EPACONGRESSNEWS

The official daily newsletter of the 21st European Congress of Psychiatry Sunday 7 April 2013 Day 1

Inside today Welcome, colleagues Page 4 It is with great pleasure that I welcome you to the Schizophrenia: Better ‘functioning’ for pa- 21st European Congress of Psychiatry in Nice. tients in their return his year marks the 30th ciations of Families of People with Men- to the community. anniversary of the European tal Illness (EUFAMI), European College Page 6 Psychiatric Association, thus of Neuropsychopharmacology (ECNP), it offers a natural opportu- World Psychiatric Association (WPA), ADHD: pharmaco- nity to both reflect on the European Brain Council (EBC), Euro- therapy is not the only element Tpast three decades of psychiatry and pean Federation of Psychiatric Trainees also look to the future of where we (EFPT) and the European Conference on Page 9 would like our journey to take us in Schizophrenia Research (ECSR). the next 30 years. In tribute, this year’s As we look to the future, it is appar- Phenomenology as a method to access programme features special presenta- ent that we need to place more focus patients’ experi- tions, Round Tables, networking events on consciously improving the health ences and improve and discussions that will set the tone as of psychiatric professionals, encourag- treatment strategies. we usher in the next era of European ing ourselves and all those in the field psychiatry. to invest more effort in improving our Danuta Wasserman Page 12 We are already off to a fantastic working conditions as well as indi- Discussing the new start, having welcomed 33 European vidually taking care of our own health, array of core symposia, plenary lectures, directions of DSM-V National Psychiatric Associations (NPAs) both mental and somatic. The latter state of the art lectures, pro and con and ICD-11 with more than 77,000 members to the by increasing awareness about the debates, early career sessions, posters Page 15 EPA in the last year. These collabora- role of diet, exercise and sleep. And and sponsored sessions that offer a tions will serve to enhance our knowl- the congress will be no exception – as comprehensive and enlightening view edge and understanding of different well as offering healthy Mediterranean of the very latest insights in psychiatry traditions, cultures and viewpoints cuisine throughout, we will be hosting and its associated fields. across Europe, thus fostering reciprocal organised walks between hotels and I hope that you have an enlighten- exchange of ideas and approaches that the Acropolis, as well as asking plenary ing and enjoyable congress, and I look will boost the advancement of patient lecture attendees to join us in a pre- forward to seeing you again in Munich, care in these economically challenging lecture warm-up with the help of our Germany, 2014. times. very own congress exercise guru. Danuta Wasserman We welcome these new associa- By strengthening our well being and EPA President Julio Licinio dis- tions alongside the fruitful and dynamic health, we will be better prepared to Head of the National Prevention of cusses his plenary relationships of our long-established serve our patients and by giving good Suicide and Mental Ill-health (NASP) at lecture on gene and collaborators, the World Health Organi- examples, our patients will profit in the Karolinska Institute, Stockholm, Sweden environment Interac- zation (WHO), European Union (EU), treatment process. Director for the WHO Collaborating tions European Union of Medical Specialists As always, the cutting-edge scien- Centre for Prevention of Mental Ill- (UEMS), European Federation of Asso- tific programme returns with a rich Health and Suicide 2 EPA Congress News 7 April 2013 Sunday

Pharmacological treatment of ADHD Athéna Sunday 10:00-11:30 Taking a step back in ADHD

he debate over the increasing prescription Europe. We see a very large increase in the num- minutes of attention span. Yes, some kids are of ADHD medication sets the stage for a bers, almost ten-fold, during a decade in autism way behind, but it doesn’t mean that they have discussion of the questions that genetic spectrum diagnosis, and this led the DSM-V to a disorder. Some kids are shorter than others, Tstudies can answer in the disorder. During his change the diagnosis.” some kids have less motor skills, some kids have presentation today on the promises of genet- Professor Zalsman will demonstrate that an attention span of 15 minutes, not 13. Some ics, Gil Zalsman (Sackler School of Medicine, ADHD is at least partially genetic, with evidence people in my profession think that since it is Tel Aviv, Israel) will take delegates through the from twin and adoption studies, as well as only developmental, if you wait long enough nature versus nurture debate in ADHD, empha- genomics. He said: “The prevalence in identi- this kid will catch up; so actually it is unfair to sising the importance of continuing collaborative cal twins is two to three times more than in Ritalin to everyone who is a little behind in the efforts to understand the disorder better. non-identical twins, which same way that we don’t Every fifth adolescent in high school in the means that if you share give growth hormone to US takes Ritalin, according to recent data from the same DNA, the odds “The EPA, and every kid that is a little the Centre for Disease Control (CDC) in the US.1 of having ADHD if your especially the Child bit short in the first few “ADHD is considered as an epidemic in Europe brother has it is some- years of school!” and the US,” said Professor Zalsman. “There is times around 50 percent. Psychiatry section While this may be a big debate about it: is it really a disease? Is it Adoption studies show that I am chairing at the case, Professor actually part of culture? In this culture, every- the same: there is a major the EPA, is trying to Zalsman was also care- body has a cellphone and everything is so quick. genetic contribution to ful to stress that some Maybe we are creating this disorder. Some other ADHD.” promote collaboration individuals will never people say that it is nothing but a neurological The high hereditability between people. This attain normal adult disorder. The main assumption is that we simply of ADHD has prompted measures of attention come to a diagnosis more often. The debate in genetic studies, look- is what EPA is about. span. In adulthood, the US is that there is over-diagnosis. The criteria ing at either candidate We have to join hands and even in childhood are too wide, and actually the whole story of the gene regions or scanning and adolescence, the epidemic of ADHD is a matter of diagnosis and the genome as a whole. and do it together.” problems of ADHD awareness. The same is true for PDD [pervasive While contradictory Gil Zalsman (Sackler School of do not end when the development disorder] and autism in the US and findings are a frustration Medicine, Tel Aviv, Israel) school bell rings. “We for the scientific commu- see today about seven nity, they may belie the to 10 percent of adults complexity of the multiple genetic and envi- with ADHD. Most of the problems of these ronmental factors that make up an individual’s kids are much bigger than school. They are ADHD symptom profile. “Often studies found a impulsive, they have behavioural problems, they EPACONGRESSNEWS few candidate genes, but none of them can be are not attentive, and they are impulsive often Publishing and Production said to be the gene for ADHD,” said Profes- within their peer group so they are not popular. MediFore Limited sor Zalsman. “It seems that some findings are They have a lot of problems with their parents, EPA President not replicable. In some cases, the findings are because they behave badly. So they have low Danuta Wasserman true in boys and not in girls. Some findings are self esteem, and very high rates of depression Local Organising Committee Chair negative, while others are positive on the same and other comorbidities. One of the studies we Philippe Courtet gene. The current state is that we actually have have done has shown that the rate of suicidality Editor-in-Chief no gene in our hand, and it seems that in many is higher, the suicidal ideation and attempts are Peter Stevenson other disorders in psychiatry – and especially higher. So actually, these kids are vulnerable in Editor in child psychiatry – that the genetics of the many things, and their functioning in school is Rysia Burmicz disorder is multifactorial. There is more than one only part of the problem.” Design gene and there is more than one factor. So it is The complexity of multiple genetic and envi- Peter Williams actually an interaction between few key genes ronmental factors, together with the theory of Industry Liaison Manager and the environment together.” over-diagnosis, presents a significant challenge Cheryl Cagiola When prescribing for ADHD in the young, for research. Moreover, genome-wide studies Head Office the normal distribution of developmental require thousands of subjects to attain the statis- 19 Jasper Road rates that children display must be taken into tical power that is necessary for a hypothesis- London SE19 1ST, UK Telephone: : +44 (0) 208 244 0583 account, said Professor Zalsman, adding that free study of such a vast array of data. “The [email protected] attention span may take longer to develop in only way really to do it is to have consortia and www.medifore.co.uk some children than others. “A child that was collaboration,” said Professor Zalsman. Copyright © 2013: European Psychiatric Association. born a few hours ago has no attention span and “The EPA, and especially the Child Psychiatry All rights reserved. No part of this publication may be we expect him to do so.” section that I am chairing at the EPA, is trying to reproduced, stored in a retrieval system, transmitted “A normal baby has very high distractabil- promote collaboration between people. This is in any form or by any other means, electronic, mechanical, photocopying, recording or otherwise ity, and this is important for its development. what EPA is about. We have to join hands and without prior permission in writing of the EPA. The Every noise, every new sight that comes in do it together. If I have 200 kids and someone in content of EPA Congress News does not necessarily front of him, he will follow. When you are six Holland has another 200 kids, and someone in reflect the opinion of the EPA Board or Committees. years old, we expect you to have about 13 Continued on page 18 Sunday 7 April 2013 EPA Congress News 3

State of the Art lecture: Early detection and treatment of depression Apollon Sunday 15:45-16:30 A wake-up call for clinical psychiatry he sophistication of clinical diagnoses that tion, and emphasised the importance of both psychiatrists make in their practice far ‘self-therapy’ and psychotherapy as tools for outstrips that of the assessment methods changing patterns of behaviour and improving Tused in psychiatric research, Giovanni Fava (Uni- self-awareness. Hence, he proposed a sequential versity of Bologna, Italy) will communicate in a treatment strategy that observes the principles State of the Art lecture today that examines the of staging. This approach entails the use of an- early detection and treatment of depression. tidepressant drugs during the acute phase, and In an interview with EPA Congress News, he the use of psychotherapeutic strategies during spoke about reviving the status of clinical judge- the residual phase while drugs are tapered and ment as a scientific way of formulating clinical discontinued. While this method relies on the decisions. By discussing the current clinical issues impetus of the patient as well as the availability surrounding major depressive disorder in his of psychotherapy, Professor Fava noted the con- lecture, Professor Fava will uncover some of the siderable advantages of reduced relapse rates possibilities for improving clinical research, diag- and the discontinuation of medication. nosis, acute treatment and long-term manage- In his latest look at the use of extended clini- ment in this and other disorders. cal measurements that form the basis of clinical Early intervention can be achieved by the judgement, in relation to the standard diag- observation of prodromal symptoms, but these nostic criteria, Professor Fava identified several symptoms may be most helpful in recognis- innovative strategies that he hopes will go on ing the onset of relapse in individuals, simply to provide the foundation for a more detailed, because of their high inter-individual variability thorough approach to evidence-based study. and lack of diagnostic specificity. “Yes, there is a Clinimetrics, repeated patient assessment, stag- prodromal phase of depression, but it is not spe- ing of both symptoms and other factors (such cific,” said Professor Fava. “In other words, the as treatment resistance), and macroanalysis are symptoms that may occur vary among patients some of the most prominent potential strate- and they may take place in depression, panic, gies that will be presented in his State of the Art social phobia, and other disorders.” lecture.3 Introduced some 20 years ago, Fava and Kell- The methods of clinical judgement, em- ner’s staging theory1 is now a familiar face on Giovanni Fava bracing this complexity, should be reflected the psychiatric scene, comprising the prodromal in clinical research as it is in clinical practice. phase, acute manifestations, residual phase, and “They are too broad,” he said. “They can consist Evidence-based medicine, randomised controlled chronic phase (in attenuated or persistent form). of different things that need to be addressed. trials and meta-analyses can neglect the clinical While the prodromal phase cannot be confirmed This will really be one of the crucial issues of my histories of patients, whose previous treatments until the emergence of an acute phase, if this talk: a single intervention is unlikely to solve the and chronicity can influence the effectiveness occurs at all, it is nevertheless useful in the clinical problem. Whether pharmacotherapy or of treatment.4 “There should be a much more longer term. refined assessment,” said “The important thing is Fava. “The treatment protocol that symptoms are very vari- “The important thing is that symptoms are very should derive from this assess- able, but for the same patient, variable, but for the same patient, relapses ment. I will attack evidence- relapses tend to take place based medicine as being with the same symptoms,” tend to take place with the same symptoms. non-scientific. Evidence-based said Professor Fava. “How can How can this be used for addressing residual medicine is based on the this be used for addressing average patient; I never see residual symptoms, the symp- symptoms, the symptoms which persist after the average patient. I would toms which persist after you you have been treated and after the most love to see them! I get all have been treated and after important symptoms get better?” of the most complicated, the most important symp- atypical, strange cases as time toms get better? For instance, Giovanni Fava (Bologna, Italy) goes by.” you may feel well in your mood, but you may still have Professor Fava will deliver his problems sleeping. I will describe an approach psychotherapy, we are dealing with complex is- State of the Art lecture on the early detection and that is making use of this way of categorising sues that need sequential, different approaches, treatment of depression, and the role of clinical judg- symptoms that is longitudinal, and not cross- the consideration of various components of the ment, at 15:45 this afternoon in room Apollon. sectional, as is the DSM.” depressive disorder.” References He went on to question the refinement of The lingering spectre of residual symptoms is 1. Fava & Kellner. Staging: a neglected dimension in psychiatric clas- sification. Acta Psychiatr Scand. 1993;87(4):225-30. the classification systems, the Diagnostic and unlikely to vanish by pharmacological treatment, 2. Fava GA et al. Cognitive behavioral treatment of residual Statistical Manual of Mental Disorders (DSM) as evidenced by the 1994 study carried out by symptoms in primary major depressive disorder. Am J Psychiatry. and International Classification of Diseases (ICD), Fava et al.2 Professor Fava described examples 1994;151(9):1295-9. 3. Fava GA. Clinical judgment in psychiatry. Requiem or reveille? in their present state, saying that precise treat- of the compound problems that can arise from Nord J Psychiatry. 2013;67:1–10. ment guidelines cannot be defined from them. the extended use of antidepressant medica- 4. Tomba E. Nowhere Patients. Psychother Psychosom. 2012;81:69–72. 4 EPA Congress News 7 April 2013 Sunday

State of the art lecture: Improving Schizophrenia Outcome Apollon Sunday 15:00-15:45 Better ‘functioning in real-life’ for people with schizophrenia

This afternoon plays host to a state of the art lecture that will explore how we can improve the outcome of schizophrenia patients when returning to the commu- nity, with emphasis placed on improving function in everyday life, and not just the lessening of symptoms.

everal changes have oc- researchers through many decades curred in the past dec- of research. As such, functioning in ade with relationship to the real-life is a concept that is hard “Sthe conceptual frame of schizo- to trace. “I will briefly touch upon phrenia outcome,” Silvana Galderisi different definitions of ‘functioning’ (University of Naples SUN, Italy) told in real life, and will then move to EPA Congress News. “In the past the discussion relevant to what do we have had very diffuse ideas that we know at this point, what do we schizophrenia was a progressive need to know and to address in or- illness with a poor outcome. And der to improve outcome,” she said. this dates back to authors such as Indeed, improvement of func- Bénédict Morel or Emil Kraepelin tioning in the real-life depends on who considered the disorder as very several variables, some of them Silvana Galderisi chronic and deteriorating with a relevant to the illness, some to per- poor prognosis. sonal resources, some others to the derisi. “At least what is considered families’ social-economic status, the “A change in this perspective context in which the person lives. today state of the art in these dimension of the social network of took place and some research- To improve functional outcome, we concepts and also the possibilities persons and the stigma associated ers as well as clinicians started to need to address as many variables to find new treatments of these to the illness in different contexts endorse a more optimistic view of as possible. For example, looking aspects that so far have not been can also influence the possibility for the outcomes of schizophrenia to at illness related variables (e.g. really treated successfully.” people with schizophrenia to lead a the point that they felt unsatisfied symptoms and cognitive impair- She continued: “Then we have fulfilling life.” of a concept of outcome limited to ment), while positive symptoms are to consider variables relevant to the Briefly touching on this aspect, the improvement of symptoms of effectively treated, there are few person’s resources. In fact, people Professor Galderisi referred to the illness, and wanted to may have the same recent studies of her own which have a much more ambi- symptoms and compared schizophrenic patient tious goal: having patients the same type of outcomes in the communities of living a satisfactory life in “Some researchers as well as cognitive impair- several northern and southern the community.” clinicians started to endorse ments but they may European locations: “We found Critically, it was be very different as out to our surprise that patients observed that while a more optimistic view of the far as some of their living in Naples [south Europe] were patients were returned to outcomes of schizophrenia... individual resources actually more frequently employed, community life with fewer and wanted to have a much are concerned. And even though they lived in a context symptoms, the limitations here I am talking of where having a job was more dif- in ‘functioning’ still had a more ambitious goal: having course of people’s ficult than in the other sites,” she significant impact on their patients living a satisfactory life coping strategies, explained. “And so we concluded quality of life. This con- people’s recovery in this paper that probably in the cern led researchers and in the community.” styles, people’s resil- south of Europe there is a lower clinicians alike to develop Silvana Galderisi (University of Naples SUN, Italy) ience – which need tendency to stigmatise mental ill- different perspectives on to be regarded as ness and to exclude affected people what would be a proper important resources from social life and from working and appropriate outcome in the treatment opportunities.” for a patient. available treatments for negative process. Among personal resources, However, as Professor Galderisi symptoms, especially those defined an important variable to consider is Professor Galderisi will discuss current noted, to this day there is still great as persistent, and for cognitive physical health – known to have an views of schizophrenia outcome, the discussion as to how ‘functional’ impairment. impact on patient outcome.” main variables influencing it, and the status in the community can be “Therefore, I will focus the at- Professor Galderisi will also unmet needs and future perspectives in management of schizophrenia in ascertained, not least because tention on the new treatments for briefly address the importance of her state of the art lecture ‘Improving measuring the symptoms has been negative symptoms and cognitive context-related variables. She said: Schizophrenia Outcome’, held today at hitherto defined by clinicians and impairment,” said Professor Gal- “I will mention the possibility that 15:00-15:45 in Room Apollon. Sunday 7 April 2013 EPA Congress News 5

European Mental Health Care in the Time of Economic Crisis Galliéni 5 Monday 15:00-16:30

we have many new treat- problems (schizophrenia, ments, new techniques, and bipolar disorders, demen- Putting psychiatry new medicines, rehabilita- tia, etc.) are not exclusively tion is now very sophisti- problems of the brain; they cated and we need to keep are problems of the mind, and the patient first in touch with that.” which is inside the brain. So Professor Palha was we have to come back a lit- he cultures that make needs of the human rights instructive in formulating tle bit to what we can once up the European of the patients. recommendations as part again call neuropsychiatry. community can lend “The first human right of his work on the board A neuropsychiatry perspec- Teach other useful insight of the patient is to be well of the Portuguese Society tive will also take care of into approaches towards treated in the best setting of Psychiatry and Mental the social part, because the mental health care amid with the best techniques, Health as Past President, mind came from society. turbulent economic times, medicines and psycho- however he was keen to When I started my training delegates will hear on therapies. We have to pay emphasise that the reality in psychiatry, I was in the Monday in a special session attention to all these things. on the ground can be very last part of neuropsychiatry, that will put the spotlight When we have a lot of different. He cited few but now it is coming back on patients’ and doctors’ countries such as in Europe, resources as a critical issue again.” rights, stigmatisms and the regardless of political prob- in serious conditions such as Professor Palha also add- various implications that a lems, the reality is that the schizophrenia and obses- ed that early diagnosis and struggling economy brings. situation is good if we have sive-compulsive disorder. He establishment of a treat- Speaking to EPA Con- conditions for good living added that policy does not ment programme, together gress News ahead of his António Pacheco Palha and good care in the com- always take into account with continual evaluation talk about the importance munity.” practical issues of modern during treatment, is the of upholding the needs days he can spend as an Professor Palha then life (such as working families key to a successful reha- of the patient as a matter inpatient? Seven days? went on to describe how being unable to provide care bilitation. He said: “Even of human right, António Fifteen days? How can we important it is that psychia- for a schizophrenic relative), in dementia there are two Pacheco Palha (Hospital save money? There are now trists should remain involved and that many psychiatrists sides: in the early stages of San Joao, University of new problems like this that in cases as they progress are striving to take these dementia, there are a lot Porto, Portugal) shared his derive from the crisis. Yet from the acute to the factors into consideration. of things that psychiatrists opinions on the role of the the patient has rights to chronic or remissive stages. Professor Palha con- can do – that rehabilitation psychiatrist within the spec- dignity and the best care. He said: “Schizophrenia is cluded on a note of and stimulation can do. It trum of treatment during Meeting the needs of is not the final step this critical period. the client is a human of life. But early di- Professor Palha began by rights question.” “But early diagnosis is the base of agnosis is the base of describing his perspective The treatment of everything. We know that if you everything. We know on the role of the psy- the patient must be diagnose within months of the onset, that if you diagnose chiatrist in current mental put first, said Profes- within months of the health reform, namely in sor Palha, and this the prognosis is fantastic compared onset, the prognosis Portugal, highlighting that begins with diagnosis, to after five years. I think we need to is fantastic compared practice does not always which emerges from a to after five years. I follow policy. “Psychia- foundation of clinical be much more broad-minded, not to think we need to be trists are, many times, an skills. He emphasised follow the DSM religiously. And the first much more broad- aside,” he said. “There are that psychiatrists, while minded, not to follow different technicians on the considering social and diagnosis very often is not definitive.” the DSM religiously. ground – social workers, community elements António Pacheco Palha (Hospital San Joao, University of Porto, And the first diag- rehabilitative workers, from of patient care, must Portugal) nosis very often is the community and from retain this founda- not definitive. The the municipality. And some- tion. “In the southern psychiatrists’ rights times there are local and [European] countries in this a chronic disease, like the optimism, with a bugle to have the best conditions national councils of forty [economic] crisis, we have majority of the important call for neuropsychiatry as to treat and rehabilitate people created to address a very nice composition of diseases in medicine such the front line of patient their patients are one of the issues in mental health, but law and intentions, etc. as rheumatoid arthritis care that considers social main supports for the fulfill- they come to nothing. In reality, everybody talks or diabetes. But why do influences as well as clinical ment of patients’ rights in “I am living here [in about mental health within they become social cases? symptoms in order to deal these days.” Portugal] and I see a lot of the community of psychia- Rheumatoid arthritis does with a particular condition. discrepancies. Now with the trists, but we have forgotten not become a social case. “There are many papers ap- Professor Palha will give his crisis and the new manage- psychiatry. Psychiatry is a [Schizophrenia patients] pearing that ask: what is the presentation ‘Patients’ and ment in health systems we clinical speciality that deals pass through another kind future of psychiatry? And doctors’ rights: the dignifica- tion of the psychiatrists in ask: what is the best time to with body and mind, and of treatment and care, but we cannot give its place to these days’ during the Euro- attend to the patient? Five social elements. We need to they should remain under neurology. Neurology knows pean Forum session on mental minutes, fifteen minutes, pay attention to psychiatry. the supervision and the care about brain, and we know health; 15:00-16:30, Monday, thirty minutes? How many Psychiatrists can fulfil the of the psychiatrist. Because that severe mental health room Galliéni 5. 6 EPA Congress News 7 April 2013 Sunday

Pharmacological treatment of ADHD Athéna Sunday 10:00-11:30

with the disorder, having problems Pharmacotherapy is in several different areas without knowing what was wrong or what to do about it. So when they come neither the beginning nor in, they are impaired in functioning, otherwise you would never get a diagnosis. If you have no impair- the end of ADHD treatment ment, you have no reason to make a diagnosis; this is very important.” t is now known that Attention- Diagnosis requires extensive as- Deficit/Hyperactivity Disorder sessment of the onset and severity (ADHD) is a highly heritable of symptoms going back to child- Ilifespan disorder, but diagnosis may hood, which can only be done by only arrive in adulthood, leaving talking to the individual patient, and sufferers with a set of complex and if possible their spouse and family interrelated array of symptoms and members – particularly parents. disorders, delegates will hear this Kooij developed with colleagues morning at the congress. San- the Diagnostic Interview for ADHD dra Kooij (PsyQ, The Hague, the in adults (DIVA 2.0). Thanks to the Netherlands) spoke to EPA Congress support of European Network Adult News about her own research in ADHD members, it is now available adult ADHD, explaining the way in for free in nine languages at www. which pharmacological treatments divacenter.eu. There is also a DIVA are being used as part of a battery 2.0 App for electronic scoring of the of strategies that tackle prag- interview. “In addition, we assess matic issues, such as the learning all comorbidities that come with of organisational skills, and other ADHD,” said Kooij. “ADHD seldom physical and psychiatric issues such comes alone; it is usually comorbid as obesity, sleep disorder, depres- with depression, anxiety, addiction, sion and anxiety. and sleep problems. The mean num- “ADHD is a lifespan disorder ber of disorders in an ADHD adult that starts in early childhood and is three.” happens to continue into adulthood Sandra Kooij Sleep problems occur in 80 and into old age,” said Dr Kooij. percent of patients, beginning in “Based on recent studies, we now childhood as well as persisting know that ADHD is also prevalent Dr Kooij continued: “ADHD is often With a relatively low public chronically. Interestingly, ADHD in older adults, and the preva- accompanied by mood swings, profile, it is understandable that patients are typically late-evening lence rate is between 3% and 5% anger outbursts, and also problems the mean age of adults referred to people – or ‘night owls’ – and throughout lifetime.” in relationships and spending too a clinic for ADHD is 35 years in the whether someone is a night owl or As with many heritable complex much money. These an early-riser is well- disorders, the genetic expression people are restless; known to be driven of ADHD is influenced by environ- they are famous for “They have lived all their lives with mainly by genetics, mental factors. Although symptoms job-hopping and the disorder, having problems in with most people are similar throughout the dura- partner-hopping. They several different areas without falling somewhere in tion of the disorder, different life are easily bored and between these ex- stages come with different sets of need new challenges, knowing what was wrong or tremes. But late-even- individual responsibilities and expec- and this is all part of what to do about it. So when ing tendencies are tations that give rise to changes in the syndrome. The not very compatible ADHD expression. “A child does symptoms lead to they come in, they are impaired with normal working not have to organise himself or impairment in daily in functioning, otherwise you hours, resulting in herself as adults do,” said Dr Kooij. educational work and chronic shortening of “Adults [with ADHD] have more dif- relationships, and it would never get a diagnosis. If sleep duration. “The ficulties in planning, organising and may lead to substance you have no impairment, you short sleep duration paying attention. You don’t expect abuse. Alcohol and have no reason to make a has been studied children to do this all for themselves drugs may diminish the extensively by internal – parents and teachers play an symptoms for a time, diagnosis; this is very important.” medicine and they important role. ADHD children need and of course this can have shown that it is Sandra Kooij (PsyQ, The Hague, the Netherlands) much more support – that is well lead to addiction and, detrimental to physi- known.” again, financial issues. cal health, that it is Adults with ADHD often end So there is a whole cascade of Netherlands. Dr Kooij explained the associated with obesity, diabetes, up relying on a spouse to organise problems and people trying to solve diligence required in forming a clini- hypertension and cancer,” said Dr their lives, but this can lead to un- their problems in their own way cal evaluation with such complex pa- Kooij. “Because ADHD patients find balanced and difficult relationships. that may make it even worse.” tients: “They have lived all their lives sleep difficult from childhood on, Sunday 7 April 2013 EPA Congress News 7

Pharmacological treatment of ADHD Athéna Sunday 10:00-11:30 they have chronic difficulties with congress, is but a single facilitating psychological treatment and light medication. So it is the first step short sleep duration.” piece in a puzzle of interdepend- therapy. “Light therapy is in rela- after psycho-education in order to Dr Kooij’s own studies into sleep ent therapeutic options. Being tion to sleep and winter depres- facilitate psychological treatment.” and physical health in ADHD have so complex, treatment for adult sion,” explained Dr Kooij. Reiterating that the issues aris- thrown up some interesting poten- ADHD involves addressing its “Medication for anxiety, depres- ing from ADHD can be solved by tial therapies that serve sion and ADHD, and a combination of means that can to bring forward sleep psychological treat- be facilitated by pharmacological onset. She noted: “We “Once the medication works, ment to educate and treatment, Dr Kooij concluded with have shown that me- they are then better able to support patient and a quick overview of the drugs that latonin is delivered too family, to facilitate she will be discussing during her late in ADHD patients. It plan and to have an overview the patient to learn talk. “We prefer long-acting stimu- is more than 1½ hours of tasks and time. So it enables organisational skills lants in adults because it reduces too late compared to patients to learn new skills that – they have never the dosing frequency, and this is normal controls. So one learned them. So once important because patients are of the reasons for their were not easy to administer the medication works, chaotic and forgetful in nature,” sleeping late is because before, because attention patients are then better she said. “So if you have too many the hormones are not able to plan and to doses per day they will forget it available on time. We was always wandering...so it have an overview of easily and the medication will not have treated them with is the first step after psycho- tasks and time. So it be effective. Stimulants are the first melatonin at night and education in order to facilitate enables them to learn choice, but there are other proven light therapy in the new skills that were effective medications as well, like morning already in order psychological treatment.” not easy to adminis- atomoxetine and bupropion.” to advance sleep onset ter before, because Sandra Kooij (PsyQ, The Hague, the Netherlands) and to increase the sleep attention was always Dr Kooij will discuss her work in adult duration in order to wandering, or they ADHD during this morning’s session prevent long term disadvantages in myriad physical and psychological were never looking when they were ‘Pharmacological treatment of ADHD physical health.” offshoots and comorbidities using explained in school or at home. from a lifetime perspective – benefits Pharmacotherapy, the subject a combination of strategies such Speed of reading and informa- and drawbacks’, held in room Athéna of Dr Kooij’s presentation at the as psychoeducation, medication, tion processing may improve with at 10:00. 8 EPA Congress News 7 April 2013 Sunday

Is mindfulness an evidence-based treatment? Apollon Sunday 10:00-11:30

people were more reluctant about Being mindful of the evidence these ‘strange’ things, but now based on the studies that we have done, and what is published, they in therapeutic approaches realise now that it is something that is evidence-based,” he said. pro/con debate that will ex- Adding his thoughts ahead of his amine whether mindfulness ‘con’ viewpoint in the debate, Joel therapy is truly evidence- Swendsen (Aquitaine Institute for Abased will take place this morning, Cognitive and Integrative Neurosci- with two invited experts offering ence, Bordeaux, France) began by opposing viewpoints on this aspect saying that the enthusiasm and pas- of the promising clinical interven- sionate support of mindfulness as an tional strategy. evidence-based treatment is a very With origins in eastern meditation positive step, but for him, it is critical and traditional yoga, mindfulness that we take a step back and analyse can be summarised as a particular the true nature of the treatment. attention state which is characterised “I want it to work; I want it to be by intentional and non-judgmental something that really is useful, but in observation of present moment order for us to call it evidence-based, experiences, including body it’s not enough that it is efficacious, sensations, feelings, thoughts, it has to be efficacious and it has to and external stimuli from the “Based on the studies that work for the reasons it is supposed environment.1 we have done, and what is Guido Bondolfi to work,” he said. Encapsulating practices Crucially, Dr Swendsen stressed that include both mindful- published, [people] realise gramme has been that as we know, being in human ness-based stress reduction now that it is something that proposed for many contact with other people is some- (MBSR) and mindfulness- different kinds of thing which has a range of benefits based cognitive therapy is evidence-based.” problems – anxiety, for many disorders, thus we need (MBCT), both approaches Guido Bondolfi (University of Geneva, Switzerland) pain, stress difficul- to identify whether it is truly the have gathered momentum ties – and it seems mindfulness aspect of therapy that as therapeutic tools, but the to address more is conveying benefit or is it other, question of whether their utilisation and more studies on the efficacies general mechanisms involved in more general (yet effective) compo- is truly evidence-based is still a bone of these approaches, and there are several psychological problems and nents. “In order for us to justify the of contention. many more studies intending to is not diagnostic-specific. This might words ‘evidence-based’, it needs Speaking in support of the understand the mechanisms – with be another criticism I suppose.” to be because there is something evidence-based nature of mindful- neuroimaging studies as well,” he Professor Bondolfi continued to really specific about mindfulness,” ness during the session will be said. “So I will probably also discuss note that an interesting observation he said. Guido Bondolfi (University of Ge- a little about the main mechanisms surrounding mindfulness is that ear- He added: “And that’s where neva, Switzerland), who will offer and also the efficacy of these mind- ly on it was proposed as something we get into trouble, because there a review of both MBSR and MBCT fulness based approaches.” “esoteric or strange” in the field of are so many studies that show that approaches and their underlying With the frame of the debate in medicine or psychiatry, but more re- mindfulness works, but the ques- evidence. In addition, he also hopes mind, Professor Bondolfi pre-empt- cently, because of experimental and tion is do we have the methodolo- to communicate the benefits of ed some of the criticisms gies in place to show us mindfulness directly, with the help that might be put forward that it works because of audience interaction. “An idea against the evidence-based “In order for us to call of mindfulness? If you was to even try to invite people in nature of mindfulness. [mindfulness] evidence- look at the criteria for the audience to participate to a He said: “Of course there evaluating the efficacy of brief mindfulness exercise in order are not so many studies based, it’s not enough that psychotherapies in clini- to let them be closer to the practice comparing mindfulness it is efficacious, it has to cal trials, there are some – i.e. not only understanding the approaches to effective criteria that are focussed rationale but also experiencing it psychological treatments be efficacious and it has to on the first question of ef- for a few minutes,” he told EPA like cognitive behavioural work for the reasons it is ficacy, and other method- Congress News. therapy [CBT] or inter- supposed to work.” ological elements that are Moving on to discuss the studies personal psychotherapy, focussed on the question in the field of mindfulness, Profes- especially in preventing Joel Swendsen (Aquitaine Institute for Cognitive of mechanisms of change, sor Bondolfi noted that during depressive relapses. And and Integrative Neuroscience, Bordeaux, France) and does it work because the last decade or so, there have what is still lacking are of the therapy itself versus been several well-controlled studies studies comparing these other things?” that have focussed on the efficacy new approaches with well-studied validation studies, it is becoming To examine this concept in more of mindfulness in the reduction and well-confirmed psychothera- somewhat of a integrative approach detail, Dr Swendsen gathered the 10 of stress, anxiety and depressive peutic approaches.” that could start to be considered most highly cited clinical trials on the symptoms. “There have been more He added: “The MBSR pro- as acceptable. “In the beginning Continued on page 9 Sunday 7 April 2013 EPA Congress News 9

New Perspectives in Psychopathology Athéna Monday 17:00-18:30 Translating phenomenology into treatment

henomenology attempts to put order to does not act directly on suppressing mechani- the experiences reported by psychiatric cal symptoms, but instead sets into motion the patients, and thus is a useful tool to help subjective referential process, i.e. intervention, Pus understand, differentiate and separate clinical whether pharmacological or psychotherapeu- data, delegates will hear on Monday during a tic, helps the subject to engage the recovery session that examines new advances in psycho- process. pathology. “Recovery is what people with mental ill- “Phenomenology was introduced in psychiatry nesses do, whereas treatment is what doctors by Karl Jaspers in the beginning of the 20th cen- do to facilitate recovery,” added Professor tury as a method to get access to the subjective Azorin. “But the effect of treatment is only an experience of patients,” began Jean-Michel Azor- indirect effect, but an effect which suppresses in (Sainte-Marguerite Hospital, Marseille, France) the symptoms of illness.” in a conversation with EPA Congress News. Referring to an example, Professor Azorin “But at that time it acquired a more general commented on the interpretation of preventive meaning which is to delineate and put to the action that lithium provides for bipolar and uni- fore the role played by subjectivity in the consti- Jean-Michel Azorin polar manic depression. Specifically, he stressed tution of any type of experience, whether scien- that while the biochemical changes caused tific or everyday life. So it helps both the patient ogy as a method to access a patient’s subjective by lithium occur very early, the true action of experience and the psychiatrist experience.” experience; his main message being the impor- lithium occurs weeks or even months after. Of course, the task of objectively reviewing a tance of putting into evidence the role played “The idea is that the biochemical changes huge amount of subjec- the subjectivity are responsible for behavioural changes, but tive factors experienced in the recovery these behavioural changes make sense only on by patients is a mammoth “Phenomenology was process. the basis of the premorbid personality of these task, compounded by introduced in psychiatry He expanded patients,” he said. “So that is also related to this the fact that the patient by Karl Jaspers in the on this concept: kind of difference between treatment and self may experience some- “For example, referential recovery processes.” thing radically different beginning of the 20th in a randomised He added: “But phenomenological perspec- than their doctor may century as a method to get controlled tive interprets the effectiveness – the true effect perceive. “This is linked clinical trial, the – of treatment practises to the consequences to the fact that we tend access to the subjective placebo effect is of the biochemical changes and also behaviour to interpret the research experience of patients.” usually consid- changes on the active way of life of patients and of randomised controlled ered as radically the kind of reactions to the environment. So it is trials as directly valuable Jean-Michel Azorin (Sainte-Marguerite Hospital, different from a complex interplay of factors, which is different for clinical practise,” said Marseille, France) what is called way of seeing the problem as a purely mecha- Professor Azorin. the verum ef- nistic or objective action of the treatment on an “But this is not the case. For the individual fect, linked to an intervention whether pharma- independent subject.” patients, the effectiveness of treatment is highly cological or psychotherapeutic. But if you look Professor Azorin underlined that these variable depending on all those personality at the curves of response (by time) of placebo concepts pave the way for a critique of cur- factors, the world in which the patient is living, and verum, they have quite a similar shape. So rent pharmacotherapy practices, as well as the the environment of the patients, and this way of one idea is to say that in fact intervention only unique source of “evidence” on which guide- putting obsesses on subjectivity is a way to deal increases the placebo response. And usually lines and recommendations are based. with the scientific approach in psychiatry and you say a placebo is something subjective, and the difference between the scientific model and dismiss this as objective, according to a scientific Professor Azorin will discuss phenomenology and clinical practice.” point of view.” how to translate it to treatment during the session In his presentation, Professor Azorin will With this in mind, Professor Azorin com- ‘New Perspectives in Psychopathology’; 17:00-18:30, focus more on an introduction of phenomenol- mented that it could be that the intervention Monday in room Athéna.

Continued from page 8 we have some big problems too a very useful tool. It is something very clear about that.” subject of mindfulness and evalu- – big differences between studies that can help people, and in most ated each one according to estab- in terms of what are the actual cases is rightfully indicated, thus it Professor Bondolfi and Dr Swendsen lished 10-point scales. “The results techniques that they are calling should have a place in therapeutic will delve into more detail on these were very disappointing,” he said. mindfulness, and big difference be- management. “I’m not at all saying concepts during the debate ‘Is mindful- “Mindfulness may work, but we are tween studies as to whether they that mindfulness therapy is not ef- ness an evidence-based treatment?’ at 10:00-11:30 today in Room Apollon. on very shaky ground saying that are using manualised treatments, ficacious and should not be used,” it works for the reasons we hope whether they’re using evaluations he said. Reference it does. So my position is we can’t of treatment fidelity etc.” “I hope it is efficacious and 1) J Piet and E Hougaard. The effect of mindful- yet say ‘OK, we have this wonderful Offering a summary of his can be used...my point is just how ness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: evidence-based treatment’. viewpoint, Dr Swendsen underlined are we going to use the words A systematic review and meta-analysis. Clinical “We can’t yet claim that, and that mindfulness in general is still ‘evidence-based’. We have to be Psychology Review (2011); 31: 1032–1040 10 EPA Congress News 7 April 2013 Sunday

EPA guidance papers Thallie Sunday 17:00-18:30 Paving the way for better suicide treatment and prevention his evening will feature a session tasked while other psychological treatments, although with exploring the EPA guidance papers promising, require further study to validate their on a number of topics, including mental efficacy. Thealth promotion and illness prevention, antide- Antidepressant treatment is recommended to pressants for unipolar depression and conflicts decrease the risk for suicide amongst depressed of interest. adult patients, as long as careful monitoring is Offering an overview of the guidance paper employed to oversee the dangerous period in on suicide treatment and prevention during the the first 10-14 days of treatment (anxiolytics session will be EPA president Danuta Wasser- and hypnotics can also be supplemented when man (Karolinska Institute, Stockholm, Sweden), anxiety and insomnia are present).1 Use of anti- who spoke to EPA Congress News ahead of the depressants in children and adolescents should session to outline the important strategies that only be under the supervision of a specialist. should be employed to combat the devastating Other recommendations include antipsy- suicide rates seen across the globe. chotic medications such as clozapine (effective Beginning by discussing the link between in reducing suicidal behaviour in schizophrenic suicide and underlying psychiatric disorders, patients) and lithium, which has been shown Professor Wasserman noted mood disorders, Danuta Wasserman to be effective in preventing both suicide and schizophrenia, substance abuse and personality attempted suicide in patients with unipolar and disorders as some of the major psychiatric cate- ings could prove in the future to be beneficial bipolar depression.1 gories that are associated with increased suicidal diagnostic tools, but at the present time they are However, Professor Wasserman stressed that risk. Despite this observation, and the fact that in need of further study. the pharmacological aspects of suicide preven- most patients will have had contact with their The EPA guidance paper itself identifies a tion are but part of the puzzle, and there are general practitioner (GP) prior to attempting sui- number of approaches and strategies that are several other factors that are important in the cide, she added that it is still true most suicidal important for suicidal prevention and treat- treatment of patients. First, she said, was the patients are inadequately treated, if at all. ment.1 The first mes- incorporation of a To that end, Professor Wasserman empha- sage pertains to treat- continuously-trained sised that there are several characteristics in ment of the underlying “A multidisciplinary multidisciplinary patients that should be explored to try and psychiatric disorders, team can make a team of specialists determine suicidal risk. These include previous stating that, when (psychologists, social suicidal behaviours (including those from within considering current proper judgements as workers and occupa- the family history), expressed intentions, under- evidence, pharmaco- to family conditions, tional therapists, for lying psychiatric and chronic somatic disorders, logical treatment and social support and the example), that will in impulsive, narcissistic or aggressive traits and cognitive behavioural turn offer a biologi- impaired coping strategies. therapy (CBT) should rehabilitation possibilities cal, psychological and In addition, she added that genetic find- be encouraged, after the discharge from social armamentarium of intervention. the hospital.” “A multidiscipli- Danuta Wasserman (Karolinska Institute, nary team can make a Stockholm, Sweden) proper judgements as to family conditions, social support and the rehabilitation possibilities after the discharge from the hospital,” she said. Indeed, education of GPs and other allied health workers by psychiatrists has been identi- fied as an effective method for reducing suicide rates.1 When this is implemented, depression, anxiety and general quality of patient care im- proves, also instilling better grounding as to the relevant legal, ethical and stigma issues. “What is also important, and we are not so aware of, is to think about the security and safety both at home and in the hospital environ- ment, because unfortunately we still have sui- cides due to negligence, with medications easily available or guns at home at a time when the patient is very depressed and suicidal,” contin- Sunday 7 April 2013 EPA Congress News 11

EPA guidance papers Thallie Sunday 17:00-18:30 ued Professor Wasserman. ment,” she said. “If they respond well to treat- That being said, clearly there is great poten- As such, ensuring a safe environment both in ment and have a good social network and good tial for improving suicide prevention and treat- hospital and at home is imperative, as is the im- opportunities to go back to work, the follow-up ment via the continuous education of health plementation of carefully-constructed follow-up period can be much shorter... but if we have pa- care staff, and with critical assessment and itera- plans, especially immediately after leaving hos- tients who are not responding and have relapses, tive improvement of currently-employed routines pital care – a critical juncture for many patients. poor social networks and are not working – or and practices. Of course, an important factor in how success- for example psychotic patients or patients with fully this is implemented will depend on the care abuse disorders – it can be even lifetime follow- Professor Wasserman will explore suicide prevention framework in place for the patient. While EPA up which must be adjusted to the resources of and treatment in more detail during the session ‘EPA guidance states that the suicidal person should the patient and of the hospital.” guidance papers’, held at 17:00-18:30 this evening in always be motivated to involve family in their Even with all these important considerations room Thallie. treatment1, Professor Wasserman noted that and beneficial actions taken into account, the References the long-term support that is both available and EPA guidance highlights that one should still be 1) D Wasserman et al. The European Psychiatric Association (EPA) required for each specific individual will depend mindful that suicide cannot be always predicted, guidance on suicide treatment and prevention. European Psychia- try (2012); 27: 129–141 on a number of factors. nor prevented, especially if there is poor compli- 2) Oxford Textbook of Suicidology and Suicide Prevention; a Global “It depends on diagnosis, the social network ance to an otherwise presumably effective treat- Perspective. Edited by D Wasserman and C Wasserman. OUP and how well the patients responds to treat- ment plan and follow-up care regime.1 (2009).m

Treatment of Depression and Anxiety in Adult, Child and Adolescent Populations Apollon Sunday 17:00-18:30 CBT in children and adolescents he treatment of depression manualised treatment for anxiety and anxiety in different age disorders is specific enough, or if groups will take centre stage you need to distinguish between Tthis afternoon, with the spotlight different anxiety disorders. And placed a range of treatments in- the reason I’m going to point that cluding antidepressants and psycho- out is it looks like we have a much therapeutics, genetics and cognitive better effect for generalised anxiety behavioural therapy (CBT). disorder compared to social phobia. Focussing on CBT in children and So I am going to raise questions as adolescents during the session will to whether you can used manual- be Krister Fjermestad (Haukeland based anxiety treatment or do you University Hospital, Bergen, Norway) need to be more specific.” who spoke to EPA Congress News Dr Fjermestad will also focus on to frame the context of his talk, first some of the treatment process vari- stressing the main question to be ables that might play a part in the addressed: whether the evidence poorer outcomes observed, includ- base for anxiety treatment in chil- ing treatment credibility, treatment dren is similar in clinical trials versus motivation and therapeutic alliance. university trials. “The main message “It looks like therapeutic alliance is yes, they are comparable, but Krister Fjermestad may play a part in the effect; that that there are some factors,” he is very much debated in the anxiety said, adding that trials conducted in area because there are very mixed ordinary clinics have on some occa- and Treatment-Anxiety in Children which has compared group cogni- results,” he said. sions exhibited poorer results than and Adults), a 182-patient study tive behavioural therapy (CBT) to Although these variables do university-based trials. individual CBT for differ- not differ between the different One explanation that could ent anxiety disorders in a institutionally-led trials, Dr Fjerm- account for this discrepancy “It looks like therapeutic cohort of 8-15 year olds. estad postulated that increased in outcome is the presence of “The results from that comorbidities and diversities of more comorbidities: “In the alliance may play a part trial is somewhat poorer disorders could in turn mean that trials where you do find poor in the effect; that is very than a lot of the other keeping children “engaged” would effects, it seems very often to much debated in the regular clinical trials that have more importance. boil down to comorbidity and have been conducted,” change in problem area,” said anxiety area because there he said. ‘Effectiveness of cognitive-behavioural Dr Fjermestad. are very mixed results.” “So I’m going to point anxiety treatments for children and During his presentation, as some of the reasons adolescents’, as part of the session Krister Fjermestad (Haukeland University Hos- ‘Treatment of Depression and Anxiety Dr Fjermestad will present why that might be the in Adult, Child and Adolescent Popula- one year follow-up data from pital, Bergen, Norway) case. What I’m going to tions. An Update’; 17:00-18:30; Sunday, the ATACA trial (Assessment focus on is whether a Apollon. 12 EPA Congress News 7 April 2013 Sunday

DSM-V/ICD-11: New Diagnostic Approaches Apollon Sunday 08:00-09:00 What changes will DSM-V and ICD-11 bring?

se of the new Diagnostic While it may be sanctioned mixed features include such classical and Statistical Manual of within society, bereavement-related manic symptoms as elated mood, Mental Disorders (DSM-V) depression perhaps does not depart inflated self-esteem and excessive Uand International Classification of far enough from other forms of involvement in risky activities, which Diseases (ICD-11) criteria in the stressor-related depression to are reported to be rare in mixed diagnosis of depressive disorders warrant its special status. These depression in both classical and will be explored this morning in recent findings ought to prompt recent literature. On the contrary, a session dedicated to their latest either an extension of the bereave- symptoms which are reported to be iterations. ment exclusion (to include other common in mixed depression, such In an interview with EPA Con- major losses) or the removal of the as irritability, psychomotor agitation gress News ahead of his presenta- bereavement exclusion entirely from and distractibility, are not included tion during the session, Mario Maj the criteria of depression. in the list. “So, there will be a major (University of Naples SUN, Italy) “The idea to delete the be- discrepancy between the characteri- identified three major issues: the reavement exclusion has been zation of mixed depression provided relationship between depression immediately endorsed by the in classical and recent literature and and ‘normal’ grief, the classification DSM-V leadership,” said Professor Mario Maj that proposed in DSM-V,” contin- of ‘mixed states’ (including ‘mixed Maj. “However, two more recent ued Professor Maj. depression’), and the approach to independent studies have re- should attenuate the divergence “Furthermore, the DSM-V the continuum between depression ported that people with a baseline from ICD-11, which will exclude solution, contrary to the DSM-IV and anxiety disorders. bereavement-related depression from the diagnosis of depres- definition of mixed episode, will not have a significantly lower risk for sive episode, in line with ICD-10, account for ‘unstable’ mixed states Bereavement-related further depressive episodes during a ‘normal bereavement reactions (in which there is a very rapid transi- depression follow-up period than people with appropriate to the culture of the tion from one polarity of mood to The boundary between depres- a baseline non-bereavement-related individual concerned’.” the other). In ICD-11, the diagnostic sion and a “normal” response to a depression. Furthermore, their risk entity of mixed episode will be kept, psychosocial stressor is not always is not different from that of people Mixed features in depressive and will be made flexible enough a clear one: “According to the without a history of depression at and manic episodes to encompass both stable and DSM-IV, even if a sadness response baseline to develop a depressive Recent research has documented unstable mixed states, and both appears understandable and pro- episode during the same follow-up that manic and depressive episodes cases in which the two polarities of portionate to a major life event, the period. Furthermore, an intensive often include contropolar symp- mood are present at a syndromal diagnosis of major depression must public debate has highlighted the toms, and that the occurrence of level, and those in which one of be made whenever the severity, consequences that the elimina- these symptoms has important the polarities, although prominent, duration and impairment criteria are tion of the bereavement exclusion prognostic and therapeutic implica- remains subsyndromal.” fulfilled,” said Profes- tions. “The DSM-IV sor Maj. characterisation of Approaching the continuum “The only excep- “The DSM-V will remain based a mixed episode, between depression and tion to this principle on operational diagnostic criteria requiring the co- anxiety is for bereavement,” occurrence of a full Professor Maj explained that, he continued. “After and will introduce some further manic and a full de- although the occurrence of anxiety the loss of a loved specifiers as well as some... while pressive syndrome, symptoms during a depressive epi- one, even if the does not account sode has been found to be associ- severity, duration and the ICD-11 will remain based on for the many cases ated with a longer duration of that impairment criteria prototypical descriptions of the in which only one episode and a higher suicide risk, are fulfilled, the various disorders.” of the two polarities DSM-IV and ICD-10 do not allow to diagnosis of major of mood is present record these symptoms in cases of depression should Mario Maj (University of Naples SUN, Italy) at a syndromal depression. not be made, unless level,” noted Pro- “Both the ICD-11 and DSM-V the symptoms persist fessor Maj. will give the clinician the opportu- for more than two months, or there would have in several cultures, in- “Hence, the decision taken by nity to acknowledge the occurrence is marked functional impairment, cluding a high rate of false positives DSM-V leaders to eliminate the of sub-syndromal anxiety symptoms morbid preoccupation with worth- and a trivialisation of the concept of diagnostic entity of mixed episode in a patient with a major depressive lessness, suicidal ideation, psychotic major depression and consequently and to introduce a specifier ‘with episode by using a specifier (‘with symptoms, or psychomotor retarda- of mental disorder. mixed features’ to the diagnosis of prominent anxiety symptoms’ in tion. The rationale is that a depres- “The final decision of DSM-V both manic and major depressive ICD-11, ‘with anxious distress’ in sive syndrome is an ‘expectable and leaders has been to proceed with episode, requiring the presence of DSM-V),” said Professor Maj. “If the culturally sanctioned response’ to the elimination of the bereavement at least three contropolar symp- patient has a full anxiety disorder, the death of a significant loved one, exclusion, but at the same time to toms.” that disorder will be diagnosed in thus not representing in that case introduce a note within the text Unfortunately, the contropolar addition to major depression in a mental disorder, according to the delineating the differences between symptoms listed in the DSM-V both systems. If the anxiety disor- definition endorsed by the DSM-IV.” normal grief and depression. This definition of major depression with Continued on page 14

14 EPA Congress News 7 April 2013 Sunday

DSM-V/ICD-11: New Diagnostic Approaches Apollon Sunday 08:00-09:00

What changes will DSM-V and ICD-11 bring? intensity of the anxiety component, and the risk for suicide), while the Continued from page 12 elements of the DSM and ICD. But between the several therapeutic op- ICD-11 will remain based on proto- der is syndromal and the depressive Professor Maj highlighted that the tions usually available in developed typical descriptions of the various component is sub-syndromal, the targets of the two systems are dif- countries, the ICD-11 is intended disorders.” ICD-11 will allow the application ferent. While the DSM-V is intended for a broad range of professionals, of a specifier ‘with including general Professor Maj will give discuss the use prominent depressive practitioners work- of DSM-V and ICD-11 classifications symptoms’ to the “Both the ICD-11 and DSM-V will ing in low-income in mood disorders during the session relevant anxiety disor- countries, and ‘DSM-V/ICD-11: New Diagnostic Ap- proaches – Do they hold a Promise?’, der diagnosis. give the clinician the opportunity aims to provide at 08:00-09:00 this morning in room “The co-oc- them with a system to acknowledge the occurrence of Apollon. currence of sub- which is as simple threshold anxiety and sub-syndromal anxiety symptoms in as possible and Note: The ICD-11 chapter on mental depressive symptoms a patient with a major depressive usable in different disorders is still in preparation, and the will lead in ICD-11, in clinical settings. definitions and diagnostic guidelines for depressive disorders have not yet line with ICD-10, to episode by using a specifier.” “This is one of the been finalised. The text of the DSM-V a diagnosis of mixed Mario Maj (University of Naples SUN, Italy) reasons why the has been approved by the Board of anxiety-depressive DSM-V will remain Trustees of the American Psychiatric disorder, while this based on operation- Association (APA); it will presented in category is going to al diagnostic criteria May. As a member of the DSM-V Work appear in DSM-V among ‘depressive for specialists in psychiatry, and and will introduce some further Group on Mood Disorders, Professor Maj emphasised that he has been per- disorders not elsewhere classified’.” aims to provide them with a diag- specifiers as well as some dimen- mitted to discuss only that information nostic system which is increasingly sions (in the case of depression, which has been made public through Harmonising DSM and ICD articulated and sophisticated, in dimensions concerning the sever- the DSM-V website and the December Clearly, differences persist between order to guide them in the choice ity of the depressive episode, the 1, 2012 APA press release.

ePosters @ EPA 2013

Alongside traditional poster sessions at the congress, EPA will again highlight several outstanding posters for presentation as electronic ePosters – a powerful educational tool that will allow browsing and even download (pending permission) of posters for further viewing. There will be 14 separate ePoster sessions held throughout the congress, and within each one more than 20 of the highest scoring abstracts will be selected for special oral presentation (4-5 minutes each). In addition, the ePosters will be available for viewing during and after the congress via a user-friendly ePoster archive that allows viewers to browse by poster sections or specific content, as well as offering the chance for them to comment on individual posters and ask questions to the authors. For more information refer to the poster and ePoster details in the programme. Sunday 7 April 2013 EPA Congress News 15

Plenary Lecture: Translating Gene and Environment Interactions Apollon Sunday 11:45-12:30 Interview: Julio Licinio rue to the moniker of the Age different diseases, so that at this point we of Information, we are busy are really ready to make a major contribu- extracting information from our tion – this was not the case even recently. Tgenes and environment that could give I began to work in pharmacogenom- us clues as to how different psychiatric ics for personalised medicine, and I got conditions emerge, and how to prevent the first research grant from the National and treat them more effectively. In an Institute of Health (NIH) in the US, which interview with EPA Congress News on was in 1999. It was the next year that the the topic of his Plenary Lecture, Julio human genome was sequenced, so there Licinio (John Curtin School of Medical were a lot of questions then about when Research, Australian National University, we are going to have personalised medi- Canberra, Australia) explained how pro- cine. Everybody was talking five years, but gress in the field of genetics is accelerat- in my head I was thinking more like 15 ing thanks to better study design, tools to 20 years. And that was 14 years ago! I and technology. think the methods are much better now, and the research is progressing really fast. How are genetic and environmental There is light at the end of the tunnel. risk factors characterised in complex disorders, and how has our under- As you note, there are two elements standing of them changed? that can emerge from a better under- The genetics is a very complex under- standing of genetic and environmental taking. What people have done is to try risk: preventative interventions and the to parcel out what is genetic; then what promise of more personalised medicine. cannot be attributed to genetics, peo- Could you explain the importance that ple look at environmental causes. So personalised medicine will have on the there is research coming from both the genetic genetics, looking at things like gene expres- future of mental health? side and the environmental side. sion in order to identify biomarkers of specific I am very committed to this area of pharmaco- From the genetics side, the latest trend is to disease traits. How far are we from the reality genetics. In my own research, I have been look- analyse very large groups of patients. So far we of understanding how these traits emerge? ing at genetic predictors of drug response. Even haven’t had a lot of new progress on variants, We have been very far because of the technical with cancer, some people respond very well to because the studies have been relatively small. limitations. But there has been a lot of progress, chemotherapy and recover, and some people But there are now some very large interna- and in my estimation I would say in the next 10 die. For many conditions, the big challenge in tional collaborations with 30,000 or 40,000 to 15 years. We will have a lot of new answers today’s medicine is that some respond very well patients being studied together, and the genetic that we do not have now. There has been a and others do not have a good response. In psy- signals are starting to emerge. That is one of lot of confluence of new work that I think will chiatry, you need to treat people, for example, the hottest areas now – trying to get very large make a difference in the field. I would say that with schizophrenia or depression, for a very long cross-national samples, trying to see if you can there has been a lot of hype in the past. But I time before you see a response. It is not the really use the latest tools in genomics to apply think that right now we have the right technol- case that you take one dose of antidepressants to these very large samples, and then coming up ogy, the right tools and very large samples for and your depression goes away. So if you are with the component that can be attributed taking something that is not going to work to genetics. for you, it is really wasted time. It can be On the environmental side, there are “I would say that there has weeks until people come up with the right two factors: one is the role of infection and treatment. Meanwhile, there is a lot of suf- inflammation in the mother just before and been a lot of hype in the past. fering and a lot of potential for complica- during pregnancy; the other factor, which But I think that right now we tions. The biggest challenge in psychiatry is not new but has got a lot of new atten- have the right technology, right now is for us to come up with ways tion, is the impact of maltreatment and to personalise treatment so that we give child abuse very early on, which apparently the right tools and very large the right drug to the right person. I have can have a very dramatic impact through- samples for different diseases, been approaching this from the genetics out a person’s life, especially in terms of perspective. Some people approach it more susceptibility to depression. There is a lot of so that at this point we are in terms of biomarkers. I think this is the relatively recent work showing that it can really ready to make a major hot frontier of the field: trying to develop not only impact on mood, but also change contribution – this was not the tools to predict who is going to respond to the expression of genes that are related what treatment. to depression. So we have a long term case even recently.” biological impact, much beyond the period Professor Licinio’s plenary lecture on ‘Translat- Julio Licinio (John Curtin School of Medical Research, of actual trauma. ing Gene and Environment Interactions into Australian National University, Canberra, Australia) Prevention and Treatment’ will take place at You hinted at going beyond straight 11:45 this morning in room Apollon. 16 EPA Congress News 7 April 2013 Sunday

Brain imaging across mental disorders: early detection and treatment Med. 5 Monday 10:00-11:30

of inhibitory control – and we might Could imaging be the key to reduce be able to intervene then. But we are at the very beginning, identifying diagnostic uncertainly in bipolar disorder? prognostic indicators that may or may not lead to improved diagnostic hile it is important to interventions. I think, generally, what remember the value of one of the messages here is that al- clinical judgement, which though we have to be very optimistic Wtakes into account emergent men- about the future of psychiatry, we tal status as well as patient history, should not actually be more optimis- tools such as neuroimaging may be tic than our data permits,” she said. useful in confirming uncertain diag- Professor Frangou concluded noses and distinguishing patients by by talking more generally about way of prognostic indicators. Ahead the perceived complexity of mental of her talk on diagnostic imaging illness, and the misconceptions re- in Bipolar Disorder at the congress, garding their aetiology. She stressed Sophia Frangou (Icahn School of that, actually, studies have uncov- Medicine at Mount Sinai, New York, ered rather a great deal of aetio- USA) spoke with tentative optimism logical findings, and that these can about what imaging has to offer help us to quantify risk, which can the clinical community. of patients and controls, but the ply inherent dimensions that are of then be modified therapeutically. The challenge of diagnosis is ‘average’ patient is a very rare thing, prognostic value but that may not She added:“One of the things that one felt across psychiatry, because as Professor Frangou was careful to be amenable to change,” said Pro- I think is important for clinicians as clinical assessment relies on behav- note as she explained why she sees fessor Frangou. “So we don’t know well as the public is to understand ioural observation and the patient’s neuroimaging at the forefront in the that we can change the prognostic mental illness a little bit as they self-reporting. Professor Frangou race towards a tool to aid diagnosis. factors. It is similar, for example, if understand having a heart attack. spoke of the consequences of the “You can have parameters that are you have a family history of breast “So there are many different subjectivity that emerges from such abnormal in patients, and these cancer and a particular DRP-2 mu- factors that increase your risk, and at a qualitative approach. “The first parameters can be informative in tation: you would be at extremely any given time we will not know all one is that sometimes diagnoses terms of pathophysiology. But here high risk for breast cancer, but we of the factors that will increase the are not reliably made,” she told EPA we are looking for things that can can change neither your family his- risk of one specific individual. The Congress News. “The second one is help you do classification, which tory nor your genetic make-up. It is personalised prediction is the difficult that it fuels public scepticism as to is slightly different. There are a difficult to say at the moment that one. But in principle, we know quite the validity of this diagnosis.” number of variables that distinguish what we are identifying is necessar- a lot about causes of heart attack Of course, diagnosis of bipolar on average a patient from a healthy ily a new pathway to treatment. and stroke, and also about causes disorder can be difficult, particularly individual, but neuroimaging is “What we are saying is that it of mental illness. It is a game of when patients present with symp- perhaps our best bet at the moment is important from the beginning to probabilities. It is not like an infective toms that are indistinguishable from to do diagnostic classification. Hav- identify people that do not have a disorder, where you have one bug, unipolar depression. The prospect ing said that, as the tools evolve, particularly good prognosis to begin one illness, with a one-to-one causa- of predicting which depressed because they are so computationally with, because the logical next step tive relationship. I think the impor- patients are likely to develop manic challenging, it will be possible to is to target these patients with the tant shift in our understanding is that episodes is a seductive one. “You test which type of information (in treatments that we have at the mo- we are talking about risk rather than see the symptoms as they evolve addition to neu- causality, as we do for any- over time, and it is very difficult roimaging) can “We are at the very beginning, identifying thing in complex disorders in to predict at the very beginning help improve this modern medicine. what the final clinical presentation classification ef- prognostic indicators that may or “There is a degree of will be,” said Professor Frangou, fort. But the main may not lead to improved diagnostic understanding that there explaining: “The tools that are be- focus really is on interventions...Although we have to will not be one thing that ing developed are really developed neuroimaging.” be very optimistic about the future of we will find that will make with a view to try and define some Diagnostic psychiatry, we should not actually be anything clear for any sort of biological, in this case, brain tools may also individual patient for 100 structural and functional param- help to distin- more optimistic than our data permits.” percent of the time – this is eters that can be reliably linked guish patients Sophia Frangou an impossibility. Very much to particular diagnoses – in our with better or (Icahn School of Medicine at Mount Sinai, New York, USA) like predicting who will case, bipolar disorder. This effort is worse progno- have stroke, you put in your beyond bipolar disorder. It involves ses, based on risk factors, you can say all aspects of psychiatry. There are markers such as verbal intelligence ment a little bit more aggressively. who is high or low risk, and that many different groups that are try- and inhibitory control. But could At the same time, as our conceptual gives people some idea as to how ing similar ways to confirm, validate addressing these markers lead to models and our statistical testing im- they can modify that risk.” and refine diagnosis across different improvements in symptoms? “There prove, we may find pathways within, fields of psychiatry.” is a degree of circularity in the say, what drives inhibitory control, ‘Brain Imaging across Mental Disorders: Physiological differences may thinking generally, in the sense that and the molecular, behavioural, neu- Early Detection and Treatment’; 10:00- be observed between large cohorts it is possible that these are just sim- ral and environmental components 11:30, Monday, Room Med. 5. Sunday 7 April 2013 EPA Congress News 17

European Mental Health Care in the Time of Economic Crisis Galliéni 5 Monday 15:00-16:30 Economic crisis is no Greek tragedy

reece was perhaps the first and hardest with the function of the family,” he said. “It is hit by the economic crisis in Europe, very important that the family network is work- but there are positive lessons there and ing. I attribute the fact that we haven’t seen any Gelsewhere showing that solidarity, and adequate direct association of unemployment with suicide mental health and welfare provisions are all to the support of the family. This can be primar- important ingredients in keeping the popula- ily moral support, but also financial support to tion resilient. George Christodoulou (Athens some extent. Of course this has negative side University, Greece), who will be presenting effects, because younger people are not in a on the psychological and psychopathological position to work independently and cut the links consequences of economic disaster on Monday with the family, which may be negative after a afternoon, spoke to EPA Congress News to give certain age. You can’t depend on your parents a comprehensive impression of the situation in for all your life! This speaks against independ- Greece and to talk about the role of the family ence, but on the other hand it has great positive in providing support in tough times. aspects, and one of them is this one – the links Tackling an issue that will be addressed in of the people are very strong. So this is very the upcoming DSM-V and ICD-11 classifications, good for the resilience of the population. In our Professor Christodoulou began with his views situation, disasters, no matter whether they are on the nature of depression as distinct from a human-made, physical disasters, or economic sadness that is justified within a social context. disasters, the two key words are resilience and “Very often in discussing the consequences of solidarity. In the case of Greece, I think we have the economic crisis internationally, the newspa- seen this solidarity functioning well.” pers talk about a depressive society, a depressive Greek family structure reflects cultural idi- nation, and things like that,” he said. “In my George Christodoulou osyncrasies, but the way in which economic opinion this is not clinical depression, but it is policies respond to financial crisis can also understandable sadness which is justified by costing more in the long term, according to Pro- impact on mental health. “There are some the situation of curtailing funds, of difficulties fessor Christodoulou. “A paradoxical finding, in protective factors against suicide, and one of that each family has in surviving, and so on. This all cases internationally, is that those who are at them is welfare provision. It has been shown sadness can be protective, because it leads to greater risk are offered less protection,” he said. in Scandinavia, in Finland and in Sweden, that a reorganisation of priorities – it is not psycho- “Mental patients can’t protest with great effi- when you have this protective factor of welfare pathological.” ciency and effectiveness like other social groups provision, suicide does not occur despite the Unemployment is generally associated with are protesting. For example, if you have people fact that the country is in a crisis. Also, reduc- suicide, but this association has not been seen working in the traffic services, when they strike, tion in state welfare spending in the States were within Greece according to both Greek and they paralyse the city. Therefore they blackmail accompanied by increased suicide rates, which European statistics, although perhaps it will the government to provide greater assistance is an indication to the same direction. In Greece, emerge in the coming year. Professor Christo- to them. If mental patients protest, nobody suicide rates are inversely associated with the doulou continued: “There has been an increase will care about it. What is going to happen to number of primary healthcare services, and in suicidality – the intention for suicide. Some the economy of the country if mental patients mental health service providers, and also with telephone services have shown that there is protest? Nothing. So they are powerless. the number of mental health infrastructures. So suicidal intention, but this is not reflected in the “There is evidence to show that providing the more we invest in mental health services, actual rate of suicide.” funding for prevention in the mental health the less you are likely to have suicide.” Homicide is another key effect of economic area, and for the treatment of mental patients, Concluding with some recommendations, downturn, with some research suggesting is cost effective. It may need some money in the Professor Christodoulou advocated active labour unemployment as a causative factor. Professor first stages, but then in the longer term it is cost market programmes like those of the Scandi- Christodoulou noted that although the rate of effective, because you will have to spend much navian region, as well as opting for reduced homicide has indeed increased in Greece, it was more money to treat these patients if you don’t working hours rather than redundancy. “Since accompanied by a reduction in the number of apply preventative psychiatry measures. So this unemployment is associated with suicide, it is drunk drivers and the overall consumption of is a language that finance ministers and people preferable to have lower salaries rather than alcohol. He went on to highlight the association dealing with economics understand. So I think dismiss somebody from work. Dismissing some- between alcoholism and homicide in northern we psychiatrists and people who are involved body from work, in addition to the economic European countries, which led the World Health in mental health visibility should point this out: destruction, also includes humiliation (which Organisation (WHO) to recommend a reduction that it is cost-effective to deal with mental health comes out of losing one’s job) and the dete- in the consumption of alcohol. “But this cannot therapeutically, and especially preventatively.” rioration in everyday habits. So if you support be generalised to the whole of Europe, because Returning to the topic of unemployment, the lesser of two evils, perhaps this would be in other countries, like Greece, we have seen the Professor Christodoulou suggested that Greece, productive in some way.” opposite: a reduction in alcohol consumption,” bucking the European trend in terms of its sui- he said. cide rate, could provide an indication as to the ‘The economic disaster in Europe: psychological and Austerity measures might involve the cutting social principles that are protective in times of psychopathological consequences’, as part of the Eu- of state benefits and services, but a reduction in crisis. “The reason that in Greece the effects of ropean Forum session on mental health; 15:00-16:30, funding of mental health services could end up unemployment are not so clear cut is associated Monday, room Galliéni 5. 18 EPA Congress News 7 April 2013 Sunday

Pharmacological treatment of ADHD Athéna Sunday 10:00-11:30

ADHD above the age of 65; this is the only paper Taking a step back in ADHD in the literature. Collaborators and researchers in Europe should concentrate on studying more and Continued from page 2 [disorders], not only in psychiatry but even in knowing more about adult ADHD. Germany has 300 kids, if we join hands we have medicine. The main candidate genes are in the “The second thing is awareness. People do a meaningful result. If each of us publish alone, dopamine system (because Ritalin works in the believe that at age 18 when you finish high these statements are worth nothing because the dopamine system, so that is why we are looking school, you finish ADHD, which is totally not true. power is too low. Association studies People with ADHD are divorced with 200 kids is not enough.” “In Israel, if you go into a pharmacy with a more, have more substance abuse, Genome-wide association studies have more car accidents, so it’s very are a critical element in identifying prescription for Ritalin from me, they will not important that people are aware new genes that aren’t related to give it to you because by law in Israel you can that they might need treatment. In any pre-existing hypothesis, noted get Ritalin after 18 only if you started it as a Israel, for example, if you go into Professor Zalsman, but such analysis child, because they try to avoid people using a pharmacy with a prescription for isn’t without its problems. He said: it as a drug. But many people are diagnosed Ritalin from me, they will not give it “They don’t come with a candidate to you because by law in Israel you gene: we are ‘fishing’, and many at age 30! So even the government and the can get Ritalin after 18 only if you things can pop out. The new problem Ministry of Health are not aware.” started it as a child, because they try with these genome-wide associa- to avoid people using it as a drug. Gil Zalsman (Sackler School of Medicine, Tel Aviv, Israel) tion studies are in multiple testing. But many people are diagnosed at You are testing 100,000 SNPs [single age 30! So even the government nucleotide polymorphisms] in the DNA, in a there) such as the DRD4, DRD2, MAO-A, the and the Ministry of Health are not aware.” couple of hundred kids. You have multiple test- serotonin transporter, and DAT-1.” ing, and only by chance will you find some very With emphasis on collaboration and raising ‘Pharmacological treatment of ADHD from a lifetime significant finding – you need to correct for this, awareness on both the public and the policy level, perspective - benefits and drawbacks’; 10:00-11:30, which is not so easy and simple. Professor Zalsman concluded with a roadmap for Sunday, Athéna “It is a challenge. Twin studies found that future research: “This is the story in genetics: you References heriditability is between 50 to 88 percent, which need collaboration. First of all, we need to know 1. Centers for Disease Control and Prevention National Survey of Children’s Health. is very high when you compare in to other more about adult ADHD. We have a study on http://www.cdc.gov/nchs/slaits/nsch.htm (Accessed April 2013)

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[email protected] +44 20 8244 0583 Sunday 7 April 2013 EPA Congress News 19 EPA Congress Committees

EXECUTIVE COMMITTEE Patrice Boyer France Co-Chairperson Gil Zalsman Israel Danuta Wasserman Sweden President Mariano Bassi Italy Zvi Zemishlany Israel Patrice Boyer France Past President István Bitter Hungary Hans-Jürgen Möller Germany Past Past President Philippe Courtet France COMMITTEE ON EDUCATION Marianne Kastrup Denmark Secretary General Andrea Fiorillo Italy Henning Sass Germany Chairperson Philip Gorwood France Treasurer Sophia Frangou UK Pierre Baumann Switzerland Michael Musalek Austria Secretary for Sections Silvana Galderisi Italy Dinesh Bhugra UK Henning Sass Germany Secretary for Education Philip Gorwood France Andrea Fiorillo Italy Silvana Galderisi Italy Advisor Siegfried Kasper Austria Marc H.M. Hermans Belgium Marianne Kastrup Denmark Christoph Lauber UK LOCAL ORGANISING COMMITTEE Hans-Jürgen Möller Germany Jean-Pierre Lépine France Philippe Courtet Montpellier Chairperson Michael Musalek Austria Amit Malik UK Frank Bellivier Paris Henning Sass Germany Nadja Maric-Bojovic Serbia Michel Benoit Nice Norman Sartorius Switzerland Amine Benyamina Villejuif EPA BOARD Gilles Bertschy Strasbourg Danuta Wasserman Sweden Chairperson EARLY CAREER PSYCHIATRISTS COMMITTEE Jean-Philippe Boulenger Montpellier Mariano Bassi Italy Andrea Fiorillo Italy Chairperson Eric Fakra Marseille Julian Beezhold UK Umberto Volpe Italy Co-Chairperson Sébastien Guillaume Montpellier István Bitter Hungary Amit Malik UK Emmanuel Haffen Besançon Julio Bobes Spain Alexander Nawka Czech Republic Denis Leguay Les Ponts de Cé Patrice Boyer France Martina Rojnic-Kuzman Croatia Pierre-Michel Llorca Clermont Ferrand Wolfgang Gaebel Germany Nikolina Jovanovic Croatia (ad interim) Luc Mallet Paris Silvana Galderisi Italy Emilie Olie Montpellier Philip Gorwood France COMMITTEE ON ETHICAL ISSUES Antoine Pelissolo Paris Cécile Hanon France Marianne Kastrup Denmark Chairperson Dominique Pringuey Nice Cyril Höschl Czech Republic Julian Beezhold UK Philippe Robert Nice Siegfried Kasper Austria Silvana Galderisi Italy Florence Thibaut Rouen Marianne Kastrup Denmark Cécile Hanon France Guillaume Vaiva Lille Jean-Pierre Lépine France Wolfgang Rutz Sweden Hans-Jürgen Möller Germany Henning Sass Germany SCIENTIFIC PROGRAMME COMMITTEE Michael Musalek Austria Norman Sartorius Switzerland Danuta Wasserman Sweden Chairperson Henning Sass Germany Danuta Wasserman Sweden

EPA SECTION CHAIRS Philosophy and Psychiatry Giovanni Stanghellini Italy Addictive Behaviours Falk Kiefer Germany Prevention of Mental Disorders Wolfgang Maier Germany Child and Adolescent Psychiatry Gil Zalsman Israel Psychopathology Michael Musalek Austria Consultation Liaison Psychiatry and Psychosomatics Albert Diefenbacher Germany Psychopharmacology István Bitter Hungary Cultural Psychiatry Meryam Schouler Ocak Germany Psychotherapy Fritz Hohagen Germany Emergency Psychiatry Pier Maria Furlan Italy Schizophrenia Silvana Galderisi Italy Epidemiology and Social Psychiatry Robert Stewart UK Sexual Medicine and Mental Health Marcel Waldinger The Netherlands Forensic Psychiatry Birgit Völlm UK Suicidology and Suicide Prevention Danuta Wasserman Sweden Geriatric Psychiatry Carlos A. de Mendonça Lima Portugal TeleMental Health Davor Mucic Denmark Neuroimaging Philip McGuire UK Woman,Gender and Mental Health Anita Riecher Switzerland Personality and Personality Disorders Klaus Lieb Germany