Consultation and liaison psychiatry (C-L psychiatry) in Switzerland can look back on a long tradition. It began in French-speaking Switzerland back in the 1960s and gradually spread throughout the country. Currently, C-L services are present throughout the country, although they differ greatly in terms of their services and dimensions. University hospitals and larger cantonal hospitals have extensive and differentiated services, while smaller hospitals in peripheral regions only offer basic services. There are also major differences in the financing models, which are decisive for the range of services offered. The question of funding, which has not yet been resolved satisfactorily despite various models and strategies, including at national level, is highly relevant for the further development and even the continued existence of C-L services. The introduction of the subspecialization in C-L psychiatry in 2010 and the lively training and CPD activities are of great importance for quality of the delivered services.

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The birth of Consultation-Liaison (CLP) in Italy was made possible thanks to Act 180/1978, which started a 20-year-process that led to closing asylums and fostered the implementation of small psychiatric units within the general hospitals. In the meantime, Italian CLP grew steadily, fostered also by the enactment of two “Objective Mental Health Care” Plans (1994-1996 and 1998-2000), that led to the implementation of the organizational model of the mental health department (MHD).

As far as psychiatric referrals are concerned, the first Plan states that the MHD covers all territorial and hospital-based activities, in order to assure, among other services, the integration with hospital (with special attention paid to the Emergency Department and to consultation activity in non-psychiatric hospital wards) and general medicine (as well as other sectors, including mother and child health care).

With respect to psychiatric referral, the Second Plan states that “In the 24 months following the entry into force of the Plan, MHDs will adopt guidelines and procedure concerning several issues, including consultation-liaison activity in non-psychiatric hospital wards (which also includes mental health care for “psychiatric” patients hospitalized for non-psychiatric disease in the general hospital) and in Department of Addictions (for alcohol and other substances use disorders. According to the second Plan, Community Mental Health Services (CMHCs) provide, among other performances, CLP activity for general practitioners. Inside general hospitals, psychiatric referrals to non-psychiatric wards are provided by inpatient psychiatric units, when CLP Services are not available.

Since a standard definition of psychiatric consultation is not available, the one provided by the Italian region Emilia-Romagna will be used. The Region includes “consultation” among mental health services provided by CMHCs, and defines it as follows: “Psychiatric or psychological assessment carried out upon request from other [non psychiatric] Departments. The consultation includes both clinical interview with the patient and the medical report for the department that referred the patient.” The ways to identify consultation as one among other types of services provided by the MHD are defined, to count the overall number of consultations and monitor the clinical activity of health professional working in the different branches of the MHD. The following types of consultations are reckoned: consultations requested by general practitioners (who work within the Primary Care Department); consultations requested by the Department of Addiction (a branch of the MHD); and consultations requested by the Department of Child-Adolescent Psychiatry (which, as the previous one, is a branch on the MHD).

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Consultation-Liaison (CL) psychiatry is the branch of psychiatric practice developed to offer support to patients with concomitant non-psychiatric diseases. In Portugal, most hospitals follow a model delivered by teams with Psychiatrists and Psychologists that support the medical team in wards. They act by advising directly other specialties’ colleagues after the observation of the patient and/or discussion of the case.

Bigger units, such as Santa Maria Hospital, in Lisbon, have tried a model of proximity to the community medical centers participating in local medical meetings, training of family doctors, discussing clinical situations directly and even doing psychiatric consultations, in community centers. This approach intends to extend primary mental health interventions and promote treatment in the community.

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Substance use disorders (SUD) affect differentially women and men. Although the prevalence has been reported higher in men, those women with addictive disorders present a more vulnerable profile and are less likely to enter treatment than men. The aim of this presentation is to present an overview of how gonadal hormones may influence in response to substances, clinical differences in the addictive disorders and implications in treatment response.Ovarian steroid hormones (estrogen, progesterone), the metabolites of progesterone, and negative allosteric modulators of the gamma-aminobutyric acid A (GABA-A) receptor, such as dehydroepiandrostenedione (DHEA) may influence the behavioral effects of drugs.

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Towards a personalized response to public health issues of PIU in women, understanding female profiles of problematic internet users and their underlying psychosocial characteristics is a crucial preliminary step.

Mobile Problematic Internet Use (PIU) is most likely present in young females, with heavy pattern of use being specifically associated to some online activities including communication, buying, video gaming and video watching.

The present talk will introduce epidemiological data on female with PIU in Europe, and will afterwards describe clinical assessment and treatment of a young female suffering from mobile PIU.

Assessment found heavy social networks (SNs) use, being mainly explained by dysfunctional coping to low self-esteem and traumatic sexual experiences in her biography.

Psychotherapy consisted in CBT for excessive time devoted to SNs, relocating life-priorities and cognitive remediation targeting self-esteem, self-compassion, and assertiveness.

Behind quantitative data on PIU in female, each patient has specific needs for treatment that should be identified in other to address PIU.

Care process model used at ReConnecte since a decade allows for a comprehensive assessment of each PIU.

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Depression and Dementia Professor Allan H Young, Head of Academic Psychiatry, Maudsley Hospital and King’s College London UK. allan.young@kcl.ac.uk

Mood Disorders are common, encompass cognitive impairments and occur in later life including first onset after the age of 50 years of age. There is a considerable overlap between depression and dementia. The relationship between depression and dementia will be reviewed and the implications for diagnosis and treatment will be discussed. Novel agents targeting alternative neurotransmitter pathways and inflammatory processes are promising potential treatment options. Neurostimulation treatments play a role with ECT at present having the best utility for late onset depression.

Key words: depression, dementia, antidepressants; pharmacotherapy

A. Young Grant / Research support from: Principal Investigator in the Restore-Life VNS registry study funded by LivaNova. Principal Investigator on ESKETINTRD3004: “An Open-label, Long-term, Safety and Efficacy Study of Intranasal Esketamine in Treatment-resistant Depression.” Principal Investigator on “The Effects of Psilocybin on Cognitive Function in Healthy Participants” Principal Investigator on “The Safety and Efficacy of Psilocybin in Participants with Treatment-Resistant Depression (P-TRD)” Principal Investigator on “A Double-Blind, Randomized, Parallel-Group Study with Quetiapine Extended Release as Comparator to Evaluate the Efficacy and Safety of Seltorexant 20 mg as Adjunctive Therapy to Antidepressants in Adult and Elderly Patients with Major Depressive Disorder with Insomnia Symptoms Who Have Responded Inadequately to Antidepressant Therapy.” (Janssen) Principal Investigator on “ An Open-label, Long-term, Safety and Efficacy Study of Aticaprant as Adjunctive Therapy in Adult and Elderly Participants with Major Depressive Disorder (MDD).” (Janssen) Principal Investigator on “A Randomized, Double-blind, Multicentre, Parallel-group, Placebo-controlled Study to Evaluate the Efficacy, Safety, and Tolerability of Aticaprant 10 mg as Adjunctive Therapy in Adult Participants with Major Depressive Disorder (MDD) with Moderate-to-severe Anhedonia and Inadequate Response to Current Antidepressant Therapy.” Principal Investigator on “ A Study of Disease Characteristics and Real-life Standard of Care Effectiveness in Patients with Major Depressive Disorder (MDD) With Anhedonia and Inadequate Response to Current Antidepressant Therapy Including an SSRI or SNR.” (Janssen) UK Chief Investigator for Compass; COMP006 & COMP007 studies UK Chief Investigator for Novartis MDD study MIJ821A12201, Consultant of: Paid lectures and advisory boards for the following companies with drugs used in affective and related disorders: Flow Neuroscience, Novartis, Roche, Janssen, Takeda, Noema pharma, Compass, Astrazenaca, Boehringer Ingelheim, Eli Lilly, LivaNova, Lundbeck, Sunovion, Servier, Livanova, Janssen, Allegan, Bionomics, Sumitomo Dainippon Pharma, Sage, Neurocentrx

The presentation will focus on long-term weight changes in patients with major depressive disorder who use antidepressants. Research studying weight change over periods of more than 12 months is scarce and the effects of depressive episodes and antidepressants on weight changes have rarely been assessed simultaneously. Using data of a prospective population-based CoLaus|PsyCoLaus study, data on the associations of antidepressant use prior to baseline and during a 5.5-year follow-up with changes in adiposity markers and multiple adjustments including for the effects of depressive episodes will be presented. The cohort included 2479 randomly selected 35 to 66 year-old white residents (mean age 49.9 years, 53.3% women) of an urban area who accepted the physical and psychiatric evaluations at baseline and follow-up (76.8% participation at the follow-up). Diagnostic information on mental disorders, treatment use including psychotropic drugs was elicited using a semi-structured interview. Independently of the effect of antidepressants used during the follow-up and the effects of depressive episodes, the number of any antidepressant compounds used prior to baseline was associated with lower increase of body mass index (BMI), whereas the use of antidepressants during the follow-up was associated with steeper increase in BMI and waist circumference. Within AD classes, the use of tricyclic AD (TCA) and selective serotonin reuptake inhibitor (SSRI) prior to baseline was associated with lower increase, the use of SSRI during follow-up was associated with steeper increases in BMI. Similarly, the use of SSRI prior to baseline was associated with lower increase, the use of TCA and SSRI during the follow-up was associated with steeper increase in waist circumference. Finally, the use of SSRI during follow-up was also associated with steeper increase in fat mass. The findings support unfavorable obesogenic effects of sustained treatment not only with TCAs but also with SSRIs, suggesting that the benefit of long-term administration of these AD classes should be carefully weighed against the potential risk of weight gain.

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Gender identity may be experienced within a broad spectrum beyond the binary understanding of sex concerning genital characteristics. In people with gender identities not congruent with the gender culturally associated with the sex assigned at birth, distress related to biopsychosocial correlates of this condition may arise. In current diagnostic systems, this is considered within the framework of “Gender Incongruence” (ICD-11) and “Gender Dysphoria” (DSM 5). Although this diversity is known to be present throughout the ages, the terms related to gender identity were introduced to medical literature a hundred years ago. They were popularized with the advances in medical procedures that assist individuals in acquiring physical features aligning with their gender identity and expression. There has been an increase in research interest with increasing numbers in medical centers working on gender-affirmative medical procedures. Starting from the 1970s, international organizations prepared guidelines on the standards of care for trans and gender diverse (TGD) individuals. Despite all the progress in the gender-affirming medical care provided to TGD individuals and the changes in the legal recognition of gender, health inequalities persist globally. The discrepancy in mental and physical health conditions has long been shown to be associated with “minority stress.” The minority stress perspective suggests that distal and proximal chronic stressors arising from society are associated with adverse health outcomes for TGD individuals. Resilience against these stressors is more robust with better coping styles and social support. Lately, structural stigma and discrimination have been shown to be an important source of inequality. Therefore, much more progress is still required with respect to societal inequalities, human rights, and structural transphobia for the improvements in medical care to impact the global health condition of TGD people. However, lately, there have been attempts to restrict TGD individuals’ access to medical care and their legal rights, even if they were not close to the level they ought to be. This backlash mostly sits on the discussion on the management of TGD adolescents and children. Models of care for these age groups have been developed for decades, and despite evidence of the protective and beneficial effects on health and development, in many countries, there are attempts to block their access to medical care. Growing debate on TGD care turned into a political combat, where scientific evidence and human rights perspectives are often ignored. These tendencies present a strong challenge for public health and the professional identity and practice of healthcare professionals.

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Introduction: LGBTQ (lesbian, gay, bisexual, transgender, queer) people often do not seek health care and do not identify as LGBTQ people because of fear of judgment, stereotyping, and discrimination by health professionals. All of this is a particularly worrying phenomenon, because various mental difficulties, risky behaviors, and certain types of somatic and psychosomatic diseases may appear in a higher proportion among them.

Attitudes related to LGBTQ people were examined in several areas in Hungary. Most of our data comes from psychologists, however, a comprehensive examination of health professionals’ attitudes towards LGBTQ people has not yet been carried out.

In a cross-sectional online survey, we ask healthcare professionals (medical doctors, nurses, other graduate healthcare professionals and medical university students) to fill out our questionnaire. The participants complete the Modern Homonegativity Scale and the Lesbian, Gay, Bisexual and Transgender Clinical Skills Development Scale.

We assume that the majority of Hungarian healthcare professionals have a neutral or positive attitude towards LGBTQ people, but they struggle with a significant lack of affirmative skills. We will present our results in detail in the presentation of the symposium.

There is an urgent need to provide the appropriate affirmative knowledge material to Hungarian healthcare workers.

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Eating disorders are severe mental disorders with a high mortality rate - suicidality - and a high incidence in adolescence and early adulthood, especially in women. The course of these disorders is uncertain and treatment outcomes are limited, with successful outcomes in 50-75% of cases. For bulimia nervosa (BN) and binge eating disorder (BED), several factors, such as duration of the disorder, eating and general psychopathology, dysfunctional personality traits and cognitive impairment, have been found to be associated with treatment adherence and response. In anorexia nervosa (AN) and atypical ED (OSFED), treatment response is poorer, with higher dropout rates and longer duration and chronicity. In this presentation, we will describe recent prospective observational studies in large samples of EDs analysing clinical, personality and cognitive predictors of treatment response in eating disorders, as well as potential associated neurobiomarkers. Optimisation of health care resources and transitions, as well as early and effective personalised treatments, can change the trajectory of EDs.

F. Fernandez-Aranda Grant / Research support from: We thank CERCA Programme/Generalitat de Catalunya for institutional support. We also want to thank the Institut d’Investigació Biomèdica de Bellvitge (IDIBELL) and ISCIII (CIBERobn is its initiative). This research was supported by grants from Instituto de Salud Carlos III (ISCIII) (FIS PI20/00132) and co-funded by FEDER funds/European Regional Development Fund (ERDF), a way to build Europe.Additional support was received from the Delegación del Gobierno para el Plan Nacional sobre Drogas (2021I031) and Ministerio de Ciencia e Innovación (grant PID2021-124887OB-I00), but also AGAUR-Generalitat de Catalunya (2021-SGR-00824), European Union’s Horizon 2020 research and innovation program under Grant agreement no. 847879 (PRIME/H2020, Prevention and Remediation of Insulin Multimorbidity in Europe) and the European Union’s Horizon Europe research and innovation program under grant agreement No 101080219 (eprObes)., Consultant of: FFA received consultancy and speakers honoraria from Novo Nordisk.

Eating disorders (EDs) have long been thought to be conditions that only or mainly affect women, especially young, affluent, skinny girls and women in Western cultures. Mostly over the last decade, we have come to realize that EDs may affect individuals of all genders, ages, sexual orientations, ethnic, and socio-economic backgrounds. This, in turn, has implications for ED presentation and assessment, and the necessity for adjustments in the provided care according to diverse treatment needs. Here, we present and discuss current advances in ED-related research in underrepresented groups as well as the need to further incorporate diversity aspects in clinical care and research within the ED realm.

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Depression is a complex and highly heterogeneous disorder with an omnigenic and multifactorial background. This diversity is obvious not only in its symptomatic manifestation but also in its neurobiological underpinnings which is one potential factor contributing to the high observed rate of treatment resistance. Thus, subtyping depressions, understanding their distinct neurobiological and genetic background, and potentially developing biomarkers aiding their differential diagnosis may bring us one step closer to more effective treatment. The present talk will overview the different etiological factors contributing to the emergence of depression along an endogenous-reactive continuum, the contributory roles of different types of stress, different genes involved in distinct processes, and the potential consequences of conceptualising, diagnosing and treating depressions developing in the context or independently of current stress.

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Is bipolar mixed depression associated with a good response to psychotropic augmentation? Zoltán Rihmer Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest and at the National Institute of Mental Helath, Neurology and Neurosurgery, Budapest, Hungary.

Suboptimal response to antidepressant pharmacotherapy (nonresponse or partial response but no remisson) is the most challenging issue in the treatment of depressive disorders. Open and controlled clinical studies show that augmentation of the given antidepressant with lithium, atypical antipsychotics, antiepileptics and thyroid hormones are effective in 30-40% in such cases.

To explore the possiblity wether bipolar mixed depression is the ideal subject of good response to psychotroic augmentation.

Literature review.

Studies consistently indicate that in contrast to unipolar MDE (=MDD) the rate of antidepressant-resistant depression is higher not only in bipolar I and II depression but also in MDE with subthreshold bipolarity (bipolar mixed depression). However, lithium, atypical antipsychotic and antiepileptic (but not thyroid) augmentation works much better in bipolar depression and in unipolar MDE with subthreshold bipolarity (mixed depression) tjan in unipolar MDE without subthreshold bipolar features. In addition to this, almost all clinical predictors of good response to lithium/atypical antipsychotics/antiepileptics are classical bipolar markers (familial bipolarity, eraly onset, intradepressive hypomanic symptoms, agitation, cyclothymic tempermanent, shorter episodes, more than three depressive episodes, and suicidality).

Considering that lithium, atyipcal antipsychotics and antiepileptics, but not thyroid stimulating drugs have more and less antimanic effect, these results suggst that tretating intradecpressive hypomanic symptoms in bipolar mixed depression is a new (if not the only) explanation among the several previously proposed mechanisms of action of successful psychotropic augmentation of antidepressants in patients with MDE.

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Introduction. Military conflicts are ubiquitous. There are many combat veterans around the world. The combat environment is characterized by violence, physical strains, separation from loved ones, and other hardships. Mood disorders and suicidality in combat veterans are a large and important issue.

To discuss the pathophysiology and prevention of suicidal behavior in combat veterans with mood disorders

A review of the literature on suicidal behavior in combat veterans with mood disorders including own publications.

Combat deployment may lead to multiple emotional, cognitive, psychosomatic symptoms, mood disorders, suicidal ideation and behavior. Pre-deployment, deployment and post-deployment adversities may increase risk of mood disorders and suicide in combat veterans. The act of killing in combat is a stressor which may raise suicide risk. Combat-related injuries are associated with significantly increased depression and suicide risk. Post-deployment difficulties of reintegrating into civilian life may lead to depression and suicidality. Studies suggest that suicidal behavior in combat veterans may have a neurobiological basis. Prevention of mood disorders and suicide among combat veterans should include pre-deployment screening to exclude individuals with psychiatric disorders; psychological support and prevention of harassment and/or abuse during deployment; psychosocial support after deployment; diagnosing and treating psychiatric and medical disorders including neurological disorders; frequent depression and suicide screening; education of mental and non-mental health clinicians, war veterans, their families and friends regarding signs/symptoms of mood disorders and suicidality; and restriction of access to lethal means.

Combat veterans are a unique population. They are frequently exposed to psychological, physical, and biological factors which are unusual for civilians or non-combat military veterans. We need to study the specific psychobiology of combat veterans to understand how to develop effective depression and suicide prevention interventions for this population.

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Antipsychotics are among the substances that are very frequently used for elderly people and dementia patients in particular. This is known from studies both in outpatient care and in nursing homes. They are often part of a polypharmacy. This group of substances is discussed in the context of the increased risk of falls, increased mortality and also - as here - in the context of the development of delirium.

On the other hand, antipsychotics are drugs for the treatment of delirium, whereby the question of their significance in modern delirium treatment is being asked anew. In the past, butyrophenones in particular have played a role here, partly because of their variable form of administration and also because of their low cardiac impact.

In the context of delirium prevention, the aim is to reduce the number of drugs on the one hand and the anticholinergic load of the drugs on the other. Algorithms and recommendations exist for this.

In the treatment of delirium, the focus is rightly placed primarily on non-pharmacological management. The use of antipsychotics should be reserved for severe states of agitation or agitation in the context of delirium. In other cases, careful judgement is required.

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Elderly patients treated with antipsychotics are often prescribed multiple medications simultaneously (polypharmacy), leading to an increased risk of various medication-related problems, including irrational polypharmacy, drug-drug interactions, and potentially inappropriate medications (PIMs). Polypharmacy may be rational with clear indications and benefits, but it becomes irrational when better alternatives are available. This irrational polypharmacy is associated with poorer clinical and economic outcomes, including a higher mortality rate. Antipsychotic polypharmacy in elderly patients with schizophrenia is not well-studied and, therefore, is not generally recommended. Long-term antipsychotic use in patients with dementia has also been linked to a higher mortality rate. PIMs, representing a greater risk than benefit, are prevalent in mental health institutions at all healthcare levels, with a prevalence ranging from 40% to 60%. Antipsychotics, along with benzodiazepines, are among the most commonly included in PIMs and polypharmacy in these institutions. Moreover, antipsychotics are frequently implicated in potential severe drug-drug interactions in elderly patients with mental disorders, particularly with antibiotics and antiarrhythmics.

Unfortunately, the existing treatment guidelines and meta-analyses mostly do not cover these aspects, which represent a gap between the ‘real clinical’ pharmacology and treatment guidelines. The speaker will summarize the medication-related problems in this population and present practical recommendations for daily clinical practice.

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Intellectual disability (according to the DSM-5) or intellectual developmental disorder (according to the ICD-11) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social and practical domains. The term learning disability (LD) is also used, although this term shows more specifically deficits in the domain of learning. The term learning difficulties is often used for specific or generalized intellectual impairment that does not meet all of the criteria of LD.

The prevalence of learning disability in prisoners is about 10%. Up to 60% of male prisoners have learning difficulties. Prevalence rates for offending behaviour in patients with LD is higher than in the general population and show a large range, from 2-40%.

The main explanatory factor underlying the link between intelligence and offending is the lack of ability to manipulate abstract concepts. Poor academic performance, common in persons with LD, is also linked to offending.

With regard to sexual offending, some persons with LD may not have learnt the rules that define acceptable and unacceptable behaviour. Sexual offences may amount to inappropriate, impulsive expressions of emotion rather than premediated violent acts. Violent behaviour in the LD population may be due to frustration, impulsivity or poor problem solving skills. There is no significant difference in the frequency of violent or property offences between individuals with LD and those without. However, sex offences and fire-setting are frequently seen in individuals with LD.

Persons with LD are vulnerable suspects and may also be disadvantaged by the criminal justice system because of a lack of appropriate support and legal representation from early stages in the process.

In this introductory paper these themes will be addressed.

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The very brief presentation will describe the initial approach to the psychiatric assessment of the case presented including the issue of fitness to participate in court proceedings. The use of screening tools at court to identify people with intellectual disabilities will be highlighted along with what support can be provided for vulnerable offenders in attending court. The potential disposal options for the court such as prison or hospital or community will be outlined. Variation in practice across Eurpean countries needs further discussion to ensure the rights of defendants with intellectual disabilities are safeguarded during their participation in court proceedings

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Legal frameworks and the challenges for treatment and rehabilitation of offenders with intellectual disabilities Speaker: Farzaneh Saeedzadeh Sardahaee, MD, PhD, Consultant psychiatrist St. Olav University Hospital, Trondheim, Norway

Lack of timely diagnostic and treatment for mild intellectual disability amongst offenders presents special challenges to clinicians and prison system alike. On the one hand, appropriate treatment for their psychiatric symptoms may not be implemented as they can be mislabeled primarily as behavioral issues. Different approaches to such perceived behavioral issues within judiciary (or prison) system and health care system is a potential conflict area. On the other hand, treatment and rehabilitation of offenders with intellectual disability require both resources and expertise that may not be readily available in prison systems, pre- or past sentencing. Furthermore, the scope of such challenges varies greatly based on different legal frameworks for sentencing offenders with intellectual disability within Europe.

In the first section an overview of Norwegian legal framework for offenders with intellectual disability is briefly presented. Then using the example of a young female offender with mild intellectual disability, drug dependence and multiple psychiatric morbidities, the speaker examines complexities of dual diagnoses, inter-disciplinary and multiagency cooperation follow-up and challenges faced in the recovery process. A brief introduction to the current Norwegian follow-up system for offenders with intellectual disability is discussed before examining recent changes in legal framework for sentencing offenders with intellectual disability in Norway, and its ramifications, as well as potential benefits for treatment and future rehabilitation of offenders. Finally, the speaker reflects on points for further improvement, especially considering the multi-agency nature of treatment and rehabilitation of offenders with intellectual disability.

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Hector, 44 years, with mild Intellectual Disability and impulse control disorder, committed serious sexual offences against two children of his partner. Considered “socially dangerous”, he was put in prison, then with a deferment of the enforcement of the prison sentence in the forms of home detention he was hospitalized in a psychiatric facility due to his depressive condition. Upon entering the Community, he presented a deflected mood as a reaction to the discomfort from the custodial experience, which was not cognitively integrated. Both psychotropic and rehabilitation treatments started. He has been involved in a gardening activity, too. After a first period of high degree of denial of the facts and a defensive mode marked by stolidity and fatuity, revealing his poor cognitive resources, during the psychiatric sessions he became even more conscious of his crime and the suffering of the victims. Services/pathways available for offenders with ID and psychiatric disorders will be presented.

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