Bipolar II depression is characterized by the occurrence of depressive episodes in alternation with hypomanic, but not full blown manic episodes. Epidemiological studies show that it is situated on a continuum with bipolar I disorder on one side and unipolar major depressive disorder on the other side, with unclear boundaries. Various authors concluded that the treatment of bipolar II depression is unclear, poorly evidence based and thus controversial: should antidepressants be avoided as monotherapy and what is the place of lithium, anticonvulsants and atypical antipsychotics? A review of the literature shows that the risk of switch to mania/hypomania during acute treatment with antidepressants as monotherapy is smaller than in patients with bipolar I depression and that it concerns almost exclusively hypomanic switches. Therefore, there is no good evidence to avoid antidepressants as monotherapy. However, there is also no good evidence for their efficacy. Available data from a few randomized controlled trials with other drugs suggest also a place for anticonvulsants, especially lamotrigine, and for quetiapine. This is also reflected in some, but not all guidelines.

Pathological gambling and multiuser internet gaming is characterized by recurrent maladaptive behaviour that resembles substance-related addictions. Some studies suggest comparable alterations in mesolimbic reward circuitry which characterize drug dependence and pathological gambling.

In a recent study we observed that excessive computer game players exhibit an attentional bias toward game-related as well as positive stimuli. Among the game players, this effect was accompanied by an increased cerebral activity in midbrain, orbitofrontal cortex, medial prefrontal cortex (mPFC) and anterior cingulate gyrus. For cue-reactivity, increased activation was found in lingual gyrus, hippocampus and inferior frontal gyrus (IFG). Connectivity analyses revealed a strengthened coupling between right IFG and mPFC in excessive game players.

Further studies from our group focused on anticipation and processing of monetary gain or loss. First analyses of the functional data, controlled for age and brain volume, revealed increased activation in the ventral striatum in pathological gamblers compared to alcohol-dependent patients during anticipation and processing of losses. Further, results from a VBM study point to an increased local gray matter volume in subjects with pathological gambling compared to healthy controls in ventral striatum and ventrolateral prefrontal cortex, both brain areas involved in reward-related decision making. The observed volumetric and functional changes in pathological gambling and multiuser internet gaming may reflect salience attribution to gambling-related stimuli and outcomes and help to explain why subjects decisions making is biased toward gambling-related activities. The question whether these neurobiological changes are a disposition or a consequence of excessive gambling has yet to be clarified.

The pharmacologically treatment in approaching gambling seems to have limited effect; better results are obtained using psychotherapy alone or in association with medication. Different psychotherapeutically approaches have been described as efficient.

Innovative concepts for outpatient consultation and mental health care service for immigrants work in cooperation with other services to guarantee an adequate cultural competent assessment and treatment plan. Special attention is given to key factors of influence on diagnostics in and therapeutic strategies for immigrants. In many health care services immigrants fall outside the existing health and social services, particularly asylum seekers and undocumented immigrants. Clinicians, policy makers and service providers should be aware of specific needs of immigrants. Cultural competence training should be everyone's business and every institution should be intercultural open. Culture broker should be employed where indicated. The WPA guidance on mental health and mental health care in immigrants should be taken into consideration. Concerning this guidance in this talk best clinical practice of innovative health care services for immigrants from Berlin, Germany, will be presented and discussed.

The appeal of the Internet rests on many factors, including intense intimacy, disinhibition, loss of boundaries, timelessness, being in control, experimentation with identity, interactivity and play, and the ease of forming supportive online communities, which may be transferred to real life. For all the pleasures the Internet may offer, recent studies suggest that some types of excessive usage may lead to symptoms associated with addiction.

Internet addiction appears to be emerging as mental health problem for society. It is associated with psychopathology, including mood and anxiety disorders, ADHD, depression, schizophrenia, OCD, and social phobia/anxiety. Thus, Internet addiction has the potential to be a severe mental health problem, suggesting that further scientific investigation is necessary.

Nevertheless, a recently published meta-study suggests that the abundance of diverse terminology and measurement currently leaves the scientific community in a conceptual crisis about the factual prevalence of and negative consequences associated with Internet addiction. Specifically, scholars claim that Internet addiction is too heterogeneous as a concept, so that it necessitates a reconceptualization with regards to specific Internet applications. Recent reviews suggest that Internet gaming addiction, Internet gambling addiction, and social networking site addiction appear as valid and discrete phenomena worthy of separate investigation.

The purpose of this talk is to

1. (i) Highlight the different conceptualizations of Internet addiction currently used,

2. (ii) And to propose a nosological framework which pays respect to the diversity of phenomena that that are presently included in the concept of Internet addiction.

In the daily clinic, patients with internet addiction show psychopathological patterns (tolerance, withdrawal, interpersonal conflict, mood modification, relapse) comparable to substance-related disorders. The outstanding psychological symptom which is reported by patients suffering from Internet addiction is the irresistibly urge to ‘be online’, which may cause psychobiological harm for the user and can lead to an addictive behavior. Also in the recent research literature it is assumed that Internet addiction as a subtype of behavioral addictions has commonalities in etiology, comorbidity and physiology with classical substance use disorders. Several representative epidemiological studies from different European countries revealed prevalence-rates of internet addiction in the general population ranging from 0.5 to 1 per cent. Taken into account that internet addiction is a common health problem, a special short term treatment program for Internet addiction, based on cognitive behavior-therapy (STICA) was developed. A pilot analysis of this manualized short -term treatment was performed in an open trial of the Grüsser-Sinopoli outpatient clinic for behavioral addiction. In this trial about 73 per cent of the treatment-seeking patients completed STICA regularly - whereas 27% of the patients terminated treatment prematurely and were considered as drop-outs. First outcomes concerning the change of concomitant assessed psychological measures will be presented.

Pathological media use (PMU) seems to emerge as a major mental health problem in children and adolescents.

Although not yet broadly recognised by addiction research, there exist clinical and neurobiological implications, that PMU resembles classical adolescent addiction patterns such as with marihuana or alcohol.

As part of either the dependency or of the out-patient psychotherapy programs in a large mental hospital covering inner-city Berlin a diagnostic and treatment system was established in April 2009 for internet addicted youth.

From 4–9/2009 we could administer 27 severe male “PMU”-cases with all signs of clinical dependency, both neuropsychological and somatic, including cardiovascular problems, severe craving and pseudo-hallucinations. 12 patients showed severe identity conflicts apart from their psychiatric disorders and chronic family conflicts.

There seems to be a small but severely ill subgroup of multiple media users that develop social isolation, craving and other features of addiction.

Using the clinical diagnosis PMU offering an out-patient approach must consider severe chronic intrapsychic conflict as well as psychiatric disorders.

Obviously intense research as well in epidemiology as in clinical treatment is needed in this worldwide broadening area.

Excessive behaviors, especially among adolescents, have become a matter of growing concern und are discussed as non-substance-related addiction disorders. Epidemiological surveys show that especially computer game addiction and pathological gambling are to be regarded as widespread in minors, according to prevalence estimations up to 2.1% for pathological gambling and 2.7% for computer game addiction. Clinically many studies supported that both forms of behavioural addictions are related to remarkable psychosocial and psychopathological strain, like depressive symptoms and anxiety. However, research on disorder-specific risk factors still is limited.

To address this uncertainty, a survey among a representative sample of 3967 German adolescents, aged between 12 and 18 years was conducted. Prevalence rates of both, pathological gambling and computer game addiction were calculated and supposed predisposing factors like affectivity, Violence Approving Norms, social insecurity, and self-efficacy were assessed.Prevalence for pathological gambling was 2.2% and 3.4% for addictive computer gaming. Further analyses show that there are rather similarities than discrepancies between both clinical groups, especially concerning heightened negative affectivity and social insecurity. However, it turned out that pathological gamblers revealed higher rates in Violent Approving norms and addicted computer gamers showed significantly diminished self-efficacy.The results point to similar etiopathological pathways, like affect-dysregulation for both investigated behavioural addictions in minors. Notwithstanding, some specific factors turned out to be primarily related to gambling resp. gaming.

Vulnerability to suicidal behavior (SB) is mediated by an underlying genetic predisposition interacting with environmental and probable epigenetic factors throughout the lifespan to modify the function of neuronal circuits, thus rendering an individual more likely to engage in a suicidal act. Recent studies have characterized SB using an endophenotype strategy, which aims to identify quantitative measures reflecting these dysfunctions. In addition to aiding in the functional characterization of susceptibility genes, endophenotypic research strategies may have a wider impact in determining vulnerability to SB, as well as the translation of human findings to animal models. Endophenotypes of SB include impulsive/aggression, serotonergic dysfunction, hyperactivity of the stress axis, low cholesterol levels. We also propose that neurocognitive abnormalities related to the dysfunction of cerebral region would be responsible of progression toward the suicidal crisis (apparition of negative emotions - emotional presuicidal states and suicidal ideas - suicidal act). Specific endophenotypes may represent new targets for successful suicide prevention and treatments. Indeed, restricting suicide prevention to the treatment of the related psychiatric disorder is not sufficient. Endophenotypes-based psychotherapies may be developed, by targeting decision-making impairment, sensitivity to social rejection or decreased attention to social support, characterizing the suicidal vulnerability. The orbitofrontal cortex being a key region in the suicidal brain, we propose that modifying its activity with rTMS may reduce the suicidal vulnerability by correcting the emotional dysregulation and the decision-making impairment. In our opinion, it is time to investigate the possibility of innovative anti-suicide treatments by targeting endophenotypes.

“Children are not simply small adults”, states the UEMS CAPP training Logbook.

Nevertheless, the core identity of Child and Adolescent Psychiatry (CAP) has been at stake for the last few decades in Europe. CAP is now an independent specialty in 23 countries and a subspecialty in 8 countries, but 5 countries do not have any structured CAP training.

Training differences are marked even within the EU member countries, and are not only in terms of content of training programs, but are also relevant to duration, trainee selection, and graduation procedures. More importantly, while almost half of the countries have integrated structured psychotherapy training as a full component of CAP training, the other half has not.

Within the UEMS, CAP psychiatrists used to be represented in the section and board of Psychiatry until recently: it is only in 1994 that UEMS established the European Child and Adolescent Psychiatry/Psychotherapy (CAPP) Section and Board.

The idea behind this initiative to split among UEMS was to promote high standards of mental health care for children across Europe, both directly and indirectly, by establishing standards and improving the quality of postgraduate CAP training, with a particular focus on training in psychotherapy. The UEMS CAP Board published a Training Logbook, which has already proven to be important in helping new EU member countries to develop their own training program in CAP.

We will discuss the discrepancies and similarities in CAP training programs across Europe, and the challenges that have arisen through harmonization processes.

This presentation will cover some of the findings of the BoSS International survey of burnout and related factors amongst thousands of psychiatry trainees conducted in over 30 countries internationally.

Burnout is a significant problem amongst doctors generally, however there is very little international comparative data available, and almost none on trainees.

The preliminary study findings on burnout in trainees interested in child and adolescent psychiatry will be presented, along with some data on correlations with working circumstances, bullying, stalking, and relevant factors such as related personality traits.

Finally, some protective factors that may be useful for trainees will be discussed.

EFPT - The European Federation of Psychiatric Trainees is an independent federation of psychiatric trainees associations and its function is to provide a forum in which trainees can learn about the diversity of the current training of psychiatrists in Europe.

EFPT consists of several working groups that focus on supporting different fields (e.g. psychotherapy, child and adolescent psychiatry etc) and carry out various projects. The aim of CAP working group is firstly to represent CAP trainees and develop common recommendations regarding training while furthering links with organisations such as UEMS. In recent years the group has also recognised the need to collect information in order to assess the quality level of training in european countries, to recognise differences and build upon positives. In 2010–2011 this focused on training standards around Europe. In 2011–2012 we focus on:

1. A. The field of psychotherapy. The CAP group recognises that family relationships play a major role in the formation of a child's personality. The survey is being conducted in conjunction with the Psychotherapy WG within EFPT; thus training in this area in both adult psychiatry and CAP will be compared. Initial results will be presented at this symposium.

2. B. We believe that awareness of mental illness in the childhood should be an important part of the education in medical faculties. Therefore, we are keen to ascertain what placement opportunities in CAP are currently offered to medical students around Europe. Gathering information on this isT is our second aim for the next year.

We discuss the possibility of shared care between primary care and secondary care, first of all from the literature, then from the experience of having set up such a service in Luton Bedfordshire, using a group of community mental health nurses who were members of both the Psychiatrist's and the General Practitioner's teams.

In particular we focus on the treatment of Depression. We discuss the advantages and the acceptability of such services, and look to the future with the possibility of telemedicine making consultation -liason between primary and secondary care more easy to organise.