Deep brain stimulation (DBS) is able to target with precision specific cerebral networks, thus offering hope for severe and treatment refractory illnesses, as well as to investigate in the detail the subcortical bases. In obsessive-compulsive disorder (OCD), DBS is being tested at several nodes of a prefrontal-subcortical circuit, including the subthalamic nucleus (STN). Functional imaging studies of OCD patients have shown abnormal metabolic activity of the orbito-frontal and cingulate cortices, as well as of the anterior part of the striatum. In animal and human studies, these structures have been associated with performance-monitoring and more generally metacognitive processes, thus suggesting that metacognitive dysfunctions might be central to OCD leading to pathological doubt. In this conceptual framework of hyperactive distrust metacognitive mechanism in OCD, checking behaviour can be regarded as an ill-founded metacognitive strategy designed to restore confidence in the outcome of one's actions. Within the basal ganglia network, the STN could act a crucial part in this process regarding its role in the inhibitory control of behaviour. Moreover, anatomy and neuro-computational models of the basal ganglia show that this nucleus is in the position to implement cortical metacognitive control by increasing the threshold for decision. This framework has the advantage of providing a theoretical basis to the promising clinical results obtained for STN-DBS in severe resistant OCD. Bearing in mind this model, it can be postulated that DBS, by its action on STN, positively interferes with the neural mechanism underlying compulsive behaviour.

A glaring lack of actionable etiological progress has revived a nosological nihilism, which proposes a downplaying of the traditional nosological classes and focusing elsewhere, e.g., on “descriptive syndromes” (e.g., “depression”, “reality distortion”), proxy-variables (endo-phenotypes), or behavioral constructs with partly known neural underpinnings (e.g., RdoC). However, another type of response may consist of a re-examination of the ontological and epistemological assumptions involved in the massive oversimplification of psychopathology, which took place as a part of the so-called “operational revolution”. This lecture will advocate a revival of psychopathology, which, if equipped with adequate epistemological ressources to address consciousness in its experiential and behavioral dimensions, is urgently relevant and acutely needed for psychiatry as a clinical and academic enterprise. As an illustrative example, the concept of self and its disorders will be briefly examined.

Over the past 20 years, the way Mental Health research has been conducted in Europe has changed dramatically. To remain isolated is highly detrimental to the impact of the data collected and is making extremely difficult the dissemination of the results. The key word from the very beginning is collaboration: to facilitate it different European networks have been established.

A network should be considered as a flexible research structure in which the participants have common objectives, are using common tools and are looking for common outputs. To achieve this ambitious aim, instruments (both psychometric and neurobiological) have to be standardized and cross validated, methods for data acquisition have to be shared by all participants, a dedicated center for data management has to be chosen and, in case of specific procedures (neuro-imaging, genotyping etc...), the modalities for storage have to be defined in advance. Without these preliminary steps a network will function more as a patchwork of different centers than as a common repository of procedures, expertise and data. To tell it more directly the purpose of a network is not only to bring in more power by offering large recruitment possibilities, but is also to create an operational database with a true open access and to be the actual basis for a knowledge transfer benefiting to the scientific community. One of the main criticism which can be made to many of the European networks which have been established in the past is that they have functioned in a closed manner with no possibilities for external teams to have access not only to the data but as well to the procedures or to the tools used. The consequence has been the difficulty to replicate the results and the necessity...to recreate new networks, which is a waste of time and a waste of money! To avoid this kind of repetitive duplication of the same types of networks a better identification of existing networks is needed (how many European research networks on schizophrenia for example - a global map will be presented-), clear criteria have to be proposed for considering a network operational and a coordination with established joint programme initiatives has to be implemented.

Depressive and anxiety disorders are prevalent psychiatric disorders that often start early in life. Heterotypic association between depression and anxiety has been well documented, with anxiety typically preceding depression in childhood and adolescence, while a more complex pattern of co-occurrence has been described for adult-onset illness. Even when starting early in life, depression and anxiety disorders are associated with poor outcomes, including not only psychiatric, social and vocational outcomes, but also development of physical problems. Although remission rates are high, in most cases episodes tend to recur, with increasing severity with every recurrence.

Identification and treatment of these conditions, therefore, is of outmost importance regardless their age of onset. However, therapeutic approaches must take into account the effect of development in their clinical presentation, the differential efficacy of the therapeutic approaches, and the adverse effects profile.

Current treatment algorithms for depressive and anxiety disorders include psychotherapeutic and psychopharmachological approaches and their combination. Although up until recently most treatment evidence came from adult studies, recent developments have increased knowledge on efficacy of interventions for younger populations. Treatment effects in children and adolescents are lower than in adults, partially due to the high placebo effect in youth. This presentation will provide an overview of the current approach to the treatment of depression and anxiety. Specificity of treatment at early ages will be stressed out. New promising treatments and their potential utility will be also discussed.

Epidemiological surveys and treatment studies have clearly established that both detection and treatment rates in depression and in anxiety disorders revolve only around 50%. This figure appears to be stable, over a number of decades, despite significant educational and policy efforts to change this pattern. Since depression is a leading cause of disability, lost productivity and health care expenditure, the societal and individual cost of this impasse is tremendous. This talk will review this data and discuss how even small changes in our therapeutic abilities may translate into major advances for patients and their environment. Meeting mental health care needs of individuals, who currently have a low rate of depression treatment, will pose an important challenge to general medical and mental health educators and practitioners. Epidemiological surveys and treatment studies have clearly established that both detection and treatment rates in depression and in anxiety disorders revolve only around 50%. This figure appears to be stable, over a number of decades, despite significant educational and policy efforts to change this pattern. Since depression is a leading cause of disability, lost productivity and health care expenditure, the societal and individual cost of this impasse is tremendous. This talk will review this data and discuss how even small changes in our therapeutic abilities may translate into major advances for patients and their environment. Meeting mental health care needs of individuals, who currently have a low rate of depression treatment, will pose an important challenge to general medical and mental health educators and practitioners.

Outcome measures are (too) often driven by what regulatory bodies request and stick to observer rated depression scales. It is already known that self rating and observer rating scales are not always concordant but recent research even indicates that what physicians and patients expect from outcome is not the same. Physicians put a lot of emphasis on (mainly) depressive symptoms not taking into account the often comorbid anxiety and somatic symptoms while patients put more emphasis on positive mood (vigor, energy, optimism) and on feeling the usual self. Moreover, research indicates that the divergence between physicians’ and patients’ expectations also influence outcome. These differences, how they manifest and what can be done to overcome them so as to provide satisfactory outcomes of treatment, will be further discussed.