Non-response, adverse effects and pharmacokinetic interactions with clinical consequences are frequent manifestations observed in psychiatric patients treated with psychotropic drugs. These risks are increased in patients belonging to the category of “special populations”: elderly patients, children and adolescents, patients with a genetic particularity of metabolism or suffering from somatic or psychic comorbidities. Increasingly, the use of generics has been shown to represent a source of unexpected treatment outcomes. Therapeutic drug monitoring (TDM) is not only recommended in these situations, but especially also in patients who are suspected to be non-compliant. In addition, the increasing knowledge of the metabolism of psychotropic drugs allows the use of phenotyping and/or genotyping techniques (e.g. cytochrome P-450, P-glycoprotein) in patients and to adapt their medication considering their pharmacogenetic status. Pharmacokinetic (TDM) and pharmacogenetic tests are therefore useful to solve problems in psychopharmacotherapy and thus improve efficacy and safety of the drugs. An earlier developed Consensus guideline on TDM (Baumann et al., 2004) has recently been updated (Hiemke et al., 2011).

The practical application of pharmacogenetics is not as straightforward as expected, particularly in psychiatric disorders. Despite the large benefit expected, only a very small numbers of clinical applications are available. The reasons for this are many, in particular the key questions are: Is science robust enough for routine application? Are physicians and patients ready? Are stakeholders (e.g. Government, insurance industry, etc) ready to pay and implementing? What is the position of the pharmaceutical industry?

The presentation will cover such aspects offering a coverage of present status and realistic expectations in the field.

Addictions are frequently occurring mental health problems that are associated with serious morbidity and excessive mortality, suffering of family and friends, societal damage, criminality, public nuisance and in some instances destabilization of certain regions or even countries. In the last decades, effective pharmacological treatments have become available for the treatment of nicotine, alcohol and opioid dependence, whereas new medications are developed and tested for cannabis, cocaine and amphetamine dependence. Unfortunately, the effect of most of the currently available medications is moderate at best. Different strategies have been tested to improve the response to these medications, e.g. combination of different pharmacological treatments, combinations of pharmacological and psychosocial interventions, and patient-treatment matching based on clinical characteristics. So far, these strategies have not been very successful. A promising direction is a better matching of patients and treatments based on differences between patients in their genetic make-up. In this presentation we provide an overview of the pharmacological and genetic background of addiction and the promising findings with regard to recent attempts to improve outcomes by a better matching of treatments and patients based on genetic information.

Bipolar disorder is difficult to treat. There are several options to treat acute mania, but combination of two or more drugs is the rule rather than the exception, indicating the limitations of currently available therapies. The evidence base for the treatment of bipolar depression is much weaker, and again combination is the rule. Although patients with bipolar disorder may experience resolution of symptoms with acute treatment, many will continue to experience impaired functioning due to the episodic, chronic, and progressive nature of the illness. Maintenance therapy is needed for a variety of reasons, including prevention of relapse, reduction of subthreshold symptoms, decreasing the risk of suicide, and reducing the frequency of rapid cycling and mood instability. Although long-term therapy is usually required to maintain or improve functioning and quality of life, it has been a significant challenge to identify clinically effective treatments for long-term management. There are few currently-available, well-tolerated treatment options that are effective in all phases of bipolar disorder and which prevent recurrence of manic and/or depressive episodes. Questions concerning when to discontinue one of the drugs when two or more are used, or how to switch from one mood stabilizer to another, have not been addressed in clinical trials. Electroconvulsive therapy may be effective in treatment resistant cases and can be used as maintenance when pharmacotherapy is not enough. Psychoeducation may help to enhance treatment adherence and healthy lifestyle. A rational combination of the above mentioned strategies may help to optimize the outcome of this challenging condition.

Psychiatric disorders per se or treatment resistance can cause life-threatening conditions. More than 25 years have passed since the term “psychiatric intensive care unit” (PICU) was introduced in the United Kingdom. This system is comprised of security units for psychiatric patients with suicidal or violent behaviour, providing a locked environment with more resources regarding personnel and care. The PICU concept at the Department of Psychiatry and Psychotherapy in Vienna, Austria, represents a progress towards optimal care of patients with serious psychiatric illnesses who also have critical somatic illnesses. One third of the patients are transferred from inpatient facilities of medical departments such as internal medicine, emergency medicine, trauma surgery or anesthesiology. Our PICU is dedicated to somatically, critically ill patients who have psychiatric symptoms (e.g., agition, aggression, impulsivity, delusions, catatonia, confusion, reduced consciousness, impaired self-reliance) complicating recovery from their critical, somatic condition. Generally, the dosages for antipsychotics are not higher than those at normal psychiatric wards. Benzodiazepine dosages of about 30mg diazepam equivalents per day are frequently used. In the years 2008 and 2009, 10% of all patients at the Viennese PICU were treated with electroconvulsive therapy. Delirium requires immediate therapy of underlying intracerebral pathologies, extracerebral illnesses or toxic features. Involuntary commitment, physical restraints and urinary catheterization were applied in approximately 50% of the patients, nasogastric tube or central venous catheter in 20%. In every case, intensive care nursing, monitoring of vital functions and specific experience at the interface between psychiatry and somatic medicine are required.

The first law on mental health dates back to 1904, and attempted to encourage a uniform national discipline of the mental institutions and established as confinement criteria ‘social danger’ and ‘public scandal’.

Very little exists in the scientific literature regarding this topic. A study conducted on the admissions to the Psychiatric Hospital of Collegno and Grugliasco (one of the largest in Italy) has highlighted few predictable aspects of mental health institutions. In particular, it suggests that the stereotype of “psychiatric imprisonment” not only does not correspond to the truth but has become misleading as well. In the past, patients were very often discharged from hospital due to overcrowding and high costs.

In 1978 the Italian Parliament enacted the law Number 180. The importance of this law made admissions compulsory but also authorized the modalities and the timing of the Compulsory Psychiatric Treatment (CPT).

By confronting the data relative to CPT in Turin from 2007 to 2009 (1,159 CPT per 868 subjects) and those dating back between 1985 and 1998 (4,819 CPT per 3,092 subjects) remarkable results emerge as regards psychiatric emergency in Italy. Recently there has been a higher incidence of CPT due to personality disorders, if compared with schizophrenia. It is clear not only the increasingly higher number of patients affected by these disorders, but also their characterization as emergency cases.

In the CPT consent form, terms such as “psychomotor agitation”, “impulsivity” and/or “aggressiveness” are often adopted when making diagnoses both for the clinical evaluation and admission to hospital. These data support the hypothesis that some cases of compulsory admissions are necessary to contain disturbing behaviors, thus confirming CPT as a of social control tool.

The institutional function of the Psychiatric Service of Diagnosis and Treatment in general hospital in Italy (PSDT) is responsible for emergency care. A study conducted for 7 years at our PSDT showed that many patients affected by schizophrenia had a positive history of substance abuse and these cases revealed a more severe psychopathology and a major resistance to treatment.

Very often the Psychiatric Unit ended up to offering health care assistance to patients presenting with social emergency situations. Our data demonstrate a significant statistical correlation between admitted patients and the length of hospital stays.

To fully understand the Italian Psychiatric Reform it is imperative to analyze the university network services and how the 40 Italian universities with psychiatric clinics deal with the education and training of the Mental Health Therapists. The reform established a department model offering diversified and specialized structures within one facility, the Department of Mental Health.

The integration and coordination among psychiatry and the other health care services such as addiction treatment facilities, developmental neuropsychiatry, disability, geriatrics and social services had to be regulated. Providing clinical governance, maintaining and improving the quality of patients’ care within the healthcare system, integrating healthcare strategies and diagnostic and therapeutic approaches will be essential to this project.

Suicide is in Austria one of the most causes of death in the age group 15–54. World wide every year 1.000.000 of people die by suicide, in Europe the number of total suicide per year is 40.000, approxymately 13.500 young man and women aged 15–24 years die by suicide. Suicidology is a science which automatically leads to active work in prevention. Preventive strategies of the last two decades results in a marked decrease of Suicide rates in most countries of the world. However different preventive concepts seems to show similar results in reducing suicide rates. So it is not easy to identify the right way in suicide prevention. We analyzed the publications of the last years and tried to find out what are the characteristics approaches of the the countries with a successful suicide prevention. It seems that countries which istitutionalized suicide prevention by creating institutes on an university level had a good fundament for research and applied research is the best groundwork for establishing preventive projects. Applied research is as well the best ground base for establishing educational programs which are the start in all well functioning national suicide prevention programs.

During the past years substanial knowledge has been obtained both in diagnostics and pharmacotherapy of unipolar depression. Today it is well-established that perturbation of the monoaminergic neurotransmission pathway is implicated in the development of depressive states, and that all currently existing antidepressants act on depressive symptoms by controlling monoamine availability at the synaptic level. According to the data obtained in Europe, it is apparent that these treatments are efficient in only 60–70% of depressed patients and their onset of action is partly delayed by 4–5 weeks. With novel pharmacological approaches recently being introduced, these figures can be improved. With the introduction of agomelatine, for instance, which affects the melatonergic as well as serotonergic pathways, higher response rates than with conventional antidepressants have been demonstrated. Furthermore, treatment of therapy resistance has been advanced with the introduction of atypical antipsychotics. For treatment refractory patients, brain stimulation as well as vagus nerve stimulation showed promising results although the later two methods are only possible in specific treatment centers. The advances in pharmacogenomics and sequencing of the human genome promise for the future to have molecular targets which have not as yet reached the daily practice. The search for new antidepressants based on these considerations has not been completed and the recent findings are promising for the future in regards to research and treatment. The lecture will include data on the neuropsychopharmacological understanding furthermore the future perspectives of treatment approaches will be discussed.

Depression in Indian Perspective is a major psychiatric problem. India is diverse country having many sociocultural factors, gender issues, Poverty and lack of appropriate psychiatric care. It is observe that patients use other modalities like yoga, satsang, Social support to deal with minor to moderate Depression. Severe problems are handled by about 4,000 psychiatrist for a total of hundred billon population and this facility are mainly centered around metropolitan cities. This paper discusses the relative merits and demerits of diagnostic problems and the management of depressive states.

Introduction A number of studies have shown that there is international variation in the prevalence of common mental disorders. Several factors have been suggested to explain such differences. Methodological challenges to comparability include: differences in settings, samples, assessment methods, and reporting practices. Also, cultural differences have been pointed out as possible cause of differential recognition and reporting of mental health issues. There is still uncertainty about the degree of international variation in the prevalence of mental disorders, and the lack of comparability of results is still an issue.

Objectives We assessed the prevalence and impact of mental disorders in the WHO World Mental Health (WMH) Survey Initiative, using common survey, assessment and reporting methods.

Methods The WMH surveys were completed in 24 countries from Africa, the Americas, Asia, Europe, the Middle-East and the Pacific. Representative samples of the adult, non-institutionalizes population were interviewed face-to-face, with the aim of estimating the prevalence, burden and unmet need for treatment of common mental disorders. The Composite International Diagnostic Interview (CIDI, 3.0) was used in all surveys to assess mental health status. Common mental disorders assessed included: anxiety, mood, disruptive behaviour, and substance disorders. Several standard measures of disability, both generic and disorder-specific, and role impairment were administered.

Results Results show that the mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25th–75th percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, disruptive behaviour, and substance disorders) is 18.1–31.1%. The IQR of 12 month prevalence estimates is 9.8–19.1%. Prevalence estimates of 12-month Serious Mental Illness (SMI) are 4–6.8% in half of the countries, 2.3–3.6% in one-fourth and 0.8–1.9% in one-fourth. Possible causes of international variation will be addressed. Analysis of age-of-onset reports shows that many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions. Mental disorders are found in the WMH data to be associated with high levels of role impairment.

Conclusions Despite this burden, the majority of mental disorders go untreated. Although these results suggest that expansion of treatment could be cost-effective form both the employer perspective and the societal perspective, treatment effectiveness trials are needed to confirm this suspicion. The WMH results regarding impairments are being used to target several of these interventions.

Additional information about the WMH Surveys Initiative and the funing of the project can be found at: http://www.hcp.med.harvard.edu/wmh/

Culture forms a part of one's identity. Cultural beliefs are intricately interwoven not only in conflicts and psychopathology but also in conflict resolution. With classificatory systems, now understanding and emphasizing on a ‘person-centred’ approach, the need to integrate cultural beliefs and attitudes can not be understated. With globalization, awareness and understanding of cultural beliefs, values, scriptures, practices, rituals and festivities, can help in personal growth, understanding psychopathology, establishing trust and rapport, aid in the help-seeking process, holistic management of the patient in a more acceptable, sensitive and compliant manner. Revisiting scriptures and trying to understand the insights gained in the past era can add on to the knowledge and skills used in the practice of Psychotherapy. Models of cultural integration that can be utilized in the teaching and practice of psychiatry, in understanding preventive psychiatry and stress-management shall be presented. Such integration shall be a definite step forward to a ‘person-centred’ approach and in addressing the soul of science.

The lifetime prevalence of mood disorders is estimated around 20% in the general population leading to a main cause of disability worldwide and a major public health issue.1 The ethiology of mood disorders is still unknown, but its various phenotypes are believed to be caused by multiple genetic variants interacting in a complex way with environmental vulnerability factors. Therefore, the identification of biomarkers and environmental markers is crucial to improve our understanding and diagnosis as well as our treatments. Despite intensive and costly research for more than two decades to unravel suceptibility genes, although pathophysiological pathways of interest have been recongnized, results have not been consistant so far and not a single genetic biomarker of depression has been identified and replicated. More recent systematic genome-wide association studies (GWAS) have reported weak associations of some genetic variants in large samples, but multiple rare variants may concur to confer only part of the suceptibility to depression. Structural variations may also be considered to be promising as is the case for copy-number-variations (CNVs). Methodological issues and limitations will also be critically discussed in light of the complexity of gene-evironment interactions (epigenetic modulation of gene expression)2 and in relation to future prospects for individualized pharmacotherapy of depressive illness.

Those with psychiatric disorders have long suffered from prejudice, their illnesses and suffering often trivialised by journalists in their columns and by government agencies. Tougher regulations appear to be imposed on the licensing of new treatments in psychiatry and harsher criteria for their reimbursement by government agencies compared with other therapeutic areas despite clear evidence that these disorders are associated with the highest levels of suffering and disability according to the WHO.

For a new treatment for a psychiatric disorder to be licensed in the EU more studies meeting stricter conditions are required than is the case with equivalent licensing authorities such as the FDA. For example, in the EU a comparator arm is required in clinical trials in addition to the more scientific placebo control. There is no adequate justification for this demand which appears to confound the demonstration of efficacy and safety versus placebo with pricing issues. A further hurdle in the EU is the requirement that long term efficacy compared to placebo is established before a treatment can be licensed which causes delay in bringing the drug to the market and adds to the cost of development. The process might be eased if access to specialist advice by the licensing agencies, strictly limited in the CHMP in contrast to other agencies, were improved.

Difficulties in the licensing process and delays following the granting of a licence inevitably have a negative effect on the viability of developing new treatments. Even when a licence is granted transparency/pricing commissions are the source of serious delays before clinicians are allowed to prescribe the treatment. Delays in allowing access to treatment by EU citizens can be so long that medications become available only after they have come off patent. These issues have led some pharmaceutical companies to withdraw from the development of treatments in psychiatry for the EU market and to close their neuroscience laboratories. The resulting loss of expertise in neuroscience will not be easily reversed. Psychiatric patients in the EU will find that the options for new treatments of their serious disorders are declining compared with other countries.

Major depressive disorder is reported to be the most common mental disorder, with a lifetime prevalence in the community ranging from 10 to 25% in women and from 5 to 12% in men. These figures are frequently quoted in the psychiatric literature, but are viewed by many, both outside and within the psychiatric field, with a substantial degree of skepticism. From outside the psychiatric field, it has been pointed out that “determining when relatively common experiences such as sadness should be considered evidence of some disorder requires the setting of boundaries that are largely arbitrary, not scientific, unlike setting the boundaries for what constitutes cancer or pneumonia” (1). From within the psychiatric field, it has been stated that “based on the high prevalence rates identified in both the ECA and the NCS, it is reasonable to hypothesize that some syndromes in the community represent transient homeostatic responses to internal or internal stimuli that do not represent true psychopathologic disorders” (2). It is likely that these arguments will be increasingly endorsed by the public opinion in the years to come, and it is therefore crucial for our profession to articulate a convincing response to the question “When does depression become a mental disorder?”. In this presentation, I will summarize three approaches to this issue, pointing out their weaknesses and the lessons we may take from each of them. The first approach is the one proposed by Wakefield (3), emphasizing the context in which depressive symptoms occur. The second approach is the one endorsed by several European psychopathologists, according to whom there is a qualitative difference between true depression and normal sadness, a difference which has been lost in the recent process of oversimplification of psychopathology. The third approach is the one according to which, since there is a continuity between “normal” sadness and clinical depression, the boundary has to be decided arbitrarily on pragmatic grounds. This is what the DSM-IV actually tries to achieve, regarding depression as a “disorder” when it reaches a given threshold in terms of severity, duration and degree of suffering or functional impairment, thus deserving clinical attention. The problem is, however, that the threshold fixed by the DSM-IV for the diagnosis of major depression is not only arbitrary, but also not based on reasonably solid pragmatic grounds (4).