The outcome of depression can be affected after chronic use of antidepressants, because of the spectrum of side effects affecting compliance and quality of life. Among the most disabling side effects are sleep disturbances and sexual dysfunction.

Agomelatine, with its unique pharmacological profile acting as an agonist at melatonergic receptors and as an antagonist at 5-HT2C receptors, improves sleep and does not affect sexual functioning in major depressive disorder. In one study, agomelatine 25 mg, increased slow-wave sleep and normalized its distribution throughout the night (P<0.05) without altering REM sleep. In another study, agomelatine 25-50mg, compared with venlafaxine 75-150 mg, showed similar antidepressant efficacy and demonstrated significant sleep improvement (LSEQ questionnaire) as early as from the first week of treatment (P=0.007 for getting off to sleep and P=0.015 for quality of sleep). This improvement was maintained throughout the entire 6-week treatment period, with a parallel improvement in daytime alertness.

A comparison of sexual functioning in depressed patients treated with agomelatine or venlafaxine indicated that agomelatine 50 mg had a better sexual profile than venlafaxine XR 150 mg in remitted patients after 12 weeks of treatment on both orgasm and preorgasm measures; both treatments showed comparable antidepressant efficacy. To confirm the favourable effects of agomelatine on sexual functions, a study in healthy volunteers has been carried out and these results will be discussed.

In conclusion, agomelatine is a novel antidepressant that ameliorates disturbed sleep and leaves sexual functioning unaffected, thus improving both depressive symptoms and quality of life of depressed patients.

Patients with schizophrenia and bipolar disorder carry a heavy burden of medical comorbidities. Patients with schizophrenia or bipolar disorder have a life expectancy that is 15 years less than that of the general population. This increased mortality is partly associated with factors inherent to the patients' psychopathology. For example, the risk of suicide is about 20 times higher than that of the general population. However, despite increased psychiatric mortality, cardiovascular disease is the primary cause of death in patients with schizophrenia. While some of this morbidity is the acknowledged result of long-term antipsychotic medication, not all can be explained by pharmacotherapy-for example, patient lifestyle choices may account for at least part of this elevated risk. Smoking, for example, is much more common among patients with schizophrenia than the general population. However, psychotic patients often have undetected general health problems despite a higher than average physician consultation rate, suggesting that there is inadequate monitoring and treatment of the physical health of individuals with mental health problems. This may reflect the fact that mental healthcare is separated from physical healthcare in many countries and access to primary healthcare is often limited for individuals with mental illness.

Second-generation antipsychotic drugs (eg, olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone) have a reduced incidence of extrapyramidal side effects compared with first-generation neuroleptics, leading to increased use in psychiatric practice. However, some second-generation antipsychotic drugs can increase cardiometabolic risk by increasing risk for weight gain, dyslipidemia, and insulin resistance. Growing evidence, including baseline metabolic data from the CATIE study, indicates that patients with schizophrenia have an increased prevalence of metabolic syndrome (obesity, hypertension, hyperglycemia, dyslipidemia, and hyperglycemia). In CATIE Phase 1 and 2, treatment with different antipsychotic medications is associated with different effects on weight, plasma lipids and risk of hyperglycemia, ranging from clinically significant increases to decreases in metabolic risk. While mortality related to cardiovascular disease is elevated in this patient population, cardiovascular disease risk is under-monitored and under-treated. Current public health efforts aim to increase attention to this at-risk population. Long-term treatment strategies in persons with mental illness should aim to address psychiatric illness as well as key medical comorbidities.

Treatment goals in schizophrenia and bipolar disorder are no longer simply the reduction of psychosis and manic or depressive episodes. Today's treatment goals encompass a broader improvement of quality of life and, as much as possible, the return of patients to premorbid levels of functioning. To achieve these wider-reaching goals, patient care must simultaneously address not only patients' psychiatric illness but also their medical problems. In addition to reducing mortality, there are good psychiatric reasons for addressing the physical well-being of patients: the presence of a comorbid physical illness worsens the prognosis of the mental disorder and vice versa. General medical monitoring should form as much a part of the routine management of patients with long-term mental illness as should psychiatric reviews, and any barriers between diagnosis and treatment in these patients should be examined. The care team needs to be expanded beyond the core psychiatric team, and patient access to primary medical care needs to be improved to ensure parity of medical treatment with the general population. As patient function improves, patients and their families can become more involved in self-management and feel empowered to affect their own outcomes.

Clinically based diagnostic criteria for DLB have limited accuracy. The availability of a biomarker to assist with diagnosis would be a major advance. Severe nigro-striatal degeneration and dopamine loss occurs in DLB but not in most other dementia subtypes offering a potential system for a biological marker. In the PDT-301 study, 326 patients with dementia with clinical diagnoses of probable or possible DLB, or non-DLB dementia established by a Consensus panel, had a FP-CIT SPECT brain scan labelling the dopamine transporter (DAT) reuptake site in the striatum. Three readers, blinded to clinical diagnosis, classified the images as normal or abnormal by visual inspection. This study which was conducted across 40 European sites, confirms the high correlation between abnormal (low uptake) DAT activity measured using FP-CIT SPECT and a clinical diagnosis of probable DLB. The diagnostic accuracy is sufficiently high for this to be clinically useful in distinguishing DLB from AD.

Although good epidemiological data do not yet exist, Dementia with Lewy bodies (DLB) is increasingly recognized as one of the most common causes of dementia after Alzheimer's disease (AD). The identification of DLB has important implications in terms of prognosis and patient management. These patients frequently develop motor, psychiatric, and sleep-related disturbances in addition to the dementia syndrome, and information and re-assuring of patients and caregivers are important. In addition, drug treatment of patients with DLB is different from that of AD patients. DLB patients may respond better to cholinergic and dopaminergic agents, but are more likely to develop severe side-effects when treated with anti-psychotic agents, including the atypical ones.

However, diagnosing DLB may be difficult. Several studies have demonstrated a low diagnostic sensitivity compared to AD when using international consensus criteria for a clinical diagnosis of DLB. Thus diagnostic markers are needed to improve diagnostic accuracy. Although emerging data indicate that neuro-imaging techniques such as structural MRI and perfusion SPECT may differentiate AD and DLB at group level, there is too much overlap for these techniques to be useful in the diagnosis of individual patients. Accordingly, the finding that Dat scan can reliably distinguish patients with DLB from those with AD, even DLB patients without parkinsonism, can improve patient management. The most important situation is a patient fulfilling DLB criteria but without parkinsonism, where Dat scan ascertain involvement of the nigrostriatal system typical for DLB. Another potentially important situation is a patient with dementia and parkinsonis and psychosis treated with antipsychotic, where it is unclear whether parkinsonism is secondary to the antipsychotic drug treatment or part of the dementia syndrome. Cases illustrating these clinical dilemmas will be presented and discussed.

Overweight/obesity is a growing concern throughout the general population. The prevalence of overweight and obesity in schizophrenia is high, compounding the burden of an already devastating illness. This is making overweight/obesity an important consideration if the physical health of patients is to be improved. Ultimately, overweight/obesity results from an imbalance between food intake and energy expenditure over several years. However, the pathophysiology of overweight/obesity is complex and involves interactions between environmental, behavioural and genetic factors. There is compelling evidence that patients with schizophrenia are more prone to weight increase than the general population. Although a number of social factors contribute to the increased risk of overweight/obesity and metabolic disturbances in patients with psychiatric disorders, there is also evidence that genetic factors may play a role. Additionally, many psychiatric medications are known to be associated with weight gain. It is thought that weight gain may be related to neurotransmitter-receptor affinity, which can have multiple effects on energy homeostasis. For example, histamine H1 receptor affinity has been shown to predict short-term weight gain with both typical and atypical antipsychotics.

Obesity, especially abdominal obesity, is associated with a number of adverse health consequences. These include an increased risk of glucose intolerance, insulin resistance, Type 2 diabetes, dyslipidaemia, hypertension and cardiovascular disease. In addition, the presence of metabolic syndrome, a cluster of metabolic disturbances, significantly increases the risk of cardiovascular morbidity and mortality. It can therefore be seen that there is an urgent need to start identifying schizophrenia patients who are at risk to help improve long-term health outcomes.

Metabolic abnormalities have consistently been identified as a part of schizophrenic illness, but with the introduction of second-generation antipsychotics and their possible association with metabolic abnormalities, the interest in this topic has been renewed. Many studies have now provided convincing evidence for a high risk of obesity, diabetes and other glucose abnormalities, the metabolic syndrome, and mortality due to elevated cardiovascular risk in patients with schizophrenia. These metabolic abnormalities are of major clinical concern, not only because of their direct, somatic effects on morbidity and mortality, but also because of their association with psychiatric outcome, such as a higher prevalence of psychotic and depressive symptoms, a lower functional outcome, a worse perceived physical health and lower adherence to medication. The reasons that underlie the high prevalence of these metabolic abnormalities are much debated, especially when considering the possible role of second-generation, 'atypical' antipsychotics in the occurrence of these abnormalities. Many studies have suggested a role of (certain) atypical antipsychotics in the occurrence of metabolic abnormalities; case reports, cross-sectional or retrospective studies and prospective studies. Different consensus groups have proposed guidelines for screening, monitoring and management of metabolic abnormalities for people treated with antipsychotic agents.

As well as the obvious medical consequences associated with physical health problems in individuals with schizophrenia, physical health problems lead to a number of psychosocial consequences - further contributing to the existing burden of schizophrenia itself. Weight gain is one that may have repercussions on both psychosocial and economic parameters. Weight gain can seriously impair quality of life through decreased functioning, social stigmatization, discrimination, and potential financial consequences. Obesity and being overweight appear to have the same impact on the self-esteem and well-being in people with schizophrenia as those in the general population, and it has been shown that patients who experienced recent weight gain had lower psychosocial adjustment and self-esteem compared with patients without weight change. However, patients with schizophrenia may be less capable of managing their weight via exercise and dietary interventions compared with the general population, and may, therefore, be more prone to non-compliance with a medication that induces weight gain. This may lead to exacerbation of the mental illness. Patients with schizophrenia may also experience other physical health problems owing to the tolerability profile of antipsychotic therapies, such as sexual dysfunction or extrapyramidal symptoms; such adverse effects also have the potential to impact on patient well-being, quality of life, functioning and compliance with therapy. Patients' perceptions and experience of antipsychotic treatments are also important as these can further impact on overall patient wellbeing. It is hoped that by increasing awareness of the psychosocial consequences of physical health impairment, we can move towards reducing the burden that patients face.

Many problems such as non-response, pharmacokinetic interactions with clinical consequences and adverse effects (pharmacovigilance) may be observed in patients submitted to psychopharmacotherapy. 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. Pharmacokinetic and pharmacogenetic tests are useful to solve problems in psychopharmacotherapy and thus improve efficacy and safety. Therapeutic drug monitoring (TDM) is particularly recommended in situations presented above and in patients who are non-compliant. In addition, the use of generics has been shown to represent a source of unexpected treatment outcomes, and TDM may help to explain pharmacokinetic particularities after switching from an original to a generic preparation (or vice versa). Finally, the increasing knowledge of the metabolism of psychotropic drugs allows taking account of the pharmacogenetic status (e.g. cytochrome P-450, P-glycoprotein) of the patients not only in adapting their medication, but also for interpreting pharmacokinetic interactions with clinical consequences. In this respect, pharmacokinetic and pharmacogenetic tests have now also to be considered as a tool in pharmacovigilance programs.

Psychiatrists who already have experience in this field will have their knowledge updated: recent progress will be illustrated by clinical situations, which will be discussed in an interactive way. A consensus paper with recommendations on the optimal use of pharmacokinetic and pharmacogenetic tests will be summarized and submitted for discussion.

Psychiatric outcome studies (POS) of treatment with psychotherapy as well as pharmacotherapy have the following three psychometric measures in common: (a) The rating of core symptoms; (b) the global clinical assessment; and (c) the rating of social functioning or quality of life.

In the psychometric evaluation of these three outcome measures, effect size is the clinically most meaningful statistic, both in placebo-controlled and in dose-response trials.

The clinically most valid outcome scales and the use of effect size statistics will be shown with reference to the literature on POS.

Among a variety of short term psychotherapies created to treat depression IPT (Interpersonal Therapy) by Klerman et al. (1984) is meanwhile one of the most well known and widespread used approaches. A variety of studies have shown empiric evidence of its efficacy. IPT's most influential theoretical grounds are Bowlby´s attachment theory and the interpersonal school of psychiatry (Sullivan), assuming that all psychiatric illnesses incl. depression develop in an interpersonal context: problems areas in interpersonal relations may contribute to onset and potentially chronicity of current depression or/and depressive symptoms may interfere with interpersonal well being/psychosocial functioning.

Based on empirical studies on e.g. life events, social support, stress & depression the authors defined four problem areas:

1. 1) complicated grief

2. 2) interpersonal conflict

3. 3) interpersonal role conflict/role transition and

4. 4) interpersonal deficits/isolation

The therapy is divided in 3 phases: In the initial 3-4 sessions the patients current depression is individually attributed to one of the four problem areas on which will exclusively be focused on within the main therapy section. IPT works in a “here-and-now” framework and connects state and change of depressive symptoms with state and change of (realtime) interpersonal functioning and well being through therapeutic work. The dual goals of IPT are achieving symptom remission and solving attributed interpersonal problem by promoting the interpersonal skills of patients both within and outside the therapeutic setting.

Open and focused exploration, psychoeducation (patient as expert of his/her illness), the transportation of the sick role (Parsons 1954), assessment of the interpersonal inventory/interpersonal resources, instilling hope, the definition of patients and therapist role during therapy, the explanation of the IPT concept, the agreement on the problem area and a therapy contract are basic procedures within introductory sessions in IPT.

In the main period (3/4-14 sessions) patient and therapist work on explore the agreed-upon focus. The IPT manual describes goals and treatment strategies for each problem area. Clarification, self disclosure, communication analysis, option seeking etc. are main techniques in IPT.

During termination period the patient recognizes what was gained, what impairments, problems are left. The motivation for booster sessions (maintenance) is clarified and the patient is prepared about prophylaxis and how to manage crises in the future.

This CME course is meant to teach IPT basics enabling participants of the course to start practicising IPT under supervision. It will be focused explicitly on the following aspects:

• • time frame

• • medical model

• • dual goals of solving interpersonal problems and symptom remission

• • interpersonal focus on patients affective engagement solving current life problems contributing to current depression

• • specific and general psychotherapeutic techniques and

• • empirical support of IPT

Short role-playing will be used to train IPT techniques. A handout will be available.

Multiculturalism in Europe is becoming a reality that increasingly affects most every psychiatrist. Effective mental health treatment adaptations to respond to the myriad ways in which migration impacts psychosocial development, help-seeking, symptom presentation, and all aspects of diagnosis and treatment. The bulk of research and theory in transcultural psychiatry has its origins in North America, and although highly laudable, represents a different context, history, and present with regard to multiculturalism and immigration. It is in response to this situation that the Section on Transcultural Psychiatry offers the following course.

This course will be an introduction to the general themes pertinent to the effective psychiatric care of migrant patients. The first part of the course will provide attendees with a general overview of key aspects relevant to the relationship between migration, culture, minority status and mental health/illness, which will then serve as the basis for the second part which will be focused on psychiatric interventions. The development of Intercultural communication and the development of a strong therapeutic relationship are key for diagnosis and treatment. Errors in the diagnosis of migrant patients is all too common due to differences in symptom presentation and meaning, as well as due to psychiatrist's lack of familiarity with this population. In addition to migration, culture, and minority status, psychiatric treatment is also affected by biological and genetic differences, which are both subtle and complex. Cultural mediation is increasingly being introduced as means of bridging the linguistic and cultural gap between psychiatrist and migrant patient, however, for a variety of reasons, effective use of this resource demands that specific steps be taken and that professionals are sufficiently well trained.

The course will be in the format of lecture, case presentations and group discussion.

The aim of the course is to give adult psychiatrists some basic knowledge in infant psychiatry that has become in the recent years, very relevant to the understanding the link between brain development, early childhood experiences, pathophysiology of personality disorders in adulthood, and psychotherapeutic transferential processes.

The course will be built as follows:

The first part will cover very recent data on the impact of early experiences in general, and attachment experiences in particular, on brain development and development of a theory of mind and empathy. Concepts of resilience, vulnerability, bio-psycho-social risk and protective factors will also be explored in length. Through these basic concepts, we will show how infant psychiatry is linked to prevention of adult psychopathology, and how the early attachment experiences reflect themselves in the psychotherapeutic process.

The second part will be clinical and will illustrate the basic concepts learned in the first part. A clinical case will be presented to show the development of borderline personality disorder from early childhood to adulthood, its transgenerational transmission to the offspring through disturbed attachment relationship, and some of the processes that took place during the dyadic mother-infant psychotherapy. We will show how parenthood can become a new motivation for change.

The course applies who any adult psychiatrist who is interested in the field of developmental psychopathology, and no previous experience with young children is needed. Clinical experience with personality disordered patients will be an advantage.

Concluding the literature in definition, pathogenesis, nosological position and treatment of delusions we are confronted with a wide range of opinions. In the first part of the course the various definitory approaches and their value in clinical practice will be discussed. The main focus of second part of the course is dedicated to the manifold results concerning the pathogenesis of delusions, which showed that delusions are caused by complex interactions of various mental, physical and social factors. The choice of a particular delusional theme is determined by gender, age, civil status, social isolation, and special experiences ("key experiences") whereas the incorrigible conviction is based on cognitive disorders and/or emotional derailments and reinforced by social factors. But delusions cannot be longer reduced to psychopathological manifestations once established and therefore persisting. The delusional conviction is a dynamic process which only persists if disorder maintaining factors become active. These disorder maintaining factors are not necessarily corresponding with the delusion's predisposing and triggering factors. In the third part classificatory problems will be raised. Assumptions concerning nosology and classification of delusions have ranged from an independent nosological entity to the attribution to a certain mental disorder, to multicategorical classification models. Previous polydiagnostic studies indicate that delusional disorders are neither a nosological entity nor due to one particular disorder (e.g. schizophrenia) but represent nosologically non-specific syndromes which may occur superimoposed on all mental disorders. Most of the so-called primary delusions (or delusional disorders in a narrower sense - delusions not due to another mental disorder) have to be considered as diagnostic artefacts caused by the use of diagnostic criteria in particular classification systems. The final part of the course will focus on differentialdiagnostics and differentialtherapeutics. As delusions represent nosological non-specific syndromes with a multifactorial pathogenesis modern integrative treatment approaches (including psychopharmacological, psychotherapeutic and socio-therapeutic methods) have to be based on a multidimensional differential diagnosis of all the predisposing, triggering, and disorder maintaining factors. In this context the disorder maintaining factors provide the basis for effective, pathogenesis-oriented treatment of the actual symptomatology, whereas the predisposing and triggering factors provide informations for planning prophylactic long-term treatment.

During the last 25-30 years a large number of randomized controlled studies have been published on Cognitive behavior therapy (CBT) for various anxiety disorders. CBT is now an evidence based treatment for all the anxiety disorders, and the only form of psychotherapy that has achieved this status.

The purpose of this course is to give an overview of CBT for anxiety disorders and for each of the disorders the following components will be presented: 1) The CBT model of the primary maintaining factor(s) for the disorder, 2) The most important CBT treatment(s) for the disorder, 3) Illustrations from current randomized controlled studies, and 4) Short- and long-term results for each disorder.

By attending the course participants will get the most current update of CBT for anxiety disorders.

Work in psychiatry can be highly rewarding, interesting, and challenging in a positive sense. On the other hand, we are confronted with an array of psychosocial stressors. Caring for others lies at the heart of our profession: the focus is on the needs of patients. And rightly so. Nevertheless, this involves the risk that providers' own needs get out of sight.

This course provides a forum for openly discussing work-related stress and coping strategies. Participants will learn to recognise their own “warning signs” of excessive stress, as well as develop strategies to successfully handle stressful situations, based on their own practical experiences. The course further addresses consequences of stress, such as the risk to develop physical health problems or burnout. Instruments to gauge one's own burnout risk and stress coping pattern will be available for a self-assessment.