In a cross-sectional study, the Italian Network for Research on Psychoses (INReP) found that variables relevant to the disease, personal resources and social context explain 53.8% of real-life functioning variance in a large sample of community dwelling people with schizophrenia. In a longitudinal study, the INReP aimed to identify baseline predictors of main domains of real-life functioning, i.e. work skills, interpersonal relationships and everyday life skills, at 4-year follow-up. We assessed psychopathology, social and non-social cognition, functional capacity, personal resources, and context-related factors, as well as real-life functioning as the main outcome. We used structural equation modeling (SEM) and latent change score (LCS) model to identify predictors of real-life functioning domains at follow-up and changes from baseline in the same domains. Six-hundred-eighteen subjects took part in the study. Neurocognition predicted everyday life and work skills; avolition predicted interpersonal relationships; positive symptoms work skills, and social cognition work skills and interpersonal functioning. Higher neurocognitive abilities predicted the improvement of everyday life and work skills, as well as of social cognition and functional capacity; better baseline social cognition predicted the improvement of work skills and interpersonal functioning, and better baseline everyday life skills predicted the improvement of work skills. Several variables which predict important aspects of functional outcome of people with schizophrenia are not routinely assessed and are not systematically targeted by intervention programs in community mental health services. A larger dissemination of practices such as cognitive training and personalized psychosocial interventions should be promoted in mental health care.

In this presentation a model for the management of difficult to treat depression (DTD) will be presented based upon a recently published international consensus statement (McAllister-Williams et al. 2020 Journal of Affective Disorders 267:264-282). This model emphasises the goals of: optimal symptom control – remission if possible; optimisation of psychosocial functioning; and optimisation of prophylaxis against relapse/deterioration in mood. Building on these goals, the model follows a number of principles. These include emphasizing the importance of shared decision making and measurement-based care, enhancing engagement and retention in services, self-management strategies and frequent re-assessments, all incorporated in an integrated service pathway. The model itself encompasses eight elements: 1. Optimal symptom control using conventional, guideline recommended, treatments but moving on to treatments beyond guidelines in an appropriate and timely way; 2. Targeting symptoms associated with poor outcomes, e.g. anxiety and pain; 3. Targeting symptoms associated with poor functioning and quality of life such as sleep difficulties, fatigue and cognitive dysfunction; 4. Screening for and managing physical, psychiatric, substance misuse and iatrogenic comorbidities; 5. Optimisation of long-term treatment; 6. Using self-management techniques to empower patients; 7. Using integrated health services to help provide a sense of containment and ensure wide consideration of treatment options; and 8. Establishing regular reviews of the patient’s diagnosis and treatment. Examples of each of these elements will be provided.

Major depression is a serious, disabling, often chronic or recurrent mental disorder affecting over 350 million people worldwide. Treatment of major depression is now conceptualized as proceeding through three phases: the acute phase, the continuation phase, and the remission phase. Patients not achieving remission after several treatment trials are defined treatment-resistant, but a debate is ongoing regarding how many trials must fail before a patient can be defined as “treatment-resistant”. It must be acknowledged that depression is a heterogeneous disease, and several personal, socio-cultural and clinical factors should be taken into account in order to develop a personalized management plan for patients with major depression. A new concept of “difficult to treat depression” has been recently proposed. According to this concept, when a complete control of the disorder is not feasible, the treatment should aim at minimizing the impact of symptoms and the side effects of treatments on patients’ daily lives. Moreover, the concept of difficult to treat depression includes the presence of co-occurring problems/ behaviours/ disorders/ situations, which can worsen the course or management of depression. The management of patients with treatment resistant depression includes the optimization of disease management, in terms of symptom control, improvement of daily functioning and of quality of life. However, an approach aiming to personalize treatment of patients with major depressive disorder and focused on the specific clinical features of each patient can be valuable for optimizing the treatment of patients with resistant depression.

The COVID-19 outbreak has left its mark on the work of mental health care staff. Many professionals had to radically change their working conditions or were delegated to work in different facilities, in many cases taking on different responsibilities with little time for training. Many psychiatrists overnight had to partially or fully start working within telemedicine. Due to the lockdown, psychiatric trainees in many countries were not able to complete their training as planned. The measures taken by the governments to limit the impact of the pandemic also affected the capacity to conduct research studies and directions of new research initiatives. Dr. Gondek will present the results of the EPA ECPC-EFPT Cross-sectional survey on the effects of the outbreak on work and wellbeing of Early Career Psychiatrists in Europe.

The Covid-19 pandemic has transformed the world since the beginning of 2020 and many aspects of health care provision has changed dramatically. Despite not being regarded as a frontline field at first look, Child and Adolescent Psychiatry (CAP) has been highly impacted by the pandemic as a fundamentally biopsychosocial branch. CAP specialty training has also become a different experience due to the reprioritization of health care services along with the restricting rules of the ‘new normal’. In this symposium presentation, we will discuss the effects of the Covid-19 pandemic on the training and practice of CAP specialty trainees and early career specialists through the results of the ‘Early Career Psychiatrists in Europe during COVID-19 outbreak’ survey study, organized by the EPA and EFPT. The survey covers different areas including reorganization of training/practice during the pandemic, personal experiences with Covid-19 and adoption of Telepsychiatry practices. This pan-European study is expected to shed a light on the emerging issues for young doctors in CAP to plan necessary improvements on a European scale.

COVID-19 has impacted psychiatric education at many levels from postgraduate training to Continuous Medical Education (CME). We invited participants at the European Union of Medical Specialists (UEMS) who are national representatives to share how COVID-19 has impacted postgraduate training and Continuous Professional Development (CPD) in their countries. They were asked to report the challenges but also the opportunities created by the pandemic and their answers were analysed. Several themes emerged. Challenges in postgraduate training have been absences caused by COVID, redeployment, reduced interactions and postponement of assessments. The mental health of trainees was affected, including burnout. Interestingly in some places, like Denmark, training was less impacted as psychiatry was designated as ‘critical’ and therefore no redeployment. Exams have moved online and there have been concerns about cheating in the new format. In countries where it is obligatory to be uptodate with CME/CPD to maintain medical registration, the usual requirements were waived. Conferences and live events have moved online and webinars became popular and widely accepted. Some positive developments included rapid adoption of technology, for consultations and training, increased relevance of CPD/CME, emphasis on team cohesion and recognition of the need for self-care and team support. The pandemic also fostered international collaboration, e.g. sharing guidelines for new ways of working. Some of the innovations described, mainly related to the adoption of technology and remote working will likely be taken in the future. However, the sentiment remains that live exchanges are valuable and should be resumed as soon as it is safe.

Pregnancy is associated with profound changes in pharmacokinetic processes. This is an important - and until recently neglected - area of research since the majority of women take drugs during pregnancy in addition to vitamin and dietary supplements. Recent evidence has emerged that the changes do not only include absorption, distribution and excretion but also drug metabolism, such as modifications in the regulation of hepatic metabolism and conjugation. Oestradiol is known to have an important role in the expression of cytochrome P450 isoenzymes and glucuronosyltransferase that are involved in the metabolism of psychotropic drugs. Recent studies of different psychotropic drug classes have shown that this can result in profound changes of plasma concentrations that commence early in pregnancy and gradually increase towards delivery. In this presentation pregnancy-induced metabolic changes that have been found so far for several psychotropic drugs will be discussed and the question addressed whether and how we should monitor plasma levels in our pregnant patients.

Suicide is one of the leading causes of perinatal maternal mortality (1). Maternal suicidality has a negative impact on the mother-baby relationship and child development. However, little is known about specific risk factors for perinatal suicide attempts in women with severe mental illness. In a sample of 1439 women with severe mental illness in the perinatal period and jointly admitted with their baby in a mother and baby unit, 154 (11.7%) attempted suicide, 49 in pregnancy (3.7%) and 105 (8.0%) in the post-partum period (2). Suicide attempt in pregnancy was related to alcohol use, smoking during pregnancy and a history of miscarriage, and in the post-partum period to major depressive episode or recurrent depression and younger age. Women who attempt suicide either in pregnancy or in the postnatal period could have different psychopathological and environmental profiles. Past obstetric history and addictive behaviours during pregnancy are essential elements to explore. In addition, depressive symptoms should be assessed in all women to treat major depression, as a means of preventing suicide attempt. Special attention to risk of suicide is needed during the perinatal period for women with severe mental illness. For women suffering from an acute psychiatric disorder, or a history of mental illness, multi-disciplinary management should be implemented. 1. Oates M. Suicide: the leading cause of maternal death. Br J Psychiatry. 2003;183:279-81. 2. Gressier F et al. Risk factors for suicide attempt in pregnancy and the post-partum period in women with serious mental illnesses. J Psychiatr Res. 2017;84:284-291.

Schizophrenia is a complex mental disorder, which has been recently conceptualized as a neurodevelopmental disease. This conceptualization has changed the psychopathological approach to schizophrenia, which is now described as lying on a continuum from mild psychotic experiences to frank psychotic episodes. According to this theory, the presence of psychotic symptoms would represent the final pathway of a complex dysregulation and interaction of different genetic and environmental risk factors. As regards genetic liability, recent genome-wide association studies have identified a total of 108 loci containing common risk alleles, and which meet genome-wide significance. As regards environmental factors, higher rates of schizophrenia have been found in ethnic minority groups, in persons who are heavy cannabis smokers, in those who suffered from severe childhood traumas, in persons who have been reared in highly deprived settings. The identification of risk factors associated with vulnerability to psychosis is essential for improving our understanding and early detection of vulnerable individuals, and to propose tailored and timely interventions for sufferers. There is the need for an interdisciplinary approach to schizophrenia which includes screening procedures for individuals reporting specific vulnerabilities and treatment strategies tailored on patients’ needs.

Introduction: Cognitive function in schizophrenia is one of the main elements related to functional outcomes. Although there is enough evidence that cognitive remediation (CR) is beneficial, there is still a limited understanding of how the active therapy ingredients contribute to brain changes and translate into improved real-world functioning. Objectives: Identify neurobiological, psychopathological, cognitive, and functional CR response or resistance predictors in schizophrenia, considering both cognitive and functional outcomes. Results: We still lack a precise understanding of how CR produce its effects with different programs, different numbers of sessions, with and without a therapist. CR exerts its maximal benefit when delivered in the context of psychiatric rehabilitation, but it is not yet clear what are the mechanisms of integrated treatment effectiveness. Only a few studies have looked for the relationship between CR response or resistance and the biological, socio-demographic, clinical and cognitive features in schizophrenia. The current knowledge on efficacy predictors of CR is sparse and include: age, illness duration, premorbid adjustment, baseline cognitive performance, intrinsic motivation, hostility, disorganized symptoms, neurobiological reserve, genetic polymorphisms, antipsychotics amount, the type of CR, etc. All of these limitations may have contributed to the poor implementation of CR in national and international guidelines, as well as in clinical practice. Conclusions: It is important that future research shift from studies of group efficacy to individual efficacy of treatments, in the perspective of precision medicine. Issues related to individual effectiveness predictors and interactions between specific pharmacologic, specific CR technique and individual patients’ characteristics should be further addressed.

Most cognitive remediation therapies now involve computer presentation that differ in their level of sophistication and incorporation of gaming technology. But sophistication doesn’t seem to affect the benefits as few outcome differences have been noted. Rather there seems to be a need for some interaction between a therapist and client with two recent meta-analyses reporting this therapist effect. For the large-scale roll-out of cognitive remediation this poses a problem – how do we train these therapists? We know that training or at least educational background is important, so we need clear training packages and supervision. Covid-19 has also given us a greater challenge as it has limited our face-to-face interactions. To remove these two challenges we can use technology. For training we need online processes to increase training availability and for a lack of face to face contact we can provide the bridge with suitable platforms which allow the sharing of screens. Both would ensure that cognitive remediation is available to a wider group, although that requires overcoming the digital divide often experienced by people with a diagnosis of schizophrenia. The tools and the training programme issues are discussed with reference to some initial data.

Transgender people represent a broad spectrum of individuals that transiently or persistently identify with a gender different from the one assigned at birth (APA, 2013). Transgender healthcare issues have become an increased matter of interest over the last years, as shown by the growth of publications on the subject and by the increase of referrals reported worldwide in all age groups. However, transgender people report encountering numerous obstacles in accessing and receiving appropriate health care with professionals being described as not properly trained on specific gender issues. Considering the diversity and complexity of the gender spectrum in the different age groups and in light of the recent changes in the formal psychiatric classification, mental health providers play a critical role in meeting the needs of gender non-conforming children, adolescents and adults, according to individualized paths. This course has the following aims: (1) learn the principles of assessment of gender incongruence in childhood, adolescence and adulthood; (2) address co-occurring psychopathology (if present); (3) identify different treatment paths according to age and individualized psychological and/or medical needs; (4) work in a multidisciplinary team in line with an integrated model.

Croatian healthcare faced dramatic changes as a response to the ongoing pandemic, which further pressured financially loaded system. Besides, the capital of Croatia was hit by an earthquake that caused material damage and organizational difficulties. Contrary to the World Health Organization’s recommendations that mental health services are essential services to be maintained during the pandemic, there was severe disruption of utilization and accessibility to mental health services during the pandemic. In the beginning, the only services maintained were in-hospital and emergency services, while daily hospitals and ambulatory visits were disrupted. Psychiatric resources were not formally implemented in the treatment and management of COVID-19 and majority of mental health workers remained within the boundaries of psychiatric services. In the following period, some of the services reopened, with reorientation to online provision. However, the interference of services gradually occurred as the second wave started, with some psychiatric departments being repurposed for non-psychiatric use. Psychiatric care was organized in some of the COVID-19 departments as liaison service. Some of the psychiatric services offered consultation and prevention of burn-out for frontline personnel. Lastly, as the University hospital centre Zagreb was implementing the flexible assertive community treatment teams for persons with severe mental illness through the Large-scale implementation of community based mental health care for people with severe and enduring mental ill health in Europe (RECOVER-E) project in the period from 2018-2022, we investigated the effect of this service on the health outcomes during the pandemic and found it superior compared with the standard treatment.

As COVID-19 began to plague the world, the term ‘social distancing’ was frequently used, encouraging people to keep a safe physical distance from others to reduce the transmission of the virus. Despite being well-intended, the term has negative implications, further isolating vulnerable groups in society by evoking feelings of rejection and exclusion. For this reason, the members of the European Psychiatric Association Ethics Committee wrote an e-letter in response to an opinion piece published by Science (https://science.sciencemag.org/content/367/6484/1282/tab-e-letters), and also wrote to the European Psychiatry (https://doi.org/10.1192/j.eurpsy.2020.60) and the World Health Organisation explaining why the term ‘physical distancing’ should instead be used among policymakers, governments and the general public. Words are important and carry great meaning. Therefore, by using the term physical distancing and not social distancing the message becomes clear, individuals should remain physically distant but socially connected to protect the vulnerable communities in societies. The World Health Organisation, as well as the Lancet journals, adopting the term physical distancing in replacement of social distancing, was a rewarding and important step in the right direction.