Introduction: Digital mental health services have been a part of routine care at a few locations worldwide since almost 15 years, most often in the form of Internet-based Cognitive Behavioural Therapy (ICBT) with scheduled weekly therapist-guidance. Personalization in the form of individual tailoring of treatment content is promising in ICBT. Digital Self-care, interventions constructed to be self-guided, would need to be constructed carefully to achieve equal levels of adherence and symptom reductions compared to therapist-guided interventions, especially when including individually tailored content. Objectives: To construct an individually tailored self-care intervention including a technical solution, acting as a proof of concept that self-guided digital interventions for mental health can be administered in a safe, effective, personalized and cost-effective way. Methods: In step I, a new digital platform is created based on the experience from previous successful implementations of ICBT together with experts on user experience. A series of digital mental health tools based on ICBT are tested for safety, usability and credibility. In step II these tools are combined into individually tailored package interventions for different conditions and optimized for greater efficiency. In step III these optimized interventions would be compared to their counterpart therapist-guided interventions in randomized trials. Results: Preliminary results from step I will be presented, including the current development of the digital platform and feasibility data from the first three studies.

Guided self-help interventions are effective in treating symptoms of various mental disorders, including depressive, anxiety, and posttraumatic stress disorders. Research also suggests that these interventions may be effective for refugee populations. However, proportion of drop-out and non-response are substantial, especially in this highly vulnerable group of patients. Tailoring treatments to the individual patient may be an important step towards improving patient-treatment fit and may help to increase success rates. While tailoring can be easily realized in face-to-face treatments, it becomes more complex in Internet-based treatments where treatment sequences are usually defined in advance. In this talk, we will present our theoretical considerations and decisions regarding the tailoring process in a randomized-controlled comparison of transdiagnostic CBT for refugee patients in an online versus face-to-face format. The trial will include N=320 Arabic speaking patients suffering from an emotional disorder. The transdiagnostic treatment includes modules for symptoms of depression, anxiety, substance abuse, post-traumatic stress, aggression, and suicidal ideation. Modules are tailored to the specific patient. We will discuss who or what should inform the tailoring decision (patient, therapist, questionnaire data, diagnostic interview) and when tailoring decisions should be made (prior and/or early and/or later in treatment). We will present options of how tailoring decisions can be standardized and be kept comparable in different treatment formats. We will present our first experiences with tailoring treatment modules to severely impaired and highly comorbid patients.

Introduction: Adaptive Treatment Strategies warns therapists of patients at risk of treatment failure to prompt an adaption of the intervention. Internet-delivered Cognitive Behavioural Therapy (ICBT) collects a wide range of data before and during treatment and can quickly be adapted by adjusting the level of therapist support. Objectives: To evaluate how accurate machine learning algorithms can predict a single patient’s final outcome and evaluate the opportunities for using them within an Adaptive Treatment Strategy. Methods: Over 6000 patients at the Internet Psychiatry Clinic in Stockholm receiving ICBT for major depression, panic disorder or social anxiety disorder composed a training data set for eight different machine learning methods (e.g. k-Nearest Neighbour, random forest, and multilayer perceptrons). Symptom measures, messages between therapist and patient, homework reports, and other data from baseline to treatment week four was used to predict treatment success (either 50% reduction or under clinical cut-off) for each primary symptom outcome. Results: The Balanced Accuracy for predicting failure/success always were significantly better than chance, varied between 56% and 77% and outperformed the predictive precision in a previous Adaptive Treatment Strategy trial. Predictive power increased when data from treatment weeks was cumulatively added to baseline data. Conclusions: The machine learning algorithms outperformed a predictive algorithm previously used in a successful Adaptive Treatment Strategy, even though the latter also received input from a therapist. The next steps are to visualize what factors contributes most to a specific patient’s prediction and to enhance predictive power even further by so called Ensemble Learning.

*MDD is the predominant cause of “Years of life lived with disability” and “Years of life lost because of premature death” as a consequence of the disorder per se, comorbidities (cardiovascular, diabetes) and the high suicide rate. The problem is increasing due to higher depression frequency with age and growing life-longevity. One third of patients do not respond adequately to conventional therapies and “more of the same” drugs will not solve the problem. Consequently, there exists a crucial need to develop treatments with different modes of action. *Neuropeptide Y (NPY) and neuropeptide S (NPS) have been mapped in brain of MDD and PTSD rodent models. NPY is reduced in genetic and environmental depression models and in PTSD and can be reversed by antidepressants. These findings are parallel to the decreased NPY in humans diagnosed with MDD and PTSD. *NPS found in locus caeruleus regulates anxiety and stress–related behaviors and intranasal administration is anxiolytic in rat. The intranasal effects in humans are being explored. *Based on known biology and our findings, we hypothesized that NPY could be a target for MDD and PTSD, the reasoning being analogous to insulin treatment in insulin deficient diabetes, and conducted - the first ever - double blind, placebo controlled trials of insufflated NPY in MDD and PTSD (Sayed et al 2018, Mathé et al 2020). In conclusion, intranasal NPY is opening a promising new avenue for efficient, fast acting treatment of MDD and PTSD. Support:The Swedish MRC #10414; Center Psychiatry Research-KI, The Torsten Söderbergs Stiftelse

As COVID-19 spread, many countries in the world responded swiftly in an attempt to reduce transmission. Sweden, however, took a different approach to many other nations and did not implement a nationwide lockdown, instead deciding on a more “holistic approach to public health”. The focus was on minimising transmission as much as possible, protecting those in risk groups, ensuring that the response strategies were sustainable long-term, mitigating other health concerns as a result of the response and that evidence-based methods were used as much as possible. At this stage, it is difficult to know how exactly the Swedish strategy has fared in comparison to other responses. In Sweden, there has been much debate about the strategy, particularly concerning the protection of the elderly due to unexpectedly high mortality rates in the older population as well as among residents in retirement homes. Many ethical questions remain in regard to which strategies would have been preferable.

The discussion about whether or not to focus our attention on the ‘average’ ECT-treatment technique that suits the majority of our patients or tailor the treatment to the needs of individual patients is ongoing. The question is, however, whether the available evidence permits us to to offer treatment ‘à la tête du client’. The start of a treatment course can be personalized by choosing electrodeplacement (EP) (e.g. bilateral in case of a severe or life-threatening condition, when fast improvement prevails over cognitive impact), parameter selection (e.g. a shorter pulse-width in order to avoid cognitive side-effects), and a dosing strategy. A fixed-dose will lead to overdosing in some patients (causing side-effects) and under-dosing in others (delaying/decreasing response) (1) Adjusting an ongoing treatment-technique can be based on response, side-effects or on the quality of the elicited seizure (EEG). In case of inadequate response, the clinician can decide to switch EP or to increase dose. There is no consensus as to the number of sessions after which technique should be changed. In case of intolerable side-effects, parameter selection and/or EP can be adjusted. The evidence that is available to guide these steps is limited. There is some evidence for a relation between several EEG-characteristics and outcome. Thus, in the event of an inadequate seizure, changing the anesthetic regimen, optimizing ventilation, lengthening the anesthetic-ECT time-interval or increasing the stimulus dose, can be of help. 1. Sackeim et al. Treatment of the modal patient: does one size fit nearly all? J ECT 2001;17:219-222.

We know from past meta-analyses that several clinical variables are associated with electroconvulsive therapy (ECT) outcome in major depression. In this lecture we give an update of clinical variables associated with ECT outcome and dig deeper into the fact that these variables also seem to be somehow associated with each other. We attempt to disentangle the interdependence between the clinical variables and try to distil the most important predictors of treatment success to help improve patient-treatment matching. Therefore we created a conceptual framework of interdependence between predictors capturing age, episode duration, and treatment resistance, all variables associated with ECT outcome, and the clinical symptoms of what we have called ‘core depression’, i.e., depression with psychomotor agitation, retardation, or psychotic features, or a combination of the three. We validated this model in a sample 73 patients using path analyses, with the size and direction of all direct and indirect paths being estimated using structural equation modelling. Results of these analyses were recently published and will also be disscussed at this symposium. The conceptual model could eb largely validated, the most important finding being that age was only indirectly associated with ECT outcome, meaning that age seems to be associated with ECT outcome only because more psychomotor and psychotic symptoms occur in elderly patients with a depressive disorder.

Electroconvulsive brain stimulation may represent the strongest manipulation available to study brain plasticity in humans. Brain plasticity induced by electroconvulsive brain stimulation, profoundly improves disturbed emotion and motivation in patients with depression. Electroconvulsive therapy (ECT) is a highly effective and safe treatment for psychiatric disorders like severe depression. However, there is ongoing concern about the negative impact of ECT on brain function and cognition that is, surprisingly, only seen in a part of the treated patients. After 80 years of research on ECT, virtually nothing is known about the mechanisms underlying these strong individual differences in cognitive changes induced by ECT. A first step would be to better quantify the pattern and severity of the adverse cognitive outcomes in order to better distinguish patients that suffer from adverse cognitive outcomes from those that do not or even improve. By better distinguishing of these subgroups, a second step towards understanding can be taken: to identify the factors that predict adverse cognitive outcomes. Our research aims to advance understanding of the mechanisms of cognitive plasticity and reveal the pre-treatment profiles that render a patient cognitive vulnerable or resilient.

wThe development of recovery-oriented practice in mental health has brought about a much greater prominence to the place of lived experience workers. Many aspects of indvidualised recovery-oriented care have been taken up in forensic mental health settings. However, the introduction of lived experience workers is arguably significantly more difficult when the dual vulnerabilities of forensic mental health services users are considered (Drennan & Alred, 2012). This paper will describe a multi-layered approach to the introduction of lived experience roles in a forensic in-patient unit. Roles have developed from being solely ward-based, to service-wide roles that include participation in management and service development, the creation of a Recovery College Forensic Campus, and to co-production and co-delivery of the psychological therapies programme. In addition to ‘mapping’ these developments in co-production, this paper will also describe the development of the governance structures that have been necessary to support this infrastructure. Lived experience workers require recruitment, vetting, placement, and aftercare, when they engage in the activities available. On-going mental health and risk stability cannot be assumed, and so regular formal and informal psychosocial support is required to ensure that workload pressures do not negatively impact on other service users and staff. The paper will suggest that much more attention needs to be paid to the development of organisational infrastructure to sustain and manage the growth of lived experience roles in forensic mental health settings than is currently in place.

Experienced Involvement (also called Peer Support Work, PSW) has existed in mental health care in Germany since 2005 though its implementation lags behind, compared to other countries. Due to the unique challenges of forensic-psychiatric settings, implementation of PSW in these settings is even less developed. We prepared the implementation of a peer support worker in our forensic hospital for addicted offenders in Germany in several steps: A survey amongst the 75 forensic hospitals in Germany was conducted to evaluate the prevalence of PSW in these settings. Individual interviews were conducted with directors and peer support workers of forensic clinics nation-wide to investigate their facilities’ experiences with PSW. Focus groups with several occupational groups of the clinic in Rostock addressed staffs opinions, expectations and reservations regarding peer support work. These were recorded and transcribed for thematic analysis. Results: revealed that the majority of forensic hospitals (83.6%) has no experience with peer support work. Interviews with external clinic directors revealed similar concerns and expectations among the employees as our focus groups did. Staff at the clinics expected the peer support worker to offer useful experiences and new perspectives. Concerns occurred about stability of health condition of the peer support worker, trust issues because of former criminal behavior and attitudes towards psychiatric treatment that might interfere with professional treatment negatively. Furthermore the clinic directors stressed the importance of a well prepared implementation and a good “fit” of the peer support workers background to the patients (e.g. regarding diagnosis).

‘Oh what a tangled web we weave when first we practice to deceive’. Marmion, Sir Walter Scott 1808. Conflict is unpleasant, it is aversive, we tend to avoid it. Yet inevitably tension between individuals or between individuals and society is inevitable as the wants of one collide with the purpose of the other. Most of these tensions resolved peacefully but a societal level aggression can sometimes spill out. In the hinterlands between individuals and larger groups these can play out more safely through the courts or sometimes the avoidance of conflict can be the only tactic that the individual can use. As doctors we are used to sing medical problems with patients have true disease believe they have two disease and want to get well-the standard social model of medicine. But sometimes this plays out differently there are those who may fabricate symptoms to avoid punishment or for reward: malingering. There are those who believe they have a disease but the distress is disproportionate to any possible recognised component; somatic symptom disorder. There are those whose anxiety about whether they have a disease or not is paralysing and perhaps most distressing for all of the groups who self-harm or malinger with authentic illness or disease. In this talk Dr Wise will, using case examples, look at a couple of the tools that exist to assist psychiatrists in piloting a pathway through the stormy waters of abnormal illness in litigation.

Faking symptoms is not an unusual finding in psychiatry; As a such is not a symptoms o sign of mental disorder; we could say that lying is frequent in the normal life of people. In psychiatry, in the community has been widely reported (), mainly related to legal psychiatry (getting some social benefits, avoiding legal obligations, etc). From forensic psychiatry, this topic have a special relevance as they have more serious consequences (to avoid prison, child custody, etc)(Resnick 2003, Gunn 2014). Another topic of paramount importance is that in psychiatry we have not complementary examinations (RMN, TAC, blood tests, etc) that help to discard some symptoms. Some test are used for detecting feigned symptoms as SIMS, The most important psychological episodes in prison are those related to disruptive / bizarre behaviour, suicide ideation and psychotic symptoms that create a great nuisance to Prison Governors. To get an accurate diagnosis is very important because this could have a psychiatric approach or a prison sanction. Sometimes a previous feigned symptom does not mean to have new episode with psychiatric symptomatology that should be treated. In this paper we´ll focus in the prison psychiatry (that probably include all the situations that has been describe above.) and to give some clinical tips to deal with this kind of situation in the everyday work and casualty job.

Stigma toward mental illness is considered a major public health problem, being a significant obstacle for the access to care by people with psychiatric disorders, not only the severe ones but also those improperly called “minor” disorders, as recent research demonstrates. Moreover, stigma per se causes further sufference, undermining the quality of life of those who suffer from mental disorders due to discrimination, social isolation and lack of opportunities. Thus, combating stigma is one of the main goal of mental health policies worldwide. After the 1978 Reform Act, substantial ideological and practical changes were introduced in Italy, such as, among others, the abandonement of custodial care and of the dangerousness criterion for involuntary treatments, along with the development of a nationwide system in mental health care. Notwithstanding there relevant changes and more than forty years of experience in community treatment of mental disorders and the widespread implementation of interventions oriented to social inclusion, no data about significant changes in public stigma toward mentally ill people could be registered in our country. Moreover, a quite limited number of specific anti-stigma programmes and campaigns at a national or local level were developed with a correspondently paucity of research regarding the evaluation of these interventions with specific reference to their quality and effectiveness

Stigma attached to mental disorders represent one of the main obstacles to patients’ full recovery and empowerment. In the last decades, many anti-stigma programmes have been implemented worldwide, but stigma still represents a major obstacle for people with severe mental disorders, their family members, friends and also healthcare professionals. Stigma is a complex social phenomenon, which entails a lack of knowledge, discriminating attitudes and excluding behaviours in the general population, which deserves a multi-level approach. In particular, anti-stigma strategies combining the three most common approaches, including contact, education, and organization of protest activity, are the most effective. Interventions should contain age-appropriate information and should be provided at an early age (e.g., in schools). Interdisciplinary approaches are recommended. In particular, contact strategies are important to reduce prejudice and change attitudes towards people with mental disorders and may be implemented either by video (interviews/personal testimonies), but ideally in person with affected individuals, reporting their real life experiences. In this workshop, the role of advocacy associations together with all stakeholders of mental health will be discussed in the process of fighting stigma according to a psychosocial perspective.