Emotional dysregulation (ED) is a dimensional, transdiagnostic domain that is associated with multiple categorical psychiatric diagnoses from childhood to adulthood, representing a risk for increased problems in affect, behavior, and cognition [1]. Traditionally, the nature of ED trait has been studied with top down approaches: quantitative evaluation of ED is possible through “Dysregulation Profile” scoring, which is measured through composite scales of the “Achenbach System of Empirically Based Assessment” (ASEBA) [2] questionnaires. Dysregulation profile is characterized by severe anxiety and affective symptoms, impulsive and/or aggressive behaviours and metacognitive difficulties. More recently, different researchers also applied bottom up approaches to evaluate the presence of ED in both general population and clinically referred samples [3]. Also in these cases, the results showed that ED is a trait, stable through time and across different cultures and societies, associated with higher presence of psychiatric diagnosis. It is important to note that these non-traditional statistical approaches highlighted that, in adulthood, ED is characterized by elevated scores in both externalizing and internalizing areas. In this contribution, the research aimed at disentangling the etiology of ED, which is crucial to treat and prevent worst evolution associated with this trait, will be revised. Many efforts have been done to understand the complex interaction between genetic and environmental risk factors which predispose patients to develop and maintain ED. [1] Aitken, et al. (2019). JAD, 253, 87-95. [2] Achenbach & Rescorla (2001). Manual for the ASEBA school-age forms and profiles. [3] Bianchi, et al (2017). ECAP, 26(5), 549-557.

While first gene-drug pairs have emerged to be clinically actionable in the treatment of major depressive disorders (MDD) (e.g., CYP2D6 and TCAs/SSRIs), genomic studies have not yet been successful in identifying replicable and valid biomarkers of pharmacological treatment outcome. While some trials suggest that candidates such as CYP2D6, CYP2C19, CYP1A2, SLC6A4 and HTR2A polymorphisms may improve the prediction of response/remission, these results should be interpreted cautiously and required confirmation in larger samples. This presentation will cover state of the art of pharmacogenomics for MDD as well as the emerging field of pharmacotranscriptomics and functional genomics analyses in MDD. Specifically, pharmacotranscriptomics in combination with genomics may be a promising avenue in overcoming some of the current limitations in treatment response prediction research. More recently, the combined genetic effect of polygenic risk scores has shown promising results in predicting treatment response. Importantly, adequately large and well phenotyped clinical trials are required to be conducted with pharmacogenomics/-transcriptomics prospectively in mind.

Several data indicate that the success of pharmacological treatment in major depressive disorder (MDD) is still unsatisfactory. The determination of the optimal treatment generally requires multiple trials with different treatments, with the sobering observation that the more treatments tried without success, the less likely a successful outcome, with the result of a long unremitted disease, worse long term prognosis, increased rates of side effects, and important medical, social and economic burden. The reasons for the low response and remission rates are multiple and depend on environmental and biological factors intrinsic to the disease and drug treatments. Pharmacogenetic (PG) tests have the potential to increase efficacy predicting outcome and to reduce antidepressant discontinuation due to side effects. Several studies investigated the utility of PG tests for antidepressants in MDD with interesting but contrasting results. To date most of them are observational studies with no comparator group, and few are randomized controlled trials (RCTs). Several limitations concerning study design, generalization of results, duration of trials, patients group studied, and cost-effectiveness ratio were found, and a number of barriers have been noted in the adoption of PG tests into clinical practice. Despite some preliminary positive results, there is the need for larger and longer‐term RCT studies, with the goal to capture the real impact of PG tests, also with stratified analysis concerning MDD features in terms of severity and antidepressant treatment failures in different ethnicity cohorts.

Until 2016, only few interventions were supposed to work in suicide prevention: restriction of access to lethal means, school-based universal prevention, treatment of depression and ensuring chain of care. Then, despite the multiplication of the therapeutic strategies for psychiatric disorders during the last decades, the incidence of suicide has not substantially decreased. Among several hypotheses, we proposed that suicidal depression is a specific form of depression, less responsive to antidepressants, carrying a high suicide risk, which deserves specific interventions. During the last decade, few controlled studies have been performed in at risk patients with short term reduction of the risk of suicide as a main objective, and the interest for old drugs such as lithium and clozapine remains. Recent data allow to propose that a new era is coming with evidence-based strategies of suicide prevention that should lead to change the way we deal with suicidal patients. Importantly, most efforts to develop interventions have moved to a perspective that suicide- specific treatments are necessary in addition to interventions for primary psychiatric disorders. By formulating the hypothesis that suicidal patients present a dysregulated response to social adversity based on specific brain areas associated with psychological pain, relying to opioidergic, immune and glutamatergic systems. Last, due to the difficult management of suicidal patients, innovative psychosocial interventions should be implemented for patients in suicidal crises and including safety planning, coordination of care, brief contact using phone calls. We have probably more solutions than ever to prevent suicide.

A literature search using PubMed and Google Scholar identified 64 articles assessing suicidal thoughts, suicide attempts and suicide during the COVID-19 pandemic in comparison with the pre-pandemic period in the six WHO regions of the world. Most studies come from high- and middle-income countries. There is a scarcity of data from South America, and no studies from the African and East-Mediterranean Regions. Compared to trends in previous years, suicide rates remained largely unchanged globally or declined in the early phase of the pandemic. However, increased suicide rates were reported among non-white residents and Afro - American groups in the US, as well as among adolescents in China. Japan and India showed a statistically significant increase in suicide rates after an initial decline. Similarly in Peru, after an initial decline, suicide rates increased among men during the course of the pandemic. This is in line with previous findings in the context of natural disasters and other epidemics where a similar increased suicide trend can be expected in the post-pandemic period in other countries. Among adolescents, there were no significant changes in suicide rates during the period of school closure, but an increase has been observed in the period after coming back to schools. The assessment of suicidal thoughts and attempts during the pandemic was mostly conducted through online cross-sectional surveys and showed significant increases, particularly in females and the young. Suicide can be prevented if evidence-based methods that exist are implemented in a systematic way (Wasserman et al. 2020; https://doi.org/10.1002/wps.20801).

Suicide is one of the leading causes of death in patients with Bipolar Disorder (BD). Several risk factors linked to suicide attempts in patients with BD have been identified, including a long duration of illness, untreated BD, female sex, positive history for suicide attempts, comorbidity with substance abuse or personality disorders, anxiety, depressive polarity and recent psychiatric inpatient care. Recently affective temperaments have been considered as possible factors for suicide in BD. While hyperthymic temperament is associated with a reduced risk of suicide attempts, cyclothymic, irritable, depressive and anxious temperaments are more represented in patients with a positive history of suicide attempts. Moreover, cyclothymic and irritable temperaments are highly connected with both aggression and impulsivity, which play a role in suicidal behaviours. Despite this evidence, the predictive role of affective temperaments on suicide behaviours is still poorly studied. In this contribution, we will report results of a study aiming at assessing the relationship between affective temperaments and personal history of violent suicide attempts, in 74 patients with BD. Violent suicide attempts were positively associated with cyclothymic temperament and inversely to hyperthymic one. BD-I patients and patients with a clinical history of rapid cycling were significantly more represented in the group of patients with a history of violent suicide attempts. Our results suggest the role of affective temperaments in the suicidality of patients with BD.

Treatment-resistant depression (TRD) is associated with poor quality of life, elevated morbidity and mortality and high economic burden.Our observational retrospective epidemiological study have estimated the rate of patients with TRD within a cohort of major depressive disorder (MDD) patients in Hungary and examine the comorbidities and mortality of patients with and without TRD.Our study included patients with MDD who experienced new onset of depressive episode and received antidepressant prescription between 01 January 2009 and 31 August 2015, using data from nationwide, longitudinal database. A patient was considered to have TRD if two different antidepressant treatments had failed during a given pharmacologically treated periode.Overall, 99,531 MDD patients were included, of which 8,268 (8,3%) met the criteria of TRD. Patients with TRD had significantly higher rate of having “Neurotic, stress-related and somatoform disorders”, autoimmune disorders, cardio-or cerebrovascular diseases, thyroid disorders and suicide attempts than non-TRD patients (for all comparisons, p < 0,005).Ths first study to assess the frequency of TRD in Hungary have found that the proportion of TRD is in the same range as in studies with similar methodology reported form other countries. The majority of our other main findings are also in line with previous studies from other countries.

ICD-11 was released by WHO in 2018 and approved by the World Health Assembly (WHA) in 2019. The revision for all chapters was guided by the principles of global applicability, scientific validity and clinical utility. The new chapter for mental health is termed 06 Mental, Behavioural or Neurodevelopmental Disorders (MBND). The ICD-11 with its chapter on Mental, Behavioural or Neurodevelopmental Disorders, its Mortality and Morbidity Statistics (MMS), Coding Tool and Reference Guide, Clinical Descriptions and Diagnostic Guidelines (CDDG), and other tools for translation and implementation offers an innovative approach for individualised diagnosis, treatment and care of people with mental disorders. For supporting the international process of implementation, WHO has installed an International Advisory Group for Training and Implementation of ICD-11 MBND. Development, Concept and Structure of ICD-11 will be presented. Selected changes from ICD-10 to ICD-11 like new diagnostic categories, revision of diagnostic criteria, introduction of dimensional symptom qualifiers or course descriptors, and options for complex coding with regard to their innovative strength, controversial potential and impact on diagnostics, treatment and care will be briefly discussed. National challenges for implementation - partly informed by international field trials, administrative, organisational, educational and training requirements - will be outlined. The new ICD-11 chapter on Schizophrenia or other primary psychotic disorders will serve as an example to discuss potential impact on treatment selection and outcome.

Catatonia is a syndrome of primarily psychomotor disturbances associated with typical abnormalities of muscle tone. It is characterized by the co-occurrence of several symptoms of decreased, increased, or abnormal psychomotor activity. Catatonia is a neuropsychiatric syndrome, not an independent nosological entity. Historically associated mainly with schizophrenia (e.g., catatonic subtype), ICD-11, similarly to DSM-5, now recognizes catatonia under a separate classification category, apart from psychotic disorders. In addition to schizophrenia and other primary psychotic disorders, it can occur in the context of other mental disorders, such as mood disorders, or neurodevelopmental disorders, especially autism spectrum disorder. Catatonia can also develop during or immediately after intoxication or withdrawal from psychoactive substances, including phencyclidine, cannabis, hallucinogens such as mescaline or LSD, cocaine and MDMA or related drugs, or during the use of some psychoactive and non-psychoactive medications (e.g. antipsychotic medications, benzodiazepines, steroids, disulfiram, ciprofloxacin). Moreover, catatonia can occur as a direct pathophysiological consequence of various nonpsychiatric medical conditions, e.g., diabetic ketoacidosis, hypercalcemia, hepatic encephalopathy, homocystinuria, neoplasms head trauma, cerebrovascular disease, or encephalitis. Due to the fact that catatonia was mostly associated witch schizophrenia, many cases were not diagnosed and thus did not receive indicated treatment. There are no specific “anti-catatonic” drugs, first-line treatment are benzodiazepines and ECT, in addition to the symptomatic and supportive therapy. The recognition of catatonia as an independent category in ICD-11 can improve medical care for catatonic patients in clinical practice.

Gamma-hydroxybutyrate (GHB) is a neurotransmitter found naturally in the human brain. Sodium oxybate (SO) is the sodium salt of GHB. In 2000 GHB was classified a Schedule I controlled substance, while SO became a Schedule III controlled substance for medicinal use under the Controlled Substances Act. SO and alcohol share a similar pharmacological profile. GHB acts on GABAB receptors and extrasynaptic GABAA receptors resulting in alcohol-mimetic effects in several CNS actions. It substitutes the discriminative stimulus effects of alcohol in rats, and has cross tolerance with alcohol. All together, this leads to think of SO as a substitution therapy for alcohol use disorders. SO was initially studied in the prevention of alcohol withdrawal, and it showed similar efficacy to benzodiacepines. The studies on relapse prevention were developed later and the results are mixed and more complex to understand. While open label studies show a positive effect, RCTs have not been able to show a significant effect for the whole sample. Nevertheless, post-hoc analysis show a robust effect in the subsample of patients with high risk drinking levels, that would be the preferred target for a substitution treatment. The potential for abuse of GHB is well documented, which should be no surprise for a substitution treatment. Nevertheless, when correctly prescribed the risk of abuse of SO remains very low, as shown both in clinical trials and in the pharmacovigilance database, with more than 260000 cases documented. SO can be considered a substitution treatment, effective in patients with high risk drinking levels.

Legislative changes in the last years have made possible the prescription of medical cannabis in several countries, often following a growing public demand. However, the medical indications for use and the access to prescribed cannabis are still limited. Prescribers face several challenges in the form of barriers and dilemmas, often related to stigma, and deficient information and training. As a result, many people keep on using illicit cannabis for medical problems. In this session we will outline the most common controversies of cannabis prescription, particularly in psychiatry. We will discuss the ethical considerations regarding prescription practices, the benefit-risk assessment, the limitations of the current knowledge, and some potential solutions to respond to the strong demand from patients and families.

Opioid misuse and its rising rates of morbidity and associated mortality is an increasing area of concern worldwide. The licit/illicit consumption of opioids ranging from plant-based substances and pharmaceutical drugs (particularly analgesia) to the new synthetic opioids, has brought opioid use disorder (OUD) back to the public health concerns, including not only prevention but also availability of evidence-based treatments. Agonist opioids have demonstrated by long high efficacy and effectiveness for OUD treatment. Although methadone has been the more prescribed drug in most of the countries where opioid agonist treatment is available, other agonist opioids can be prescribed. We will present a start of the art of other agonist opioids available for the treatment of OUD, emphasizing in the differences among them, in line with of personalizing treatment in addiction. We will focus on morphine slow release, buprenorphine (with or without naloxone, sublingual or long-lasting) and diacetylmorphine.

Telemental health care can be defined as the delivery of mental health care services at distance, by using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of mental illnesses, as well as for research and education in the field of clinical psychiatry. While telemental health care practice was long established in many countries, its development proceeded with some variability worldwide. Over the past months, however, the recent COVID-19 pandemic has abruptly spread telemental health care practice worldwide, mostly to ensure the provision of care and assistance to psychiatric patients in spite of the governmental social contact restrictions. Although the process of rapid implementation has often happened at different rates and with different quality standards, across the various countries and sites, a global increase of the use of digital technologies has been reported. On the other hand, such recent events have also sparked a real paradigm shift in mental health care, significantly expanding the scope of e-mental health, given the recent availability of newer tools of digital psychiatry. In more detail, the use of mobile phones applications, of social media, of immersive reality and of chatbots is now driving psychiatry towards envisioning a more hybrid form of psychiatric practice, which holds the potential to finally overcome the traditional gap between the unmet needs of psychiatric patients and the relative lack of services and resources in mental health care. Here, the research evidence and the most compelling implementation issues in digital psychiatry will be reviewed.

Digital treatment for neurodevelopmental disorders is being developed in order to treat patients online when possible, to reduce waitinglists, and to improve efficiency of treatment. In this workshop, first experiences with the so called Start Programme of the Super Brains app for ADHD in adults are presented. The Super Brains app has been developed by Rutger den Hollander, who himself has ADHD and owns an ICT company in the Netherlands, in cooperation with the speaker of this workshop and Parnassiagroep. The Start Programme is a new part of the Super Brains app, meant for patients referred for treatment that have to wait on often long waitinglists. Now they have no longer to wait, but can start immediately preparing for assessment by filling in questionnaires, and with psycho-education, lifestyle tips and support by experience experts that welcome them in the app and show them around. First data on the use of different parts of the Start Programme, the activity of patients in the app, and the satisfaction of patients will be presented. We also aim to study whether the Start Progamme is effective in reducing severity of ADHD symptoms. Super Brains can be adjusted for use in patients with other (neurodevelopmental) disorders easily.

COVID-19 pandemic had an important impact in mental health across all countries and populations. However, health care professionals, particularly those in the front line have been subjected to increased levels of stress, workload, deterioration of work environment and working conditions while potentially being afraid of contracting the infection themselves or infecting love ones due to the higher risk of contagion when dealing with infected patients. Some studies have stressed out this impact showing increased levels of burnout, depression, hopelessness, stress and post-traumatic stress in all physicians however, the impact of the pandemic may have been different depending on the specialty. We intended to study the impact of COVID-19 pandemic for doctors working at general hospitals and liaison psychiatrists dealing with COVID-19 patients in Europe. We developed and applied online questionnaires to physicians working at general hospitals and psychiatrists working at liaison services, in different European countries (Portugal, Italy, Belgium, Greece, Poland, Croatia), in order to determine what were their working conditions and it they reported mental health symptoms during the pandemic. This questionnaire included demographic data, questions about working conditions when dealing with general and COVID patients and the Hospital Anxiety and Depression scale (HADS). It was distributed thought email and social media platforms used by doctors. This work has been approved by each local Ethics committee and all participants signed an informed consent.

The number of UMY in Spain is increasing, since the early 1990s, mostly coming from the Maghreb, although the number of those coming from different sub-Saharan African countries has gradually increased. Most of them leave their countries fleeing poverty, violence, and in search of better opportunities. They may be influenced by traumatic experiences and social stressors that can lead to emotional distress and mental health problems. They have particular needs and characteristics, so the local Child Protection Systems need to adapt their procedures to facilitate the youngsters’ social Integration and psychosocial development. This presentation will describe an ongoing project being carried out in Catalonia, the main objective is to guarantee the right to mental health of UMY in the Protection System through culturally competent biopsychosocial care, and to effectively coordinate care between the public mental health network and the Child Protection System. Finally, through training and the acquisition of competencies, the aim is to avoid burnout in professionals who care for these youths on the front line. The approach is consistent with the cultural consultation models developed in Montreal and London with the goal of providing structural support for localized and culturally competent responses. This project, to be developed over two years, has four main subprojects: 1. On-line training for professionals in “Cultural competence in mental health and psychosocial intervention”. 2. Training of “peer” UMY as “Community Mental Health Agents”. 3. Creation and implementation of multidisciplinary groups of psychosocial intervention. 4. Culturally competent psychiatric and psychological assessment.

According to the data, more than 50% of elderly patients with mental disorders have at least one comorbidity and are treated with multiple medications (e.g. 5 or more medications), which can lead to problems in medication selection and medically unnecessary polypharmacy (i.e., irrational polypharmacy). On the other hand, there are still many untreated patients, which can lead to severe disturbances and an excess death rate. Due to frequent comorbidities and treatments in the elderly, medication-related problems are very frequent. Drug-drug interactions (DDIs) between somatic medications and psychotropics often occur in this population. These patients are also excluded from many clinical trials and consequently, this age group is underrepresented in clinical guidelines, which leads to a lack of evidence-based medicine supported results useful for daily practice. In this context, prudent medication selection is a key step in pharmacotherapy selection. There are some tools available that can help in clinical practice, including different medication lists (e.g., Beers criteria, STOPP/START, and guidelines) and pharmacological recommendations.

The participants will learn about general recommendations on medication selection in this population, focusing on general principles on somatic comorbidities treatment, supported by evidence-based data and real clinical pharmacological tools useful for daily practice.

The treatment of sleep disorders in older people requires knowledge of the changes in sleep in old age. In the case of multimorbid older people, pharmacological aspects such as interactions must also be taken into account. Sleep in old age is characterised by a lower depth of sleep and more frequent awakenings. The duration of sleep corresponds to that in middle adulthood. In multimorbid older people, sleep is often chronically impaired by pain and/or obstructive breathing disorders. Many medications can have a negative effect on sleep. This applies to cortisone, for example. Antipsychotics can also worsen sleep by worsening nocturnal myoclonia. Ideally, sleep disorders should first be addressed non-pharmacologically. For benzodiazepines, preparations with a short half-life should be chosen. An algorithm is presented. References:

Gulia KK, Kumar VM. Sleep disorders in the elderly: a growing challenge. Psychogeriatrics 2018;18(3):155-165. Samara MT, Huhn M, Chiocchia V, Schneider-Thoma J, Wiegand M, Salanti G, Leucht S. Efficacy, acceptability, and tolerability of all available treatments for insomnia in the elderly: a systematic review and network meta-analysis. ActaPsychiatr Scand. 2020;142(1):6-17.

This presentation highlights core pharmacological aspects of opioid and non-opioid pain medications in the elderly patient. Specifically, it covers pharmakinetics, pharmacodynamics and drug-drug interactions of select pain medications. The presentation aims to promote safe use of pain medications in the elderly.