A carefully planned comprehensive and integrated care model of in- and outpatient depression treatment is a promising way to achieve improvements in care. Within the framework of the Freiburg Model of integrated care for depressive disorders a network of psychiatrists and primary care physicians offers in collaboration with the Department of Psychiatry and Psychotherapy of the University of Freiburg a coordinated treatment for patients with depressive disorders. Complementary to an evidence-based outpatient treatment the department of Psychiatry and Psychotherapy offers a complex treatment where patients can use the different inpatient measures during their outpatient treatment. In addition patients with a chronic depression can make use of a specific treatment program.

In spite of the fact that suicidal behaviour is very complex, multicausal human behaviour, untreated current major Axis I affective disorder (bipolar and unipolar major depressive episode: 56-87%) is the most powerful predictor of suicide, particularly in the case of prior suicide attempt. Prospective and retrospective follow-up studies clearly support the eivedent clinical observation that if patients with unipolar or bipolar mood disorder committ or attempt suicide, they do it mostly during the major depressive episode (78-89%) and less frequently in dysphoric mania or mixed affective episode (11-20%) but very rearly during euphoric mania or euthymia, indicating that suicidal behaviour in mood disorder patients is a state-dependent phenomenon. Consequently, effective treatment of acute major mood episodes and successful long-term management is very important part of suicide prevention of patients with affective disorders. Indeed, it has been repeatedly demonstrated that long-term lithium treatment of bipolar disorder and unipolar depression reduces the risk of completed and attempted suicide markedly, even in this high-risk population. The marked anti-suicidal potential of lithium seems to be more than the simple reflexion of its phase-prophylactic effect, as it has been demonstrated that during the long-term prophylaxis of recurrent unipolar and bipolar affective disorder patients with at least one prior suicide attempt, a significant reduction in the number of suicide attempts was found not only in the excellent responders (93%), but also in moderate responders (83%) and in poor responders (49%).

Migration is perhaps best understood as a sociodemographic context that can increase vulnerability to both mental health problems and emotional crisis. Crisis can be understood as a specific moment of psychological upset that the individual experiences as beyond his or her capacity to cope with effectively. Migrants in crisis, from this perspective, are different from native born individuals on two major fronts. One has to do with the degree to which migration constitutes a stressor, and the other the degree to which culture and migration impact the stress process A contextual process model of acculturative stress will be presented as a means of making sense of migrants in crisis. Specifically, a crisis occurs with a sort of accumulation of stressors, that are appraised to constitute a grave danger to individual or collective well-being, and, in turn, the evaluation that the individual or collectivity does not have the necessary resources-psychological, social, and material—to mitigate the deleterious effects of the event or situation. Migrants may be more susceptible to crisis precisely because they have access to fewer social and material resources and because their psychological resources-particularly coping styles—may not be consistent with what is normative in the host culture. Effective response at both the clinical and institutional levels requires appreciation of the complexity of the issue without falling prey to cultural reductionism.

Migration-related factors could be additional risk factors for the development of depression and suicidal behaviour in migrant populations. In particular, the success or failure of migration will impact on migrants’ mental well-being. The premigration experiences, the act of migration itself, the motive for migration, postmigration experiences and the structural prerequisites in the host country play a central role. On the basis of the results of a population based study on the factors associated with mental distress in female Turkish migrants in two German cities (Berlin, Hamburg) the impact of migration-specific factors on the expression of mental distress will be discussed. Factors which will be examined among others are, reasons for migration, residence status, perceived ethnic discrimination and acculturation strategies, socio-economic status and traumatic experiences (pre- and post-migration).

A nationwide register study was carried out in Denmark comprising 50,877 persons aged 18-66, who were registered in 2003 in the Danish Psychiatric Register or the National Patient Register with a psychiatric ICD-10 diagnosis.

Of the population 87.1% were ethnic Danes, 7.8% migrants, 4.0% descendants with one Danish born parent, 0.7% descendants with both parents born outside Denmark and 0.3% foreign adoptees. Males comprised 49%, women 51% of the population.

The 5 ethnic groups had significant differences in utilization of care, in diagnostic distribution and in the use of coercion.

Self-mutilating behaviour was seen more frequently among female descendants from non-Western countries than among migrant women from non -Western countries as well as among young adopted women. Similarly, we see that personality disorders were higher in adopted and descendant young women. In males, we found that substance abuse was higher among men in all ethnic groups, but lower among migrant groups compared to Danes.

The paper will discuss possible explanations to these findings in terms of e.g. cultural identity, acculturation and gender issues and relate findings to findings found in other European countries.

The process of migration can be a risk factor for suicidal behaviour. Factors such as circumstances of the migration and individual characteristics like age, education, and his offspring play an important role. The empiric evidence of today's suicide prevention therapy strategies - following a suicidal crisis or a suicide attempt - in order to prevent prospective crises are limited. There are not enough protective therapy recommendations. Psychotherapeutic interventions and antidepressants are not proven to be better than a standard treatment. An appropriate treatment of depression (antidepressant, psychotherapy, psychoeducation, self-help) seems to be preventive. In this contribution the current state of epidemiology, ethiopathogenesis, models of suicidal behaviour and suicide prevention will be discussed.

The classical mechanisms of action of antidepressants suggest that they act through inhibition of monoamine transporters. There is evidence that antipressants indirectly modulate GABA-A receptors through neurosteroids. We showed that antidepressants may also directly modulate the function of the serotonin type 3 (5-HT3) receptor in an allosteric fashion. This non-competitive inhibition of receptor function occurred with different classes of antidepressants including tricyclic antidepressants, SSRIs and NARIs. Moreover, these antidepressants were differentially accumulated in lipid rafts. Their concentartions in lipid rafts were related to their ability to allosterically modulate this ligand gated ion channel. However, lipid raft integrity was not a prerequisite for the allosteric modulation of this ion channel by antidepressants. Morover, differential results were observed with regard to NMDA and GABA-A receptors. Our data show that the allosteric modulation of ligand gated ion channels is an underestimated pharmacologcical principle which challenges the concept of target specificty of antidepressants for monoamine transporters.

Clinical studies have demonstrated an impairment of glucocorticoid receptor (GR)-mediated negative feedback on the hypothalamic-pituitary-adrenal (HPA) axis in patients with major depression (GR resistance), and its resolution by antidepressant treatment. This GR impairment is driven by different pathophysiological mechanisms, including the effects of inflammatory mediators, changes in GR-associated proteins, reduction of intracellular access of glucocorticoid hormones, and GR gene variants. Our research has looked at the multitude of pathways affecting GR and MR function, using both clinical models and experimental systems, including most recently the use of prednisolone as a new neuroendocrine test, the in vitro evaluation of GR function in peripheral blood cells from depressed patients, the use of mice with knockout glucocorticoid transporter (p-glycoprotein) genes, and the examination of polymorphisms in inflammatory genes. This presentation will review our most important recent findings in this field, including:

1. 1) that GR in peripheral blood mononuclear cells is resistant to the modulating effects of antidepressants in the context of increased activation and production of interleukin (IL)-6;

2. 2) that p-glycoprotein knockout animals have normal entry of corticosterone into the brain but do not show the effects of antidepressants on the HPA axis;

3. 3) that polymorphisms in the IL-6, IL-10, phospholipase A2 (PLA2) and cyclooxygenase-2 (COX-2) genes regulate the interaction between stress, inflammatory challenges and the development of mood and somatic symptoms; and

4. 4) that, in contrast to the GR, the mineralocorticoid receptor (MR) function remains intact in depression, except in a subgroup of individuals who do not respond to treatment.

Growing evidence suggests that alterations in cytoskeletal microtubules dynamics may be involved in the effects of antidepressant drugs on brain structural neuronal plasticity phenomena such as remodelling of axons and dendrites. The speaker will review the most recent data in the field obtained in either naïve animals or in animal models of stress/depression. These results were gathered using a multidisciplinary approach, ranging from behavioural tests to neurochemistry and molecular analyses of specific markers of microtubule dynamics and synaptic remodelling. Several classes of antidepressant drugs have been shown to differentially modulate the expression of microtubular proteins and synaptic markers in specific rat brain regions depending from the dose and length of administration. Importantly, such antidepressant-induced effects on microtubular and synaptic proteins showed a very different pattern of changes in environmental (social isolation from weaning) or genetic (Flinders Sensitive Line) rat models of depression, which were not always accompanied by recover of the “depressive-like” behavioural phenotypes. Therefore, antidepressant drugs can modulate brain cytoskeletal and synaptic remodelling, but the pattern of these phenomena seems related to a complex gene-environment interaction. These data may be considered of translational human relevance when put in the context of partial- or non responders to antidepressant therapy. Finally, MAPREG developed new molecules specifically targeting neuronal microtubules and promoting structural neuronal plasticity, which may represent novel tools for the therapy of depressive disorders. Novel data on the antidepressant efficacy of one of these promising molecules in rat models of depression will be presented.

For years, addiction prevention was centered on substance abuse. This focus has shifted recently, especially in regard to children and teenagers, with a growing concern on potentially knotty behaviors, namely gambling and computer, Internet or video game abuse. With the recent soar and availability of the new technologies, it is however extremely difficult to assess which kind of behavioral patterns can be considered as normal, or not, in the contemporary teenage population. To gather benchmark results, we therefore initiated two nationwide surveys, reaching all the students enrolled in the public or private high schools in the Grand Duchy of Luxembourg.

The first survey aims at assessing the frequency and modalities of gambling in Luxembourg's high school students. These data will be especially relevant for the pending legislative discussions whether the national gambling regulations should include a paragraph about the protection of minors or not.

The second survey aims at assessing multimedia use by Luxembourg's high school students. These questions not only inquire the accessibility to various technologies, but also try to depict teenagers’ daily behavior and use of the available technologies. The main objective of this survey is to assess to which extend the technologies are used in different tasks (i.e. work, communication, leisure), but also to appraise whether this population has pleasing access to the current media.

Schizophrenia is an ethologically heterogeneous disorder with a complex gene environment interaction as the most likely cause. A number of susceptibility genes, such as DTNBP, NRG1, DISC1, G72 and others have been identified. However their pathophysiological mechanisms are not yet fully understood. Further, a number of environmental factors (birth complications, cannabis abuse, etc) have been replicated as risk factors. Traditionally, Schizophrenia is being diagnosed according to psychopathological criteria. Yet, there is little data on the interaction between etiological factors, psychopathology and brain function/structure. On the behavioural level, psychopathological symptoms can hardly separate the many pathophysiological subgroups. Contrary to nosological categories, biologically based phenotypes - referred to as intermediate phenotypes - consisting of neuropsychological, electrophysiological, functional and structural brain imaging parameters, could represent the etiological basis more directly, but these findings have to be linked to psychopathology. In this presentation, we will try and bridge the gap between these levels of description in an attempt to disentangle nosological and dimensional features of psychosis.

Promotion, prevention and early intervention (PPEI) are now part of the jargon in health policy statements, but accommodating this in conventional health and mental health services is proving difficult. Effective collaboration across services in mainstream health, psychiatry, other social agencies and into the community is not easily accomplished. One fundamental problem is that the terms: “early intervention” and “mental health” are defined differently by different disciplines and specialties; another is that underlying issues for the woman and family are poorly understood. In addition, there are many silos, stakeholders, egos and agendas, and much competition for funds. For best PPEI results in the perinatal field, these barriers must be overcome. An inclusive model of service delivery being implemented in both public and private health systems in several States in Australia will be described and the resistances discussed.

Contrary to the previously spread myth, pregnancy does not protect women from either relapses of previously diagnosed psychiatric illness nor development of new ones. Prevalence of psychiatric illnesses during pregnancy is similar to that in the general population, whereas that number significantly increases in the postpartum period. Peripartum has its own uniqueness for both etiology and presentation of different psychopathological conditions.

Multiple studies have been published describing affective, anxiety, and psychotic illnesses in peripartum. Specific psychosocial circumstances during that time along with multiple physiological changes occurring in female body in that reproductive period predispose women with and without previous psychiatric histories, to various psychiatric illnesses. Several potential contributing factors for these phenomena have been proposed so far. One of the most frequently studied ones has been the drastic hormonal shift occurring during peripartum that could directly increase the sensitivity for developing mood instability, anxiety and/or psychotic symptoms. Genetic predisposition and previously existing psychiatric disorder especially those occuring during specific reproductive phases significantly increase the risk as well. Presentation of psychiatric illnesses during peripartum has its’ particularities which are essential to understand of in order to provide an appropriate care.

Being aware of the potential etiology and risk factors as well as sensitivity to psychopathology of some women in peripartum could greatly improve treatment as well as open up avenues for prevention in this area. Unrecognized and untreated psychiatric illnesses in peripartum have serious consequences.

Psychiatric disorders are relatively common among women of childbearing age, who may become pregnant while they are taking psychotropic drugs. There remains a high level of anxiety regarding their safety among women and healthcare providers alike, most likely because of the conflicting studies that have been published in the literature and warnings from government organizations. In addition, most recently in the case of paroxetine, a successful lawsuit against the manufacturer, holding them responsible for a baby born with a heart defect, following use of the drug by the mother in the first trimester of pregnancy. Consequently, treating a psychiatric disorder during pregnancy with pharmacotherapy, is a complex decision making process, which has to be made between the pregnant woman and her health care provider following careful evaluation of the evidence-based information.

The objective of this presentation is two-fold,

1. 1) to discuss models used for studying the use of drugs in pregnancy and

2. 2) to provide current information on the safety/risk of psychotropic drugs used in pregnancy.

The body of evidence in the literature to date suggests that psychotropic drugs as a group are relatively safe to take during pregnancy and women and their health care providers should not be unduly concerned if a women requires treatment. Optimal control of the psychiatric disorder should be maintained during pregnancy, the post partum period and thereafter. All pregnancies where a mother has a serious psychiatric disorder should be considered high risk and the mother and fetus, carefully monitored.