Monday 30 March 2015 EPA Congress News 1 EPACONGRESSNEWS

The official newsletter of the 23rd European Congress of Psychiatry Monday 30 March 2015 Inside ‘Excellence in psychiatry’: today Page 5 a guiding motto Tipping the scales on coercion in mental health Page 6 Afzal Javed on the joint AFPA-EPA symposium Page 9 Primary care mental health in the elderly Page 14

Have we lost our he Congress was declared offi- Quoting the work of American the physician best qualified to disen- way in depression cially open at Saturday evening’s psychotherapist Glen Gabbard, he tangle the often complex relationship treatment? opening ceremony, which was continued: “’Psychiatrists occupy a between biological, psychological, and Page 17 infusedT with a number of musical inter- unique niche among medical special- social factors in both somatic and men- ludes from outstanding local musicians ists. They are integrators par excellence tal disorders. While next to this idea of Timing matters - the Franz Bartolomey, Matthias Bartolomey of the biological and psychosocial in the psychiatrist as a ‘biopsychosocial impact of early life and Nikola Djoric. both diagnosis and treatment.’ Are we generalist’, further differentiations and events As part of his presidential lecture, generalists, or are we specialists? Are specialisations are advisable in order to Wolfgang Gaebel spoke of what it means we both? Or do we have to become cope with the growing diagnostic and to be a psychiatrist: “According to Aristo- more and more specialist?” therapeutic complexities of the field, tle, ‘excellence is always the result of high Posing an answer to these ques- it is important that the identity of the intentions, sincere effort, and intelligent tions, Professor Gaebel quoted his 2010 profession and its integrative strength execution.’ So excellence in psychiatry paper on the challenges and opportuni- are further advanced.’”1 may thus be the guiding principle and ties for psychiatry that he felt were still Reference motto for European psychiatry.” relevant today. “’The psychiatrist is thus 1 World Psychiatry. 2010 Feb; 9(1): 36–38. 2 EPA Congress News 30 March 2015 Monday

Concepts of mental disorders: time to change? Hall B Tuesday 15:30-17:00

Concepts of mental disorders Time to change? ur concepts and classifica- who discusses the incorporation of tions of mental disorders cultural factors in classification, in continue to evolve amid light of recent global migration and ongoingO progress in our under- its consequences. standing of them. During an edu- Dr Reed will describe the current cational symposium taking place phase of the development of ICD- tomorrow afternoon, session chairs 11 (set for final approval in 2017) Wolfgang Gaebel (Heinrich-Heine and the critical issues that arose University, Düsseldorf, Germany) during the development process and Geoffrey Reed (Department regarding the conceptualisation of Mental Health and Substance of mental disorders. Speaking to Abuse, WHO, Geneva, Switzerland) EPA Congress News, he explained reflect on where our concepts are how new disorder groupings have headed, particularly in light of the recent emergence of DSM-5 and the impending ICD-11. “Neither DSM-5 nor ICD-11 They are joined by Wulf Rössler have introduced (University of Zurich, Switzerland), neurobiological or genetic factors into the classification EPA of psychotic disorders.” CONGRESS Wolfgang Gaebel

NEWS been created by subdividing large Publishing and Production conglomerations necessitated by MediFore Limited the structure of ICD-10: “Based on EPA President a lifespan development perspective, Wolfgang Gaebel separate sections on disorders of Local Organising childhood have been eliminated,” Committee Chair he said. Michael Musalek “New chapters on Sleep-Wake Editor-in-Chief Disorders and conditions related Rysia Burmicz to sexuality have been proposed Editors Pete Stevenson, Aisling Koning to overcome the false dichotomy Design between ‘organic’ and ‘nonorganic’ Peter Williams disorders inherent in ICD-10. New Industry Liaison Manager categories have been added in Bethan Coulbeck several areas (e.g., bipolar type II Head Office disorder, hoarding disorder, com- 19 Jasper Road plex PTSD, binge eating disorder), London SE19 1ST, UK and subtypes lacking validity and Telephone: utility (e.g., for schizophrenia and +44 (0) 20 8761 2790 somatoform disorders) have been [email protected] eliminated.” www.medifore.co.uk Continued on page 4 Copyright © 2015: European Psychiatric Association. All rights reserved. No part of this publication may be reproduced, “There are various regional adaptations in the use stored in a retrieval system, transmitted in any form or by any of ICD. This all will improve treatment and care, other means, electronic, mechanical, photocopying, recording or otherwise not only in various regions of the world but also without prior permission in writing of the EPA. The content of EPA Congress the respective treatment approaches of migrants.” News does not necessarily reflect the opinion of the EPA Board or Wulf Rössler Committees.

4 EPA Congress News 30 March 2015 Monday

Concepts of mental disorders: time to change? Hall B Tuesday 15:30-17:00

the border towards normality is still Field Study Coordination Group.” Concepts of mental disorders uncharted terrain in both classifica- Indeed, 85% of the world’s tion systems, and open for discus- population live in low- and middle- sions about concepts of subclinical income countries; as such, field Time to change? or otherwise dimensional ratings testing of ICD-11 takes a similarly of subdiagnostic symptoms in the robust approach, being carried out Continued from page 2 well-harmonised, Professor Gaebel general population.” in multiple languages and in numer- Following this presentation, emphasised that other areas are less On the topic of cultural sensitiv- ous countries throughout the world. Professor Gaebel reviews the main so: “Differences in duration criteria ity, Dr Reed was keen to highlight “The diagnostic guidelines them- differences between ICD-11 and lead to different approaches regard- the sensitivity of WHO to issues selves will also include a section on DSM-5 with a special focus on the ing brief psychotic disorders. And of global and cultural applicability culture-related issues that describes classification of psychotic disorders attenuated psychotic symptoms did as a part of the development of documented cultural differences and ensuing questions that may not receive full diagnostic status. ICD-11 – necessary if it or indeed in the presentation of particular be pertinent for the more general “Neither DSM-5 nor ICD-11 DSM-5 are to be usable across dif- disorders,” continued Dr Reed. “So, issue of concepts of mental disor- have introduced neurobiological ferent regions of the world. “The we are confident that we are ders. In an interview ahead of the or genetic factors into the clas- International Advisory Group that is developing a manual that will be as congress, he noted that both diag- sification of psychotic disorders,” advising WHO on all phases of the useful as possible around the world nostic systems base the classifica- he added. “And some differences current revision includes individuals and across cultures, and by the end tion of mental disorders on psycho- still prevail regarding time course from all WHO Global Regions and of the process we will have a great pathology rather than nosology, criteria and the handling of brief a high proportion of experts from deal of evidence to that effect.” but he nevertheless highlighted psychotic disorders, which may low- and middle-income countries. Sharing his views on the issue, a major difference in the role of indicate different concepts of chro- This is also the case with all of the Professor Rössler felt there is “no functional impairments, mandatory nicity underlying these decisions. Working Groups responsible for doubt” about the need of cultur- in DSM-5 but not ICD-11. An important aspect was the non- making recommendations for the ally-adapted classification systems. Concerted harmonisation efforts inclusion of attenuated psychotic structure and content of diagnostic Explaining how the two systems have worked to minimise such dif- symptoms syndrome among the guidelines for all Mental and Behav- have dealt with this, he said: ferences between DSM-5 and ICD- mental disorders, indicating that ioural Disorders areas, as well as the “DSM-5 has incorporated a cultural 11, as Dr Reed explained: “Most framework considering the cultural of the ICD-11 and DSM-5 Working identity of a person, cultural expla- Groups had at least one member in nations of the individual’s disorder, common. Although the DSM-5 pro- or cultural factors related to the cess was ahead of ICD-11, ICD-11 psychosocial environment and level Working Groups were familiar with of functioning. DSM-5 changes during their delib- “Likewise, we also find cul- erations and avoided unintentional tural considerations in ICD,” he differences between the systems. continued. “And there are various “Therefore, remaining differences regional adaptations in the use of – which are particularly notable in ICD. This all will improve treatment the areas of personality disorders, and care, not only in various regions trauma and stress-related disorders, of the world but also the respective treatment approaches of migrants. Aside from these more practical “We are confident that questions, there are much more we are developing a fundamental concepts of mental manual that will be as disorders behind them; namely, the question of the universality of useful as possible around mental disorders, which is implic- the world and across itly linked to a biological model of cultures.” mental disorders.”

Geoffrey Reed “Most of the ICD-11 and paraphilic disorders, substance use DSM-5 Working Groups disorders, and somatic symptom/ had at least one member body distress disorders – are con- ceptual and intentional, based in in common.” part on the different purposes and Geoffrey Reed constituencies of the two classifica- tions.” While acknowledging that time The symposium ‘Concepts of mental course criteria and the introduction disorders: time to change?’ takes place of dimensional assessments are tomorrow at 15:30 till 17:00 in Hall B. Monday 30 March 2015 EPA Congress News 5

Workshop: Coercion in Psychiatric Services in Different European Countries Hall B Monday 17:00–18:30 Coercion: A force to be reckoned with?

he ethics, clinical and there are many cases months later the legislation practice, human of community treatment or- was revised, therefore we rights and legal regu- ders, CTOs, that have never had data from the period lationsT of mental healthcare been legalised in Germany, before, where medication coercion – with particular except for pharma foren- was possible, seven months focus on country-wide dif- sic patients. That means without, and then the time ferences – will be explored it is not possible to force where it was again possible. this evening in a Workshop a patient to take medica- “In our hospital group, with one clear message: tion outside of hospital in consisting of seven psychiat- there needs to be more Germany.” ric hospitals, our data clearly emphasis on a patient’s Professor Steinert noted indicated that the number autonomy, and a balanced that the next big difference of mechanical coercive and limited use of coercive would be involuntary treat- measures, such as restraint measures. ment: “Since the decision of and seclusion, increased Various European ac- our constitutional court in when medication was not counts of coercion will be 2011, the threshold for the possible, and the number laid bare during the session, use of involuntary medica- of aggressive incidents also with chairman Tilman tion has become much increased. After medication Steinert (University of Ulm, higher,” he said. was possible again, it de- Ravensburg, Germany) tak- “That means a sepa- creased to the former level. ing attendees through the rate decision of a judge is “Interestingly, all of that German perspective. required by external review. concerned only a small In an interview with EPA There are a lot of steps, so number of patients. Six Congress News, Professor it has become very difficult. out of seven patients with Steinert framed psychotic disorders were not the current prac- involved with any coercive tices in Germany, “All over Europe we measure, but for this rather using the UK as have a tendency for small number of patients, a comparative patient empowerment coercive measures doubled example. “They during the time where no use physical and patient rights, and medication was possible.” restraint in the UK, I think that is a good Offering his perspectives i.e. holding people of what needs to be done down manually, development.” in order to strike the right and in Germany Tilman Steinert balance between regulation we use belts to fix and patient rights, Profes- patients to a bed sor Steinert commented: [as mechanical restraint],” Only a relatively small num- “All over Europe we have he said. “The biggest dif- ber of patients now receive a tendency for patient ference is that mechanical involuntary medication. I empowerment and patient restraint lasts much longer know that it is of very little rights, and I think that is than physical restraint. concern in the UK, where wrong direction,” he said. one particularly interesting a good development. Of “Maybe the reason for they say, ‘It is a treatment’. Discussing the data that study from his own centre in course patients want to this is that we have fewer But in Germany it has be- is now in the ether regard- Suedwuerttemberg, which decide their medication, so nursing staff available on come a big issue.” ing how coercive measures emerged during a period of I think we do need some the wards. However, we While Professor Steinert affect patient outcomes, legislative dormancy, as he regulation, but we should have more psychiatric beds, stressed that involuntary Professor Steinert spoke of explained: “For a period of not overregulate. It is pos- and more patients with medication was seven months sible to keep everything in not-so-severe psychiatric still a “wrong we had no view while also protecting disorders can be hospital- direction” from “Since the decision of our legislation for the rights of staff not to ised in Germany. Also we his perspective, he constitutional court in medication at be harmed during their use seclusion rooms I think conceded that it is all. That meant work – I think all of that a bit more than the UK – good to evaluate it 2011, the threshold for that only in belongs together. We need although some hospitals in intently, in order to the use of involuntary cases of acute ‘clever regulations’, taking Germany don’t use seclu- make sure it is in emergency was into account all of these sion rooms at all. The next the best interest of medication has become medication aspects. We need fund- big difference is involuntary patients. “I think much higher.” actually possible. ing for psychiatry. Overall, outpatient commitment. In to be too strict This was a quasi- many aspects are a ques- the UK, as I am aware, it has and too restrictive Tilman Steinert experimental tion of staffing levels and been legalised since 2009, may lead us in the situation. Seven of architecture.” 6 EPA Congress News 30 March 2015 Monday

Europe Meets Asia: Lessons to Be Learned Hall F Monday 17:00-18:30 East meets West: The AFPA and EPA joint symposium

he Asian Federation of Psy- the practice of attaining mental chiatric Associations (AFPA) wellbeing. In Asia, such an impor- has joined forces with EPA tant role for spirituality demands thisT year in a unique symposium a dialogue between conventional that aims to highlight valuable healthcare professionals and alter- learning points that can be trans- native healers. lated from East to West and vice These differences can be put versa. The session takes place this down to resources as much as afternoon, with European perspec- tradition, explained Dr Javed: “In tives from Wolfgang Gaebel (Hein- the UK, for example, you can rich Heine University Düsseldorf, rely on the NHS. In the West, the Germany) and Danuta Wasserman conventional systems are more valid (Karolinska Institute, Stockholm, and approachable, and there is less Sweden) being aired alongside reliance on non-NHS psychiatry re- those from Pichet Udomratn (Prince sources. But when it comes to many of Songkla University, Thailand) and countries in Asia (and even Africa), Afzal Javed (Coventry & Warwick- unfortunately those resources are shire NHS Trust, Nuneaton, UK; and not there. The pathway of care Fountain House, Lahore, Pakistan). does not go through the profes- The AFPA was formally an- sionals. nounced in 2005 during WPA’s “In countries in Asia and Africa, World Congress in Cairo, becom- the emphasis on other avenues is ing a reality after its launch in there first because of availability, 2007 in Lahore, Pakistan. Speak- and second because of cultural ing to EPA Congress News, AFPA beliefs; for example, people might President-elect Dr Javed noted that think that some mental illnesses the need for such an organisation are due to spiritual possession or had been present for many years. something similar.” “The unity and collaboration of But this is not to underestimate the potential value of spiritual and religious healing. In addition, there “There is a lot that can be are approaches to practices such learned from these mutual as psychotherapy unique to Asian collaborations… The ‘best’ countries that could provide more options for patients in Europe: “The will be a combination of Western world can also learn the approaches from different different ways of healing, overcom- ing stress, or how a support system regions for different needs.” can be developed and offered,” Afzal Javed explained Dr Javed. “So there is a lot that can be learned from these mutual collaborations. psychiatric societies in Asia was the And it doesn’t mean that main objective for the formation of “In many Asian countries, any particular system is AFPA,” he said. “It has now been this, there are a number of two important institutions the ‘best’ – the ‘best’ will actively involved in the promotion conceptual differences. be a combination of ap- of mental health and the better- “Hospital psychiatry – family and religion – proaches from different re- ment of psychiatry in Asia. AFPA is still a norm in most of play an important role in gions for different needs. has now organised a number of the Asian countries with supporting the mentally ill.” But there is a need to look world congresses, the last one held fewer facilities for commu- at all of these treatment in Japan in March 2015.” nity psychiatry. Manpower Afzal Javed methodologies in a more Naturally, a great deal of diver- resources are grossly less in scientific way. Rather sity exists within both Europe and Asia, and Asian psychiatry than just purely relying Asia, but Dr Javed highlighted that is still governed by a number of the treatment of mental health on belief, there needs to be some considerable differences can never- socio-cultural determinants for the problems.” scientific evidence behind it.” theless be drawn between Asia and practice of psychiatry. So there are This poses an interesting Dr Javed’s talk during the Europe’s practices of psychiatry in still big mental hospitals in many contrast to what is the predomi- symposium focusses on rehabilita- general: “Economic and financial Asian countries, and patients do nant situation in the West, where tion psychiatry – the application of resources vary a lot between the go to faith healers, shamans, and perhaps religion or spirituality is not measures aimed at reducing the im- two continents, but in addition to religious and spiritual places for regarded to the same extent within pact of disabling and handicapping Monday 30 March 2015 EPA Congress News 7

Europe Meets Asia: Lessons to Be Learned Hall F Monday 17:00-18:30

East meets West: The AFPA and EPA joint symposium “Rehabilitation in general means limiting disability, mental health conditions, thereby are the ‘homes’ of many homeless have a problem, enabling disabled people to achieve mentally ill, and children with intel- you will talk to minimising the handicaps social integration. “Rehabilitation lectual disabilities (mental retarda- someone thou- and impairments. It means a in general means limiting disability, tion) are cared at these places.” sands of miles minimising the handicaps and im- Spiritual and religious communi- away on the culture of healing and hope.” pairments,” he explained. “It means ties provide some support to suf- phone, but you Afzal Javed a culture of healing and hope with ferers, but, as Dr Javed explained, will never talk to emphasis on recovery and partner- in the absence of state-run health your neighbour! ship, citizenship and quality of life, infrastructures (as is the case in This is a fact. This is, in my view, sort of cultural background,” social inclusion, empowerment, many Asian countries), the burden the impact of urbanisation. said Dr Javed. “That needs to be skills training, and meaningful that falls upon the family can be “There are many ‘push’ factors respected. Unfortunately, training occupation and resettlement, and weighty. Moreover, considerable for urbanisation, such as poverty. in the West may not give enough re-housing for mentally ill. shifts towards urbanisation may be People are coming into towns and attention to those social and cul- “In many Asian countries, two dismantling these critical networks cities for resources and facilities. But tural needs.” important institutions – family and of care, and policy must be devel- as a result we are losing the social The symposium is set to religion – play an important role in oped to swiftly bridge this gap. fabric. That is going to have a big generate a wealth of future col- supporting the mentally ill. The fam- “African and Asian countries impact on mental health. We don’t laborations in service provisions ily provides a sense of support, and are becoming more urbanised in yet have any answers to this.” as well as in teaching, training, religion provides a sense of direction. different ways, and we are paying Of course, migration also and policy development in dif- However, with the current globalisa- the price,” said Dr Javed. “One of occurs between nations, which ferent fields of mental health, tion, both of these protective factors my friends jokingly said once that presents issues around the separa- explained Dr Javed: “We hope are losing their importance. you might be sitting in New York, tion of families and cultures amid that it will lead not only to social “While considering rehabilita- London or Paris, and when you the hope of finding a better networking, but also to concrete tion, these two as- quality of life. From steps towards mutual training pects play a vital role the psychiatrist’s and a greater understanding and in many Asian “In New York, London or Paris, and perspective, these of each other. It will help to countries. In contrast when you have a problem, you factors need to be implement some of the policies to many Western taken into account: that can be translated from one countries, many of the will talk to someone thousands of “For the many peo- culture to another.” chronic mentally ill are miles away on the phone, but you ple that are coming managed by the fam- will never talk to your neighbour!” from remote places Dr Javed speaks on the topic of psycho- ily and religious insti- in Asia and Africa social rehabilitation in Asia during the tutions. In the Indian Afzal Javed to Europe, they joint AFPA-EPA symposium, which takes subcontinent, shrines need to retain some place today between 17:00 and 18:30.

PsychiatrySpeaks – what’s it all about? An international market research survey of psychiatrist opinion — the role of the caregiver and treatment choice. sharing insights on current practice in psychiatry and schizophrenia Call out: The survey is part of a wider project created to inspire everyone — people with schizophrenia and all those who care for them — with a new sense of o two psychiatrists are the same. Opinion and practice differ considerably what’s possible. with regards to mental health, its management and its intervention; differ- The results of the survey reveal several key themes, one of which is the focus of Nences that cannot always simply be explained by reference to healthcare the first PsychiatrySpeaks report — Autonomy, choice and schizophrenia. This report system, nationality or culture. To support a better shared understanding and good explores the autonomy of the individual with schizophrenia, their caregiver and the psy- practice in psychiatry, pharmaceutical companies Otsuka and Lundbeck have chiatrist managing their care, with discussion and commentary from experts in the field. conducted an international market research survey – PsychiatrySpeaks. This first PsychiatrySpeaks report is expected to be available in May 2015. PsychiatrySpeaks explores the beliefs and behaviours of psychiatrists with Along with expert commentary and video reactions, downloadable reports, articles respect to their practice and their management of schizophrenia. With over 1600 and data infographics will also be available, giving psychiatrists the opportunity to participants from 8 counties worldwide — Australia, Canada, Germany, France, compare practice and challenge perceptions. Italy, Spain, United Kingdom and the United States — it provides a valuable insight Visit psychiatryspeaks.com to sign up and be one of the first to receive the Psy- into the current state of mind of those working in psychiatry. chiatrySpeaks report and the latest updates on the release of the full survey results. An international panel of psychiatrists facilitated the creation of the questions Find out more at the EPA Cyber Corner today! for the survey, identifying topics of interest to them with respect to psychiatry in general and schizophrenia in particular. The topics selected include the role of the Approval Code: OPEL/0315/MTN/1218 Date of preparation: March 2015 ©Ot- psychiatrist, developments in the management of schizophrenia, informing patients, suka Pharmaceuticals Europe Ltd. and H. Lundbeck A/S 8 EPA Congress News 30 March 2015 Monday

Symposium: The “Mad Axman”: The Relationship Between Psychosis and Violence LIVE @ EPA Sunday 08:00–09:30 World-view and culpability within psychosis A study of “The man without qualities”

uring yesterday morning’s symposium on ini said: “Two strategies were locked in combat, the relationship between psychosis and two integral positions, two sets of logical con- violence, Giovanni Stanghellini (Univer- sistency.” The passage illustrates the emergence Dsità degli Studi “G. d’Annunzio”, Chieti-Pescara of the logic that is employed by Moosbrugger, Italy) spoke about the nature of responsibility that his act could be reasonably understood when the individual’s life-world is taken into within a certain frame of reference. “Musil account. clearly shows in his novel is that the life world “To be human is to be at odds with respon- inhabited by Moosbrugger is totally different to sibility: being aware that we cannot fully control that of our own,” said Professor Stanghellini. the involuntary dimensions of our existence, but Speaking of another phenomenon illustrated at the same being held responsible for it,” said in the same section dedicated to Moosbrugger, Professor Stanghellini, adding that responsibility so-called ‘hang-togetherness’, he then quoted is both a presupposition and a task in our cul- the following passage from the book: ture: a presupposition, because society expects “A squirrel in these parts is called a tree kit- a person to responsible for their deeds; and ten, it occurred to him. But just let somebody try a task, because responsibility is not an inborn to talk about a tree cat with a straight face! In characteristic for a human beings. “It is achieved Hesse, on the other hand, it’s called a tree fox. through education,” he But oh, how curious the psychiatrists got when said. “As French philoso- “To be human is to they showed him a pictured of a squirrel and he pher Paul Ricœur put it, said, ‘That’s a fox, I guess. Or it may be a hare, ‘education is education to be at odds with or maybe a cat or something.’” responsibility’.” responsibility: being “Moosbrugger’s experience and convic- And responsibility is tion were that no think could be singled out, achieved through the aware that we cannot because things hang together,” explained integration of responsibil- fully control the Professor Stanghellini. “First and foremost, we ity and vulnerability, he ex- use words in order to indicate details of our life plained, via the awareness involuntary dimensions to hang together as a meaningful perception of that we are vulnerable to of our existence, but our surroundings, linked together by mean- the involuntary dimension at the same being ingful connections. It is believed that a deep of our existence. The ethi- to discover the right metamorphosis of life space also involves two cal consequence of this, held responsible for it.” way to live. or three distinct directions of objects in the life particularly with respect “Musil commented space: firstly, the separation of the object from Giovanni Stanghellini to forensics, is that it is to himself in a let- the complete scene; secondly the experience very difficult to extricate ter when he almost that everything hangs together; and lastly, the responsibility from non-responsibility. completed his novel: ‘I am concerned with the concept of ‘rubber-banding’, a common sense Professor Stanghellini argued that standard scientific study of psychology and I believe that, natural attitude to reality.” procedures for determining responsibility are in the fine reports of the French psychiatrists, for In his conclusions, Professor Stanghellini unhelpful, and he illustrated this through an example, I can both experience vicariously, and asked whether we need transformation of the exploration of the 20th century three-part unfin- depict every abnormality, transporting myself life-world to determine accountability: “Is there ished novel by Robert Musil, The Man Without into the corresponding horizon of feeling, with- a link between the transformations of the life- Qualities (Der Mann ohne Eigenschaften). out my own will being world in schizophrenia? The novel explores a variety of human seriously affected.’ This Is the assessment of themes through the eyes of Ulrich, whose the is of course the empa- “Should we have a psychiatric symptoms book’s title describes. It includes, amongst many, thetic understanding of fuller reconstruction and anaemic symptoms the protagonist Moosbrugger, a murderer and another’s subjectivity.” devised to assess the rapist who is eventually condemned. Musil Ulrich, explained of this person’s life- accountability of the discusses this case in finely tuned phenomeno- Professor Stanghellini, is world to establish their patient, or should we logical terms, using the standard notion of ac- preoccupied with reality have a fuller reconstruc- countability and anaemic concept. Quoting this (wirklichkeit) and ef- accountability when tion of this person’s life- section of the book, Professor Stanghellini read: fectiveness at the same they exist in life-worlds world to establish their “’To the judge, Moosbrugger was a universe, time. This manifests that are not our own?” accountability when and it was very hard to say something convinc- in Ulrich’s fascination they exist in life-worlds ing about a universe.’ with Moosbrugger’s Giovanni Stanghellini that are not our own? “Musil immerses Ulrich, his hero, in the inner subjectivity, and his pur- The tentative conclusion experiences of a murderer, and identifies Ulrich’s suit Ulrich perceives as is that a person can be determination to fulfil his primary task, namely ‘intellectual dynamite’ to blow up wirklichkeit. held not responsible for their deeds, if and only to find the vital link between thinking and do- Reading the quotation from the passage de- if they emerge out of an ontological framework ing, exploring the realm of responsibility in order scribing Moosbrugger’s trial, Professor Stanghell- that radically differs from our own.” Monday 30 March 2015 EPA Congress News 9

Workshop: Geriatric Psychiatry and Primary Care MentHealth: An EPA and WONCA Joint Workshop Hall N1 Sunday 15:00-16:30 Communication: The key to effective primary mental health care for the elderly

he World Organization of approach’ is sometimes adopted National Colleges, Academies when dealing with mental health and Academic Associations problems. In primary care, he ofT General Practitioners/Family Phy- explained, a three-dimensional, sicians (WONCA) and EPA are hold- holistic approach, encompassing ing a joint workshop this afternoon, social, mental and general medical dedicated to the topic of geriatric problems, is most fruitful. psychiatry and primary care. Henk “Often, when problems arise, Parmentier (Croydon Out of Hours what we see in primary care at Virgin Care ltd, Croydon, UK) of the WONCA Working party on Mental Health, spoke to EPA Con- “The degree of specialisation gress News ahead of the session to in psychiatry can make discuss the state of primary care for it difficult for general older persons with mental disorders in the UK. practitioners to find the Dr Parmentier began by address- correct psychiatrist for a ing what primary care constitutes in the UK in the context of mental particular patient.” illness, explaining that primary men- Henk Parmentier tal health care has a different role to that of psychiatry: “Primary care is a different concept in care to any is different to that observed in other specialty in medicine, because secondary care,” he explained. “In issues is for primary and secondary No guidelines on recording and it involves care from the cradle to secondary care, a depressed pa- care to work together.” disseminating this kind of informa- the grave, and it is not specialised. tient may present mood changes, Sharing his personal experience tion are currently in place at the “Sometimes the degree of whereas in primary care we will of this, Dr Parmentier described UK’s National Institute for Health specialisation in psychiatry – for often be presented with physical the importance of communication and Care Excellence (NICE), he example into elderly care psychia- symptoms like back pain, exhaus- in making sure that patients’ best explained, and there is considerable try, biological psychiatry or social tion and headaches as the primary interests are kept at heart: “When evidence that it needs centralisation. care psychiatry – can make it dif- symptoms – which are also symp- working in a care home of severely “This is currently being spearheaded ficult for general practitioners to toms of depression.” demented patients, I did joint ward in London using ‘Coordinate My find the correct psychiatrist for a Dr Parmentier then went on to rounds with the resident consultant Care’, a web-based clinical service particular patient.” discuss end-of-life care in elderly psychiatrist. At the earliest stage we coordinating information between Indeed, this situation is wors- patients with mental illness in the discussed end-of-life decisions and healthcare providers and recording ened if the patient has comorbid UK, noting increasing numbers palliative care plans with relatives the wishes of patients regarding health problems. A patient with in care homes that fall under this – and patients where possible. We their care. This clear and modern schizophrenia, alcohol depend- bracket of palliative care. “This found that this integrated approach way of communication is accessible ence, and some of the mental brings up some very critical and clarified the wishes of the patients by every doctor and nurse involved, health problems associated with ethical issues,” he said. “Other and relatives very well, and I would and has already proved successful.3 normal ageing, would have a com- conditions such as schizophrenia, strongly recommend guidelines “Clearly, dementia and the plex diagnosis. As such, their needs alcohol and substance depend- promoting joint ward rounds.” problems connected with it are an will be similarly multifaceted. ency, or cancer can impact on Yet storing and communicating increasing burden on the NHS [Na- “Because of the specialisation life expectancy. Consequently, any decisions regarding treatment, tional Health Service] and society as of psychiatric domains, the patient patients with these conditions may especially concerning end-of-life a whole. We need more resources may fall between the remit of a effectively require end-of-life care. care, can be problematic, especially and better communication to bet- specific care procedures, and end However, dementia is the only when multiple agencies are involved,2 ter support patients and the needs up being seen in primary care” said condition in psychiatry that has an as Dr Parmentier described: “In my of careers.” Dr Parmentier. “Linda Gask claims end-of-life diagnosis. experience in out-of-hours services, References that 90% of all patients with “Indeed, the most basic question I have sometimes seen a lack of 1 Gask L et al (Eds.). Primary Care Mental Health. mental health problems (including regarding end-of-life care is whether communication between carers and Oct 2009. London, UK: RCPsych Publications. 2 Moran WP et al. (2012): Where are my 30% to 50% of all those with seri- to resuscitate. The ethics of whether emergency services; the carers may patients? It is time to automate notification of ous mental illness) only use primary to resuscitate are complex and the not be aware of end-of-life decisions, hospital use to primary care practices. South care services.”1 rights of patients (i.e., whether they and this has resulted in hospitalisation Med J. 2012 Jan;105(1):18-23. He described further issues in want treatment) are central to any at the last stage of life, which was 3 Smith C et al. Coordinate My Care: a clinical service that coordinates care, giving patients dealing with mental and physi- decisions that are made. The only not the desire of the patient nor that choice and improving quality of life. BMJ cal health, noting that a ‘medical way to deal with these contentious of the treating team.” Support Palliat Care. 10 EPA Congress News 30 March 2015 Monday

Workshop: The Recent EU-Funded Imaging Projects in Psychiatry: Presentation and Update Hall L4 Sunday 08:00–09:30 New trimodal imaging device to shine light on early schizophrenia diagnosis

number of EU-funded projects in psychi- – both on the clinical side and on the construc- results and clinical data obtained from sub- atric imaging were laid bare yesterday tion side.” objective (a). morning, with a fascinating exploration There are three sub-objectives planned as “The performance has to be beyond what is ofA new technologies, paradigms and cutting- the TRImage system takes shape, detailed as state-of-the art, otherwise there is no point in edge concepts. follows: (a) the discovery and validation of doing it,” commented Professor Del Guerra. Speaking first in the workshop, held bright new biomarkers, along with the definition of a Discussing the paradigm of biomarkers and and early at 08:00 in Hall L4, was Alberto Del suitable multimodal paradigm with currently- multimodal imaging, Professor Del Guerra noted Guerra, a physicist from the University of Pisa, available PET, MR, EEG and PET/MR systems, that the idea would be to utilise the Loud- Italy, who introduced his work in the ness Dependence of Auditory Evoked development of a simultaneous tri- Potential (LDAEP) as a biomarker. This modal (PET/MR/EEG) imaging tool for “The instrument will comprise a is based on the serotonin hypothesis early diagnosis of schizophrenia and that states there is reduced LDAEP other mental disorders. 1.5 T, cryogen free, very compact in patients with higher serotonergic Known as TRImage, the basis of the superconducting magnet, with a activities. technology is to make an early diagno- PET insert with better performance “You really have to check if that is sis of schizophrenia. “But certainly it feasible, that the relationship holds, can be used for other mental disor- than any available clinical PET and there is no contradiction – and this ders,” said Professor Del Guerra. scanner, and a fully-integrated EEG.” has to be checked in healthy patients, Led by an FP7-funded consortium as well as those which are already of seven research institutions and four Alberto Del Guerra diagnosed with schizophrenia,” said small and medium-sized enterprises, Professor Del Guerra. the project began in December 2013 Discussing whether, if you go for an with an estimated developmental timeline of thus providing clinical evidence on the feasibility EEG, going for a PET or MRI is strictly necessar- four years. of early schizophrenia diagnosis; (b) to construct ily, he stressed that it is important to validate “Basically what we have done up until now and test the planned cost-effective trimodal this multimodal approach’s true benefits. To that is we’ve designed exactly what we want to imaging instrument for diagnosis, monitoring end, he noted that validation of LDAEP can be do,” commented Professor Del Guerra. “So we and follow-up of schizophrenia disorders; (c) to done using: fMRI, to obtain spatial correlation are at the stage where we can start assembling validate the imaging device with regards to the with EEG; PET – to study influences of other Monday 30 March 2015 EPA Congress News 11

neurotransmitters; and magnetic resonance spectroscopy – to study influences of other GABA, glutamate or similar neurotransmitters. “This evaluation will be done concurrently, while the instrument is being constructed,” noted Professor Del Guerra. Clinical recruitment will be divided into two phases, the first, utilising currently-available EEG, PET, MR and PET/MR devices, will incorporate 40 patients with schizophrenia diagno- sis (ICD-10) and 40 gender-matched healthy controls. “After this phase “The performance has to be we will obtain, hopefully, biomark- beyond what is state-of-the art, ers and a multimodal paradigm,” said Professor Del Guerra. otherwise there is no point in The second and final phase will doing it.” be to validate the new trimodal im- therefore representing a relatively compact aging device using 15 schizophrenia Alberto Del Guerra scanner by today’s standards. patients, 15 prodromal individuals Outlining the timeframes for development and 15 healthy controls matched in of the TRImage device, Professor Del Guerra age, gender, education, IQ, etc. He added: “Altogether, the performance of shared that the biomarkers and multimodal Discussing the finer details of the planned the PET would be a very high spatial resolution imaging paradigm stage of development is TRImage device, Professor Del Guerra began: of 2 mm, which is a factor of two higher than planned for completion in December 2016. “The instrument will comprise a 1.5 T, cryogen what is available. Its high efficiency (14%) is a After that, the PRT/MR/EEG prototype will be free, very compact superconducting magnet, factor of 2.5-3 times higher than now avail- completed, tested and installed the following with a PET insert based on silicon photomul- able. The axial field of view is 15 cm … and June (2017). The final step – clinical validation tipliers with better performance … than any the transaxial field of view is 11 cm in radius.” of the new prototype – will be completed by the available clinical PET scanner, and a fully-inte- Further benefits of the device include a weight end of 2017. “This will be a very challenging grated EEG.” of only 1.5 tonnes, and a length is only 1.2 m, project,” he said in closing. 12 EPA Congress News 30 March 2015 Monday

Pro & Con Debate: Is Neuroimaging Over-Valued? LIVE @ EPA Congress Sunday 10:00-11:30 Role of neuroimaging hotly debated

ophia Frangou not to negate the behav- (Icahn School of ioural symptoms – but to go Medicine at Mount beyond them. Finally, the SSinai, New York, USA) went other significant contribu- head-to-head with Andreas tion is providing a mecha- Meyer-Lindenberg (Central nistic link between risk and Institute of Mental Health in disease expression.” Mannheim, Germany), dur- Professor Frangou also ing a debate on the topic marked out the role that has of the place and value of neuroimaging has played neuroimaging in unravelling in the understanding of the the causes of mental illness biological meaning of much yesterday morning at EPA of the early and ongoing Congress. “Neuroimaging is moving us epidemiological research Starting by defining the in a different direction and linking risk factors to actual history of psychiatry itself, biological pathology, as well Professor Frangou pointed helping us to reconceptualise as offering great potential out that the discipline has the minimal landscape for in neuropsychological thera- evolved in two threads: of mental disorders, regardless pies such as neurofeedback. embodied psychiatry, i.e. Andreas Meyer-Lin- the mind as output of the of the specifics of their denberg then took to the brain, aside from other opposing visions presentation.” ses have shown stand to present his views, organs’ involvement; and of psychiatry that that, by ignoring explaining that, from the disembodied psychiatry, a makes people Sophia Frangou classification perspective of understand- more abstract concept in look at neuroim- entirely, that ing aetiology, neuroimaging considering mental phe- aging sometimes structural and cannot identify the causes nomena as separate or not as an extremely reductionist lies within the evolving functional neuroimaging of mental illness as the necessarily directly linked to tool that can never fully landscape of understanding. could identify common pa- causes are rooted in genes a particular organ. capture what it is to be hu- “Neuroimaging has provid- thologies pervaded multiple and environmental factors The evolution of these man and what it is to suffer ed us with an unequivocal clinical diagnoses, includ- and interactions thereof. and similar concepts in psy- as a human.” link between the brain and ing schizophrenia, bipolar “The most that imag- chiatry has both informed The second duality is the mental illness,” she noted. disorder, substance abuse, ing can hope for is to find the role of neuroimaging as notion of aetiology, and “You may dispute the con- and others. mediating mechanisms,” well as its evaluation. Professor Frangou described tribution of brain disorders, “Neuroimaging has he said. “But for arguments “Over the years, the em- that we have moved into networks, neurotransmit- therefore helped us identify sake, I would be willing to bodied camp has dominated the idea that, rather than ters, etc. to mental illness something potentially revo- entertain the potentially the field,” she said. “The direct causative agents of – but you cannot dispute lutionary: a superordinate misguided idea that imag- most recent reinventions of psychiatric disease, multiple the link.” neural network for mental ing might be helpful for embodied psychiatry involve risk factors increase the It has been demonstrated disorder,” said Professor identifying those mecha- the fact that most of the in- likelihood of a disorder oc- that brains of individuals Frangou. “We have spatial nisms linking from genes to terventions that we have in curring within a spectrum of with certain mental disorders convergence between func- behaviour.” psychiatry have to do with other possible outcomes be- can be differentiated from tional and structural data; Professor Meyer-Linden- changing another biological yond the discretely categori- those of controls. Particu- we have the main general berg then pursued this line component within our bod- cal into a more dimensional, larly pertinent to Profes- networks. These do not, of of reasoning by dismantling ies, e.g. neurotransmitter fuzzy approach. sor Frangou was the fact course, at this stage explain the relationship between functions and other related As an instructive analogy, that this work essentially the clinical pleiotropy, so we genetics and imaging, and things.” Professor Frangou looked to demonstrated that there cannot use this information environment and imaging: Non-embodied psy- the field of cardiovascular is a biological significance to explain why someone “Genetics, of course has chiatry, on the other hand, medicine, noting that heart to currently-used clinical may present with anxiety been extremely successful in emerged from theological attack and stroke would be diagnostic labels. She added: as opposed to, say, bipolar actually finding causes. But thought and was more very easily characterised as “Neuroimaging is moving us disorder. But it does explain some misguided individuals recently transformed into discrete disorders with con- in a different direction and comorbidity, which is preva- then try to use neuroimag- what is termed moral verging risk factors identify helping us, as different forms lent, and it also explains the ing, for example, in trying psychiatry: “When we ask a common substrate, i.e. the of imaging did in cardiovas- trans-diagnostic efficacy of to find out how these genes this question, part of us is ease of flow of blood within cular medicine, to reconcep- medications. work. But it is open for de- representing this dichotomy the veins. tualise the minimal land- “This is a phenomenal bate whether that is actually within ourselves and within With this in mind, Profes- scape for mental disorders, contribution in moving quite that successful.” our speciality, about what is sor Frangou looked at what regardless of the specifics of us towards a different He then went on to the essence of these prob- neuroimaging has achieved their presentation.” conceptualisation of mental speak of, what is for some, lems…that is part of the so far, and where its place More recent metaanaly- disorders altogether. That is a disappointing lack in Monday 30 March 2015 EPA Congress News 13

Pro & Con Debate: Is Neuroimaging Over-Valued? LIVE @ EPA Congress Sunday 10:00-11:30

“Neuroimaging is always correlative. This is always something different from causation, so it cannot prove causality.”

candidate gene identifica- ogy of mental illness. If that Andreas Meyer-Lindenberg tion to have emerged from were true, there should be large-scale imaging-genetics much higher penetrance at consortia such as ENIGMA: that level. The penetrance of underlying substrate that features, such as enlarged disorders have a neurodevel- “The is not what people genetic effects in neuroim- might be a unified con- ventricles, are so non-spe- opmental component and would have expected if it is aging is underwhelming and tributing cause to different cific that they are to a large are subject to environmental in fact true that structural that argues for that being mental disorders, Professor degree meaningless. influences that may hit the neuroimaging gives you a overvalued.” Meyer-Lindenberg com- And data that have at- brain at certain vulnerable privileged view on the biol- Referring to the common mented that such common tempted to make associations periods in the lifespan. The between high-risk genetic most important of these variants and altered neuronal periods – perinatal – are not systems have not borne fruit accessible to us. We can either. “You can look at the image people later and then systems that are altered; claim that we find a cor- but those systems do not all relation. And neuroimaging overlap. There is no common is always correlative. This is core system of those high risk always something different genetic variants that we can from causation, so it cannot identify. So in that sense the prove causality.” complexity of the genetics of A general problem emerg- mental illness maps poorly ing from all of this is the very on imaging mechanisms. reliability and robustness of The same is of course true if neuroimaging in all its forms we go beyond genes to less as a method, which, Dr biologically-defined things Meyer-Lindenberg stressed, such as symptoms or treat- is an area of research that is ment response. In all of these not well patronised. Looking things, the complexity hasn’t towards some of the techni- really mapped very well in cal aspects that may under- these illnesses.” mine data reliability, he noted Turning to the environ- that intra-subject variability in mental interactions with both structure and function neuroimaging, Professor has been demonstrated over Meyer-Lindenberg high- varying durations of time lighted one particular line in healthy individuals, and of enquiry looking at the indeed the statistical analysis effect on brain function of and interpretation of, for city versus rural life. Again, example, fMRI data must be he noted, this has little approached with caution. meaning: “If you look at the Turning to machine-learn- immense complexity that ing methods that have been ubanisity very likely entails – shown to be capable of clas- from social factors, to green sifying two-thirds of patients space, to toxins, to noise, accurately, Dr Meyer-Lind- light pollution, etc. – these berg presented his conclu- are not captured in this sions: “I would submit that, image simply because you as a clinical psychiatrist, I show that there is a correla- could probably identify more tion between the number than two-thirds of the peo- of people living around ple with schizophrenia and you and aspects of brain distinguish them from the function. There needs to be people who have no mental a strategy that links one to illness. And, even if I were the other, but that strategy at the same level, I would isn’t obvious. argue that it tells me nothing “Both of those have an about causation. The same important further dimension goes for prognosis – finding that we need to consider, in something that would be the sense that many of us useful for prognosis has not believe that many mental really happened.” 14 EPA Congress News 30 March 2015 Monday

Symposium: Nature and Narratives of Depression Hall L1 Tuesday 13:30-15:00

I believe Professor Maria Luisa Nature and narratives of depression Figueira’s experience with affective patients have been key to what we An interview with Luís Madeira present at EPA Congress. What could the implications be in Have we lost sight of the roles of phenomenology, subjectivity and intersubjectivity in di- treating this group of disorders agnosing and treating depression? In a clinically-focussed, EPA Section Symposia award- as you describe both for the prac- winning session dedicated to nature and narratives of depression, Luís Madeira (Univer- titioner (in diagnosing) and the sity of Lisbon, Portugal) will argue that broadening focus beyond objective classifications, patient (in the way they perceive themselves)? How do you see this and including the exploration of personal meaning with patients, will ultimately bear fruit impacting the ‘nuts and bolts’ of in clinical therapy. In an interview with EPA Congress News ahead of the symposium, he intervention? explained his thoughts around the topic. For classifications, we foresee many possible scenarios from withhold- You suggest that this group of dis- jective phenomena and reintroducing logical detail. More recently, there ing these inputs and remaining the orders could be approached along them into our classifications might are extraordinary contributions by same, or needing major changes. different axes in order to better be key to understanding mental phe- Giovanni Stanghellini, Matthew For practitioners, they might see help patients’ diagnosis and clas- nomena and allowing treatment. Ratcliffe, Massimiliano Aragona, themselves attending to other sification. What is the rationale Louis Sass, Thomas Fuchs, Joseph phenomena, allowing an in-depth for this? What explorations have been Parnas and John Cutting. discussion of personal meanings The meanings of melancholia and made in different psychopatho- I’ve also met many other re- (semi-structured interviews) and depression have changed hand in logical studies on the topic of searchers who are very much into the focusing on interpersonal experi- hand with the history of psychiatry segregating phenomenological importance of phenomenology and ences (atmospheres, and what they in its search for reliability, and the particularities of each episode of of subjectivity and intersubjectivity in are experiencing) in their process of selection of objective markers as unipolar or bipolar depression or diagnosis. We have huge amounts of diagnosis. symptoms has been the main focus dysthymia? input (literally “from everywhere”), Diagnostic interviews will then of this process. I would risk saying In fact this work is as ancient as which we can’t fully cover in this focus in the (inter) personal explora- that not only have we chosen ob- psychiatry itself. Most (if not all) of keynote, but that should be (and are tion of meanings and building a(n) jective symptoms, we have objecti- seminal psychiatric contributions being) empirically verified in their use (inter) personal narrative for the pa- fied everything we could (including have involved extreme phenomeno- to distinguish affective syndromes. tient’s experience, rather than iden- subjectivity) and have dismissed the tifying (or objectifying) phenomena rest (e.g. intersubjectivity). In this ef- of a specific disorder. We hope that fort, we haven’t really gained much reliability, and we have dismissed the validity of our disorders. “Much of the meaning of Indeed, the categories we are having a mental disorder is now using for diagnosis and re- search have been the target of many having a period of life that criticisms. These include: (1) that does not make sense along they lack phenomenological detail – the objectiveness of objective one’s life narrative.” symptoms is only apparent; (2) that Luís Madeira if it weren’t for hierarchical principles there would be many overlapping syndromes; (3) that findings in this might also help the patient neurobiology and neuroimaging retrieve meaning from his experi- present contradicting and overlap- ences. This is important, because ping evidences; and (4) that, specifi- much of the meaning of having a cally, many depressive syndromes mental disorder is having a period are almost impossible to segregate of life that does not make sense across their clinical presentation if along one’s life narrative. Personal we sustain just the diagnostic criteria exploration of meanings (stitching (e.g. bipolar depression, hyperthymic back experiences and meanings) depression, anxious depression, etc.). might therefore hold diagnostic and We believe that many psychia- therapeutic properties. trists ignore a vast amount of phe- nomena, while others use them “off Dr Madeira presents, ‘Distimia, Unipolar the record” (and sometimes savagely, and Bipolar Depression: Is Modern unfortunately, as they are not part Nosology Making Us Crazy?’ during the of the psychiatric curriculum) in their symposium, ‘Nature and Narratives of diagnostic endeavours. Testing the Depression,’ which takes places tomor- relevance of subjective and intersub- row between 13:30 and 15:00 in Hall L1. Monday 30 March 2015 EPA Congress News 15

Pro & Con Debate: CBT - Is It Sold-Out? Hall F Monday 10:00–11:30 Interpretation is key for CBT

debate that will ask evidence for CBT, which, as focusing on the more-than bluntly whether Professor McKenna noted 50 trials evaluating its ef- cognitive behaviour in the BMJ ‘Head to head’ ficacy, and the journey that therapyA (CBT) for schizo- before, had ‘run into diffi- has led to its position in the phrenia has been oversold culties’ in terms of demon- treatment space today. “In will be held this morning, strating its efficacy in large, medicine in general there with two rather opposing well-controlled trials.1 is a progression from small, views being shared with With this in mind, Profes- early, open trials – some- the audience. Framing the sor McKenna will be taking times with no control group, debate on either side will the viewpoint that CBT or if there is, the control be Peter McKenna (FIDMAG has indeed been oversold, group is examined blind – to Germanes Hospitalàries Research Founda- tion, Barcelona, Spain) “The vast majority of large well- and David Kingdon controlled studies have failed to (University of South- ampton, UK), who have show a significant effect on their larger and better- in one or more large very met on similar debates primary outcome measures, which controlled trials,” he well-controlled trials, with a few times before, told EPA Congress lots of desirable design most notably the British are generally reductions in overall News. “And it is features built in. Medical Journal’s (BMJ) symptoms, and/or reductions in probably fair to say “And this has certainly Maudsley Debate.1 positive symptoms.” that in most areas happened with CBT. ‘Large’ At the core of this of medicine, if it is a means up to about 100 morning’s debate Peter McKenna promising develop- patients in each arm, so it is will be the issue of ment, it culminates Continued on page 16 16 EPA Congress News 30 March 2015 Monday

Pro & Con Debate: CBT - Is It Sold-Out? Hall F Monday 10:00–11:30 Interpretation is key for CBT

Continued from page 15 based on meta-analyses, nine month follow-up after not particularly large when just like our meta-analysis, treatment… then they then you compare it with some but we have quite severe followed up at five years other areas of medicine, criticisms of the style of the and saw benefits.” but certainly these are large NICE meta-analysis,” said Professor Kingdon’s own numbers of trials of psycho- Professor McKenna. “In the 2002 analysis was also de- logical treatments.” BMJ debate we said, and scribed,5 with an emphasis He added: “The vast we still feel, that the NICE on the duration of time CBT majority of large well-con- approach was flawed. It had needs to be implemented trolled studies have failed hundreds of analyses, and in order to see an effect. to show a significant effect the majority of the analyses “It really was concentrating on their primary outcome were negative. But obviously therapy into the first three measures, which are gener- if you carry out hundreds months,” he said. “But ally reductions in overall of analyses, some of them in retrospect now we are symptoms, and/or reduc- will come out positive, pretty clear that these types tions in positive symptoms.” and it was those that were of therapies … you need A comprehensive emphasised … We would 6-9 months really to see an meta-analysis by Professor argue that it is a flawed effect. And in fact in that McKenna and colleagues meta-analysis, and the study we could see an effect will likely also be a talking summary that appeared in at 18 months.” point, the conclusion of the NICE guidelines was not In his concluding re- which being that while CBT balanced.” marks, Professor Kingdon has a therapeutic effect on Offering his conclud- offered a succinct answer schizophrenic symptoms in ing remarks, Professor to the question of whether the ‘small’ range. This re- McKenna re-emphasised CBT has been oversold, say- duces further when sources ing: “A huge step is actually of bias, particularly masking, making these treatments are controlled for.2 “A huge step is actually making available! Far from being “That was a comprehen- oversold, they are under- sive meta-analysis, includ- these treatments available! Far available, and not being ing all possible studies,” from being oversold, they are bought.” said Professor McKenna. ”There was no effort at under-available, and not being Professor McKenna and Profes- all to exclude studies. We bought.” problem of interpretation: sor Kingdon will tackle the followed a normal approach “I think there are people question of whether CBT has a to meta-analysis which is David Kingdon who see schizophrenia rightful place – and appropri- ate evidence – in the treatment to include as many studies as being an intrinsically of schizophrenia in more detail as possible to give the best biological illness, which during this morning’s debate, possible estimate of the size the message from his own In the previous BMJ cannot be helped by a held from 10:00 till 11:30 in of the effect.” meta-analysis, i.e. that CBT debate, Professor Kingdon ‘talking treatment’, because Hall F. Professor McKenna has significant limitations, stated his concerns with the conceptually that is not pos- References went on to discuss his also arguing that that the meta-analysis performed by sible,” he told EPA Congress 1. McKenna P and Kingdon, D. Has cognitive behavioural therapy criticisms of the series of message seems to have Professor McKenna and col- News. for psychosis been oversold? meta-analyses commis- been unfairly treated by leagues, describing it as an Commenting on the BMJ 2014;348:g2295 2. Jauhar S, McKenna PJ, Radua J et sioned for the National In- peers. “These findings ‘extraordinary interpretation NICE meta-analyses, and al. Cognitive-behavioural therapy for the symptoms of schizophrenia: stitute for Health and Care should be provisionally of their own forest plots, eventual addition of CBT systematic review and meta- Excellence (NICE), which recognised,” he said. “Of which show that in nearly to the guidelines, Professor analysis with examination of potential bias.Br J Psychiatry. 2014 ultimately concluded course, if further studies all the studies selected cog- Kingdon said: “What we Jan;204(1):20-9 CBT as being effecting in overthrow it that’s fine, but nitive behavioural therapy is see with CBT is an enduring, 3. NICE. Psychosis and schizophrenia in adults: treatment and management. 1 reducing rates of readmis- what is actually happen- favoured over controls’. longer-term specific effect, NICE clinical guideline 178. 2014 sion to hospital, duration ing at the moment is that A core issue is effect size and that is why NICE have (Available at: guidance.nice.org.uk/ cg178) of admission and overall this meta-analysis, which from this and other various picked it up.” 4. Sensky T, Turkington D, Kingdon symptom severity both is the largest and most analyses, ‘consistently’ Backing up its benefit, he D, Scott JL, Scott J, Siddle R, et al. A randomized controlled trial of at the end of treatment, comprehensive analysis shown to be around 0.3, referred to a few examples cognitive-behavioral therapy for and at 12 months follow- of CBT to date, and has and which Professor King- of data which he feels persistent symptoms in schizophrenia 1 resistant to medication. Arch Gen up. This led to approval five years’ worth more of don noted as being up for exemplify the value of CBT, Psychiatry 2000;57:165-72. of CBT for treatment of studies compared to the interpretation as to whether firstly the 2000 paper by 5. Turkington D, Kingdon D, Turner T. schizophrenia in the NICE last meta-analysis by NICE, this translates into clinical Senksy et al.,4 focusing on Effectiveness of a brief cognitive- 3 1 behavioural therapy intervention in guidelines. is just being ignored, or effectiveness. In fact, he positive long-term results the treatment of schizophrenia. Br J “The NICE guidelines are misinterpreted.” noted there is a general in particular: “They had a Psychiatry 2002;180:523-7. Monday 30 March 2015 EPA Congress News 17

Symposium: Prevention of Mental Disorders in Children of Mentally Ill Parents Hall B Monday 15:00-16:30 Transgenerational vulnerability: Timing is key in preventing depression

il Zalsman (Geha Mental Research has shown that bipolar Health Center, Tel Aviv, Is- disorder is also highly heritable.3 rael; and currently EPA vice Significantly, if an individual who Gchair of child psychiatry section), has a familial vulnerability to will be discussing transgenerational depression is exposed to several transfer of psychiatric disorders major life events, the probability of today, during a symposium on the depression is elevated.4-5 prevention of mental disorders in To this notion of ‘gene by children of mentally ill parents. environment interaction’, Profes- EPA Congress News met Profes- sor Zaslman’s group characterised sor Zalsman to find out about this the importance of timing6: “I am emerging concept and how it could be applied to prevent serious men- tal health episodes in this vulner- “I am a child psychiatrist, able group. and in seeing children, it “Most of the public think prob- is very clear to me that ably about depression as a reaction to life events,” he began. “And life event is very crucial, learned helplessness than later life. Being genetically for about thirty years this was the but more crucial is when when compared to depressed (WKY) together with leading idea, because psychiatry the wild-type Wistar life events in childhood and not started with psychoanalytic theories it happens.” rats, all of which are adolescence will make you much more than 100 years ago. The Gil Zalsman reversible with fluox- more depressed. There is damage assumption was that you become etine. to the development of the brain in depressed because something bad Three groups of specific areas such as the amygdala, happens to you.” a child psychiatrist, and in seeing WKY rat were compared: one emotional areas – all the limbic sys- And such an association seems children, it is very clear to me that exposed to a very early life event (of tem. Although we must be careful intuitive, and has been drawn as life event is very crucial, but more two hours duration), one exposed not to say that we can translate the such for so long purely because crucial is when it happens,” he said. to a later life event (during ado- results immediately from animals to depressive-type feelings in other- “Children are most vulnerable to lescence), and one which was not humans, we have used the rats to wise healthy individuals can usually life events, and all forms of abuse exposed at all (with an additional validate our hypothesis that we cre- be connected to particular negative have more severe consequences if fourth group placed in an enriched ated from observations in humans.” life events. In contrast, true major they happen earlier in life. Losing a environment). Measures of depres- Although this study used male depression is much more than parent before adolescence is a very sion were taken before and after rats, it will be repeated in females this, explained Professor Zalsman; high risk factor for depression, and the study period, and MRI scans to study the effect of gender on halting normal functioning (such losing a parent to suicide because performed to detect structural gene by environment and timing. as eating and sleeping) or result- they were depressed is an even abnormalities such as changes in He explained: “Depression and ing in suicidal ideation or suicide bigger risk.” white matter tract organisation and suicide are gender-specific. In fe- attempt. It is now understood to be During his presentation, Profes- integrity. males, the prevalence of depression the result of the complex interac- sor Zaslman will describe recent “The results are amazing, we increases after adolescence.7 Before tion a major adverse life events and work in which he tested this gene proved our hypothesis: life events in adolescence, male and female de- genetic makeup. by environment and timing interac- early life are much more damaging pression is equal. So timing, again, Depression is very common, tion, in an animal model is very important.” occurring in up to about 20% of of depression using Wistar Gender also plays as a the population in terms of lifetime Kyoto (WKY) rats. In tests of “This screening would be risk factor for suicide, he prevalence1, and family history of depression and anxiety, WKY easy to do, but it costs! added, with studies showing depression is a major risk factor: rats behaviorally demonstrate And the problem here is that while females tend if an individual has a parent with increased anxiety, anhedonia to show higher rates of depression, their risk of developing (demonstrated by poor eating one of stigma.” reported non-fatal suicidal depression is elevated, and more and no preference for sweet- behaviour, males show a Gil Zalsman so if both parents are depressed2. ened over plain water) and Continued on page 18 18 EPA Congress News 30 March 2015 Monday

Symposium: Early Career Psychiatrists: Symposia: Prevention of Mental Disorders in Children of Mentally Ill Psychotherapy Update Parents Hall B Monday 15:00-16:30 Hall N3 Monday 08:30–09:30 Transgenerational vulnerability: Q&A: Ana Moscoso Timing is key in preventing depression on psychotherapy in practice

Continued from page 17 suggested measures require much considerably higher rate of completed groundwork before they could be im- suicides.8 plemented, Professor Zalsman outlined If further investigation proves fruit- the current paradigms that mar the ful, the concept that early events affect more prominent place of mental health depression could be used to tackle a on the public conscience: “This screen- child’s subjective perception of a life ing would be easy to do, but it costs! event in order to reduce the risk of de- And the problem here is one of stigma: pression later on. “Early intervention is people don’t want to donate money crucial,” emphasised Professor Zalsman. to psychiatry; there are not enough “You can’t treat people when they are budgets for psychiatry; and psychiatry depressed or wanting to kill themselves patients are a ‘weak’ population. They – at that point it is too late. You have to don’t go and shout at parliament, be- trace them as kids. cause they don’t want anyone to know n Early Career Psychia- coming from different “We have genetics; we could define that they have problems.” trist session that will therapists, which you will il- them as high risk from this and examine how we can lustrate with a specific case. their family history. We follow Aapply different models and What techniques will you be them, and if one of them is “We have genetics; we theories to any given clinical discussing? exposed to a life event, they case will take place today, with The clinical case revolves would need to go into therapy, could define them as Ana Moscoso (Hospital de D. around depression, and I will and then we can avoid the high risk from this and Estefânia, Lisbon, Portugal) focus on the psychothera- severe depression and suicidal- taking the lead on the topic of peutic approach of cognitive ity. You don’t have to treat eve- their family history… psychotherapy in practice. behaviour therapy, psychoa- rybody, but you have to check You don’t have to treat Dr Moscoso’s presentation nalysis, systemic therapy and to see who those at greater risk everybody, but you have will explore how psycho- mentalisation, but other are.” therapeutic practices vary techniques will be also men- Finding those individuals to check to see who according to their component tioned. The common traits of whose parents are known to those at greater risk are.” techniques and theoretical any psychotherapeutic tech- have depression ought to be models. Speaking to EPA nique will also be addressed. relatively easy via health records Gil Zalsman Congress News, she spoke of in psychiatric clinics. Suggesting the roots of this concept, with Would you say that the that children of such parents particular emphasis on the ‘ideal’ approach is one that could then undergo routine screening References psychotherapeutic environ- comes from accumulated (as is conventional in other diseases, 1 Andrade L et al. The epidemiology of major ments that psychiatrists will training across psychiatry depressive episodes: results from the International such as cancer) throughout childhood Consortium of Psychiatric Epidemiology (ICPE) often wander into. and psychotherapy? till after puberty, Professor Zalsman Surveys. Int J Methods Psychiatr Res. 2003;12(1):3-21. I would definitely say so! They then noted that serious life events could 2 Weissman MM et al. Psychopathology in the children Should psychiatrists pursue both increase our understand- (ages 6-18) of depressed and normal parents. J Am be dealt with better, and more swiftly. Acad Child Psychiatry. 1984 Jan;23(1):78-84. more training to better ing of what it is to be human, The issues around preventing de- 3 McGuffin P et al. The heritability of bipolar equip them for psycho- and what it is to be mentally pression, suicidal ideation and suicide affective disorder and the genetic relationship to therapy? ill. When combined they’re unipolar depression. Arch Gen Psychiatry. 2003 have been scored out by the recent May;60(5):497-502. Well, I suppose it depends even more powerful than tragic airplane crash over the Alps, said 4 Kendler KS et al. Genetic risk, number of previous what kind of psychiatrist you alone – as Von Bertalanffy Professor Zalsman. While the separation depressive episodes, and stressful life events want to become! However, put it regarding the general in predicting onset of major depression. Am J of suicidal ideation and suicide itself Psychiatry. 2001 Apr;158(4):582-6. at least some basic psycho- systems theory. must be broad, he explained that idea- 5 Caspi A. et al., Influence of life stress on depression: therapeutic training would be tion and depression ought nevertheless moderation by a polymorphism in the 5-HTTgene. useful for any psychiatrist, as What is the main message Science. 2003 Jul 18;301(5631):386-9. to be considered high-risk in certain oc- 6 Zalsman G. Timing is critical: gene, environment and it will improve communica- you want early career psy- cupations. “What can we say about bus timing interactions in genetics of suicide in children tion skills, understanding of chiatrists to come away with drivers and train drivers that might have and adolescents. Eur Psychiatry. 2010 Jun;25(5):284-6. non-verbal communication, from this symposium? 7 Cyranowski JM et al. Adolescent onset of the gender genetic vulnerabilities to depression? difference in lifetime rates of major depression: as well as understanding of The take-home message is Nobody asks them – but with genet- a theoretical model. Arch Gen Psychiatry. 2000 psychopathology. that psychotherapeutic treat- ics and life events, we can know much Jan;57(1):21-7. ments are alive and well in 8 Canetto SS and Sakinofsky I. The gender paradox sooner and treat much sooner.” in suicide. Suicide Life Threat Behav. 1998 You will be examining the psychiatry, and will remain so Acknowledging that all of these Spring;28(1):1-23. differences in treatment in the future. Monday 30 March 2015 EPA Congress News 19 EPA Congress Committees

Executive Committee Scientific Programme Committee Dmitry Krupchanka Belarus Wolfgang Gaebel Germany President Wolfgang Gaebel Germany Chairperson Dusica Lecic Tosevski Serbia Danuta Wasserman Sweden Past President Danuta Wasserman Sweden Co-Chairperson Mario Maj Italy Silvana Galderisi Italy President Elect Michael Musalek Austria 2015 LOC Chair Manuel Martin Carrasco Spain Julian Beezhold UK Secretary General Sue Bailey UK Andreas Meyer-Lindenberg Germany Philip Gorwood France Treasurer Julian Beezhold UK Matthijs Muijen Denmark István Bitter Hungary Merete Nordentoft Denmark Board Patrice Boyer France Mariana Pinto da Costa Portugal Sue Bailey UK Geert Dom Belgium Anita Riecher Switzerland Julian Beezhold UK Peter Falkai Germany Martina Rojnic Kuzman Croatia Geert Dom Belgium Silvana Galderisi Italy Jerzy Samochowiec Poland Peter Falkai Germany Philip Gorwood France Graham Thornicroft UK Andrea Fiorillo Italy Cécile Hanon France Wolfgang Gaebel Germany Andreas Heinz Germany Local Organising Committee Silvana Galderisi Italy Cyril Höschl Czech Republic Michael Musalek Austria Chairperson Paz García-Portilla Spain Marianne Kastrup Denmark Michaela Amering Austria Philip Gorwood France Tamas Kurimay Hungary István Bitter Hungary Cécile Hanon France Wulf Rössler Switzerland Wolfgang Fleischhacker Austria Andreas Heinz Germany Rutger Jan van der Gaag Netherlands Martin Hollý Czech Republic Marianne Kastrup Denmark Zvi Zemishlany Israel Hans-Peter Kapfhammer Austria Levent Küey Turkey Siegfried Kasper Austria Tamas Kurimay Hungary Advisory Committee Wolfgang Maier Germany Michael Musalek Austria Siegfried Kasper Austria Chairperson Peter Pregelj Slovenia Wulf Rössler Switzerland Dinesh Bhugra UK Georg Psota Austria Jerzy Samochowiec Poland George Christodoulou Greece Roger Pycha Italy Rutger Jan van der Gaag Netherlands Sophia Frangou USA Gabriele Sachs Austria Danuta Wasserman Sweden Marc Hermans Belgium Pierre Vallon Switzerland Reinhard Heun UK Livia Vavrusova Slovak Republic Valery Krasnov Russia Johannes Wancata Austria

MediFore are the proud publishers of EPA CONGRESS NEWS MediFore is a full-service medical communications and publishing company, working closely with local and international medical societies and associations, and industry, to develop conference publications, including newsletters and newspapers, as well as reports and medical summaries, medical writing and scientific publications

[email protected] +44 (0) 20 8761 2790