Empirical evidence for psychopharmacological treatment has grown over the past decade substantially. While it was quite difficult to perform metaanalyses 20 years before, we now have a large body of evidence available to perform metaanalytic studies, not only on data published in the literature, but also on individual databases called a pooled-analysis. The field moved from eminence-based psychiatry to evidence-based psychiatry. Since indications for psychotropic agents are with a few exceptions given for diseases and not syndromes, it is obvious that the available empirical database is diagnosis-driven. However, recent developments in psychopharmacology indicate that medications primarily used for one diagnosis can also be useful for other diagnoses as we learnt from the serotonin-reuptake-inhibitors (SSRIs), which were firstly used for depression and then for different forms of anxiety disorders. A recent example is quetiapine, for which the first indication was schizophrenia, then bipolar disorder and now depression and general anxiety disorders. Does this mean a denosologisation of psychopharmacology? Not really, however recent developments could be indicative that trials should be performed not only on a diagnostic but also on a syndromatology-level as has been shown for suicidality within schizophrenia, but for instance not in depression.

The issue of the differentiation between depression and “understandable” intense sadness (representing a “normal” response to an adverse life event) has significant clinical, scientific, political and ethical implications, which have become particularly visible in the past few decades, in parallel with the escalation of the prevalence rates of depression in the community, of the estimated social costs of depression, of the number of people on treatment for depression, and of the prescriptions of antidepressant medications. According to the DSM-IV, periods of sadness are inherent aspects of the human experience, which should not be diagnosed as a major depressive episode unless criteria are met for severity, duration and clinically significant distress or impairment. The implication of this statement is that “understandable” intense sadness following an adverse life event does qualify for the diagnosis of major depression if the severity, duration and impairment criteria are fulfilled. The proposal has been recently put forward to exclude loss-triggered uncomplicated intense sadness from the DSM-V diagnosis of major depression (i.e., to introduce a “contextual” criterion excluding intense sadness which appears “proportionate” to a loss). However, further research is needed to explore the applicability and reliability of this “contextual” criterion and its clinical utility for the prediction of treatment response and clinical outcome. The limited available research evidence suggests that “situational” major depression does not differ from “non-situational” major depression on many clinical and psychosocial variables, and that response to antidepressant medications is unrelated to whether or not major depression is preceded by a life event.

The DSM and ICD diagnostic systems have developed largely in response to clinical interests, though they are used for other purposes as well. Careful attention is also needed to consider the balance of ethical and commercial interests. Public health aims of representing the burden of disease and disorder help to mobilise resources globally, nationally and locally; and relevant diagnostics and assessments guide services and programmes for the mental health of patients and populations. Like other areas of public health, the scope of community mental health extends beyond the treatment orientation of clinical services and community psychiatry. Priorities also include reducing vulnerability to prevent mental health problems and enhancing resilience to promote mental health. As the next wave proceeds in revising our psychiatric systems of classification, advancing such an agenda will help ensure that efforts to achieve the mental health of populations are effective, as they become more responsive to current developments in public health-which have recently been characterised with reference to four revolutions.

The classification of mental disorders in the International Classification of Diseases (ICD) will be revised in the course of the next three years and its publication (as the 11th Revision of the ICD) will be published, after the approval of the World Health Assembly in 2014. In parallel, the American Psychiatric Association created a Task Force which has begun work on the proposals for the revision of its Diagnostic and Statistical Manual which is to be published as the DSM 5th Revision, in 2012. The World Health Organization has established a special advisory group that should assist it in developing proposals for the classification of mental disorders for the 11th Revision of the ICD and this group collaborates closely with the APA Task Force creating the DSM5 proposals.

Numerous ethical issues arise in this process and need to be discussed now so as to inform the process of agreeing on the proposals for the new classifications. They include the importance of an internationally accepted classification as a protection against abuses of psychiatric patients; the need to set the threshold for the diagnosis of a mental disorder at a level ensuring that people with such disorders receive help, the need to avoid imposition of diagnostic systems or categories without sufficient evidence and others. The presentation will briefly discuss the process of constructing the proposals for the new classifications and ways in which the groups established by the WHO and the APA handle these ethical questions.

In her talk, Sigrid will focus on a number of aspects that arise as a consequence of an individual's diagnosis as suffering from a severe mental disorder, such as schizophrenia, and particularly how a diagnosis affects the wider family unit.

From the wider family perspective, the onset of any mental illness is very traumatic and frightening, resulting in total confusion, angst and upset for all members - the sufferer, parents and siblings. So when a diagnosis is finally made, a sense of relief prevails but soon this relief changes when a person realises the real impact of such a diagnosis - in other words, the longer term effects and changes which they will face. A lifetime sentence looms for many.

There is a critical need for information to help understand the illness, support and education to help develop one's coping skills, to name just a few issues. Also, a very negative result of someone being diagnosed as suffering with a mental illness is the onset of feelings of stigmatisation, discrimination and isolation. Sigrid will deal with these topics and will explore the efforts which EUFAMI has been employing to counter these.

Individuals diagnosed with borderline personality disorder usually seek for treatment as adolescents or young adults. As age progresses, longitudinal studies suggest that borderline patients improve psychosocially, suggesting that they may somewhat belatedly achieve the milestones of young adulthood. Affect regulation may be particularly subject to major changes in young adulthood, as the prefrontal brain areas involved in affective processing underlie maturation processes up into the late third decade. From studies in healthy volunteers we know that that the capacity to process positive affects improves with age. Young adults with borderline personality disorder, however, display a negativity bias in emotion recognition and they have difficulties in inhibiting the recall of negative information. Neuroimaging data suggest that they suffer from deficient implicit affect regulation but they are able to profit from explicit strategies to suppress negative emotions, an observation which could have interesting implications for treatment. Regarding future research more efforts on developmental psychopathology on the one hand, brain maturation on the other will help to further understand the nature of borderline personality disorder. Regarding clinical issues early treatment designed to foster affect regulating competencies and self-esteem and to develop interpersonal skills might benefit young patients diagnosed with borderline personality disorder.

In adult psychiatry early recognition and treatment of schizophrenia has become a major goal because of manifold evidence of a relation between delayed initiation of treatment and an unfavourable developmental course. The duration of untreated psychosis (DUP) seems to be significantly prolonged in adolescents compared to adults due to both a protracted sub-threshold development of psychotic features and the failure of families and health professionals to take seriously the initial signs of psychosis that mimic quasi normal adolescent emotional perturbations. Although in adults studies have shown a subset of prodromal signs and attenuated psychotic features to have predictive evidence for the development of schizophrenia, these symptoms however seem of limited specificity in adolescence. Basic symptoms represent subjective experiences of the prodromal phase and will be presented in a sample of schizophrenic adolescents in comparison to non-psychotic patients and normal controls. Results reveal that basic symptoms do not show any specificity for schizophrenia, but schizophrenics present with higher amounts of basic symptoms in the prodromal phase compared to non-psychotic controls. For early recognition a combination of psychopathological and biological markers seems fruitful. First data on perceptual closure and event related potentials of the optic system will be presented that seem to differentiate between early and late onset schizophrenia.

Suicide is one of the leading causes of mortality among adolescent suicides. Data from the WHO European Multicentre study on attempted suicide indicates that rates of attempted suicide and suicide in the young co-vary. The association is strongest and significant for male adolescents and young adults. Furthermore, recent studies have reported a shift to suicide methods with higher lethality for both genders.

Suicide prevention strategies are directed at the general population and health care services. Suicide risk is high among adolescents with psychiatric illness, so adequate treatment and detection of psychiatric illnesses in young people is essential. Preventive measures in health care services after a suicide attempt and early recognition of young people at risk in schools are also essential strategies.

The emphasis of suicide prevention work needs to shift to an earlier stage of the suicidal process. This question is addressed by the global suicide prevention initiative SUPRE (SUicide PREvention), in the WHO publication Preventing suicide: a resource for teachers and other school staff, which can be adapted to local conditions and inserted in syllabuses for training both pupils and staff.

An intervention project called SAYLE: Saving Young lives in Europe is funded by the EU for adolescents in European schools over 12 EU countries. Its main objectives are to lead adolescents to better health through decreased risk taking and suicidal behaviours. Outcomes of preventive programs will be evaluated and culturally adjusted models for promoting health of adolescents in different European countries are planned to be developed.

Epidemiological data indicate that about one third of all pregnant women receive at least one psychotropic drug (Goldberg & Nissim 1994). Women with mental disorders bear a considerable risk of relapse when psychotropic medication is discontinued during pregnancy and the postpartal period.

TDM aims to better individualize dosing regimens taking into account relevant pregnancy-induced metabolism returning to baseline activities within 24 hours (Adab 2006).

Despite the frequent use of psychotropic drugs in pregnancy, for several psychotropic drugs only few documented cases regarding their influence on organogenesis, delivery complications or long term effects are available. Therefore, one should follow some general guidelines when treating pregnant women (cf. Bergemann & Conca). Furthermore, it is recommended to guide any psychopharmacological therapy by TDM. TDM in pregnant women and/or mothers is recommended to be carried out at least once per trimester and within 24 hours after delivery. For TDM at delivery umbilical cord blood of neonates exposed in utero to psychotropic drugs should be collected, since possible neonatal symptoms has to be differentiated from a withdrawal syndrome versus toxic effects of the substances (cf. Koren 2006, Pakalapati et al. 2006).

The use of psychotropic medications during breast-feeding has some implications. All psychotropic medications enter breast milk. However, current data do not support monitoring breast milk levels in attempt to estimate individual infant plasma levels, since the effective drug concentration in the neonate is essentially determined by its own metabolism (Weissman et al. 2004). A systematic monitoring of mother and child including TDM is recommended.

More than 80% of all adverse drug reactions are Type A reactions and dependent on drug concentrations. Therapeutic Drug Monitoring (TDM), Drug Interaction checking programs and pharmacogenetic tests are valuable instruments in elucidating or preventing Type A reactions. It stands for Quality Assurance in clinical practice. The TDMplus algorithm (Jaquenoud Sirot E et al 2006) is helpful in clinical practice and prevents unnecessary testing. This decision tree leads in several “stop/go” steps from the clinical situation of inefficacy or adverse reaction to measuring and interpreting plasma levels, checking for pharmacokinetic interactions and finally, if indicated, to pharmacogenetic tests with gentoyping and/or phenotyping. Genetic results are noted on a personal “pharmacogenetic card” for the patient's future treatments.

The interplay of genetics, drug interactions, life style and other personal vulnerabilities like comorbidity make prediction of drug response very complex. The use of TDMplus has proven useful guiding the clinicians in difficult clinical situations and helping elucidating the causality of adverse drug reactions. Its practical benefit has been shown with pharmacovigilance cases from the AMSP program (Arzneimittelsicherheit in der Psychiatrie = Drug Safety in Psychiatry).

Evidence has been given that antipsychotic effects of dopamine receptor antagonists are associated with 60 and 80% striatal dopamine D2 and D3 receptor occupancy. Receptor occupancy correlates well with concentrations of the antipsychotic drugs in serum or plasma, much better than the dose. The latter is consistent with weak correlations between antipsychotic dose and serum concentrations and explained by the high interindividual variabilities in drug metabolism. Using positron emission tomography (PET) for in vivo determination of dopamine receptor occupancy in conjunction with drug concentration measurements “therapeutic windows” could be calculated for the atypical antipsychotic drugs amisulpride, risperidone and ziprasidone. On the other hand, analysis of drug concentrations in serum of schizophrenic patients who were treated with these drugs and who had responded to the medication confirmed the PET derived target levels and with some modifications also those of aripiprazole and clozapine. In vivo characterisation of dopamine receptor occupancy and measurement of blood levels should therefore be part of the clinical trials during the development of new antipsychotic drugs. They provide most relevant information for the later use of therapeutic drug monitoring to optimise the treatment of individual patients.

A dose related reference range is calculated as a concentration range within that a drug concentration has to be expected in human blood specimens under medication with a given dose of the drug. The calculation is based on the direct correlation of the drug dose De (constant dose under long term therapy) to its blood concentration c with the total clearance of the drug (Clt) being the correlation coefficient (De = D / t = c × Clt). The clearance is taken as arithmetic mean ± standard deviation from phase II clinical trials of the drug. Thus the dose related reference range will statistically contain 68,27 % of all the drug concentrations determined under normal condition in the blood of a normal patient, where “normal” is defined as the patient population in the respective phase II clinical trial. It usually consists of patients 18-65 years of age without relevant comorbidity, comedication, and genetic abnormalities in drug metabolism. Therefore, any drug concentration determined outside its dose-related reference range creates a signal to alert for individual abnormalities in a patient such as drug-drug-interactions, gene polymorphisms that give rise to slow/rapid metabolizers, altered function of the excretion organs liver and kidneys by age and/or disease, compliance problems, a missing pharmacokinetic steady state and even signal overlay in the laboratory analysis. A table listing factors that allows the calculation of dose-related reference ranges for all relevant psychopharmaca will be included in the first update of the TDM consensus guideline to be published in Pharmacopsychiatry.

Movement disorders in psychiatry can be divided in those related to an underlying neurological or other somatic disease, related to a psychiatric syndrome, drug induced and psychogenic. In this workshop the typical clinical aspects of each of these movement disorders will be discussed and shown on video with the focus on drug induced. Drug induced can be divided in acute and tardive movement disorders. Acute movement disorders such as acute dystonia, akathisia, parkinsonism and mycoclonus, start short after taking dopamine receptor blocking agents, often an antipsychotic. Once recognized they are relatively easy to treat. Tardive movement disorders such as tardive dyskinesia and tardive dystonia start months or years after using dopamine receptor blocking agents. Treatment is often disappointing, therefore prevention is needed.

Patients with movement disorders do not always complain about their ‘troubles with muscles’ spontaneously, and sometimes, often out of shame, they try to hide their involuntary movements. E.g. a hand tremor can be temporarily suppressed by pushing the hand against the body or sitting on it. To reveal these movement disorders, a systematic investigation of the patient is required. This investigation consists of a (hetero) anamnesis and a physical examination. The anamnesis demands knowledge of sensitive questions such as: ‘Do you notice any movements that are not under your control? Do you feel restless: an inability to keep the legs still? Do you tremble, are you slower than usual?’ Next, a physical examination is required. The investigator lets the patient execute several movements such as stretching the arms, opening the mouth and walking.

In this workshop you will learn and practice this highly sensitive examination. In clinical practice this investigation takes less than 5 minutes and will reveal all drug induced movement disorders.

Hypomania is perhaps the most difficult psychiatric syndrome to rule out retrospectively. However, the retrospective detection of hypomania is crucial for a correct diagnosis of bipolar disorder, and particularly bipolar II, and for the implementation of the right pharmacological treatment. Unfortunatelly, still nowadays, the misdiagnosis of bipolar II disorder as unipolar depression is very frequent, and may carry serious consequences for the patients. The availability of a good screening tool for past hypomania episodes would be extremely helpful.

The psychometric study of the development of the HCL-32 scale in Spain exhibits high internal consistency and similar stability over time, in comparison with other instruments such as the MDQ and suggests that this scale may be very useful for the detection of bipolar disorder and past hypomania.

The results of our study suggest the usefulness of the HCL-32 to screen out previous hypomanic symptoms in psychiatric patients, thus leading to better detection results than with the MDQ, although with the possibility of obtaining more false positives. HCL-32 has been shown to be a useful instrument for the detection of hypomania in patients with an affective disorder. The Spanish version exhibits good psychometric properties in relation to sensitivity and specificity. Given the difficulties involved in both the retrospective and cross-sectional diagnosis of hypomania, a key aspect of appropriate management of bipolar disorders, this questionnaire represents a potential improvement in clinicians’ ability to detect and correctly treat bipolar disorder, and in some aspects such as internal consistency, obtains better results than the MDQ.