was a significant effect on the MMSE, FAB, and GDS scores, after excluding pre-rehabilitation scores as covariates [F (1, 81) = 43.98, p < 0.001; η2 = 0.35; F(1, 80) = 28.37, p < 0.001; η2 = 0.26; F(1, 79) = 19.66, p < 0.001; η2 = 0.20].

A NRGP including cognitive rehabilitation, reminiscence therapy, and reality orientation proved to be effective on cognitive and executive functioning, and on depressive symptoms of institutionalized elders with cognitive impairment no dementia.

The Beck Depression Inventory-II [BDI-II] (Beck et al., 1996) is the self-report instrument to depressive symptoms most widely used. A 2-factor structure is frequently obtained in clinical and nonclinical samples. Our group found an identical 2-factor solution in pregnant (3rd trimester) and postpartum women (3 months); the two factors were: Cognitive-Affective and Somatic-Anxiety (Bos et al., 2009).

To investigate the BDI-II factor structure in a sample of childbearing age women who were not pregnant or that did not have children in the last year and to compare the structure of depression symptoms experienced by women in the perinatal period versus outside the perinatal period.

120 non-perinatal women (students and employees at health and education institutions), aged 18-44 (M=29.42±7.159 years), currently or in the last year unpregnant, were asked to to fill in the BDI-II. A principal components analysis with Varimax rotation was performed.

The internal consistency coefficient Cronbach alpha (α) was of .82. Following the Kaiser and the Cattel's Scree Plot criteria, a two factors structure was selected, which explained 43.56% of the variance [EV]. Based on items content, Factor [F] 1 (EV=33.55%; a=.83) and F2 (EV=10.26%; a=.82) were respectively denominated’Somatic-Anxiety’ and’Cognitive-Affective’. The dimensions composition completely overlapped with the Bos et al. (2009) structure, obtained with perinatal women.

The BDI-II factorial structure in non-perinatal childbearing age women is robust and meaningful. Our results support the view that the structure of depressive symptoms does not differ between perinatal and non-perinatal women.

Ketamine, an N-methyl-D-aspartate antagonist, rapidly improves depressive symptoms in individuals with treatmentresistant depression. However, most trials using ketamine were limited to single administration and were performed with the racemic mixture of ketamine. The aim of this case series was to investigate the clinical efficacy of multiple intravenous administrations of S-ketamine in the acute treatment of treatment-resistant depression.

In 6 patients suffering from Major Depression (DSM-IV criteria) and being pharmacoresistant to at least 2 antidepressants, intravenous Ketamine treatment was started with a 40 minute administration of 0.25 mg S-ketamine/kg body weight i.v. The treatment was performed over 3 weeks using 2 infusions per week. Patients were kept on their current pharmacotherapy regimen (including antidepressants). The patients were rated using the 21-item version of the Hamilton rating scale for depression (HAMD-21) before and 120 minutes after each ketamine infusion.

In 5 of 6 patients a strong improvement of depressive symptoms occurred already after the first ketamine infusion. The response could be stabilized by the following infusions. In 2 patients dissociative symptoms could be seen.

Multiple administrations of ketamine appear to be well tolerated, although negative effects on cognition have been described after longer use. The occurrence of dissociative symptoms in two patients in our study must be viewed as an unpleasant side effect. In the literature there is some evidence, that S-ketamine has better tolerability than racemic ketamine but similar antidepressant effects.

At the conclusion of this presentation, the participant should be able to achieve a global perspective into mental illness.

Influenced by the social philosophy of Rousseau, primitive man was believed to be free of the anguish of mental illness. Studies of mental illness across cultures has brought out important differences in different illness variable: incidence, types, manifestations, outcome and treatment. In so far as variations across cultures exceed those within, culture can be said to play an important role in mental illness.

Schizophrenia has been reported from all societies, but there are differences, particularly in incidence, types and outcome. Paranoid schizophrenia appears to be less common in traditional societies. A distinctly better outcome of schizophrenia has been reported from the developing countries. Depression was felt to be less common in these countries. Personality disorders and neurotic illnesses seem to be less prevalent in developing countries. Multiple personality disorder seems to be rare. Sexual deviations are very rarely reported from many countries. Finally, the traditional, technologically less advanced countries have reported a number of specific conditions that are called culture-bound syndromes.

Separating the differences from similarities across cultures can give us better insight into the’core’ nature of a mental illness. Also, all countries can learn from each other, so as to augment the variables associated with lower incidence and better outcome; obviously a matter of great public health significance.