In our presentation we look at the outcomes of mental health patients with a treatment order (in Spain called “Medidas de Seguridad”) for people suffering from a mental disorder that had committed an offence. This kind of order could apply (generally related with severity of offence) for compulsory treatment in community, psychiatric hospital or psychiatric penitentiary units.

The sample are patients with “medidas de seguridad” (treatment orders) that they finished it between 2005 (April) and 2009 (April), in each of the types where they were admitted (community, hospital and prison psychiatry), The geographical area of study will be Barcelona province (about 5.500.000 population).

The number of patients included in all types of tretament order were 220 patiens (108 admitted and 112 in community treatment).

The variables that we will look there are:

1. 1) When they finish the order (gender, psychiatric diagnoses on discharge, psychopharmaocological treatment and kind of psychiatric follow-up recomended, type of offence and length of treatment order.

2. 2) In the outcome will look at variables like psychiatric diagnosis (in order to see the diagnosis stability), accommodation (housing), recidivism, treatment and working (other legal and social factors) and hospital admissions and current psychiatric follow-up.

There are few studies that review the outcome of patients having a treatment order and serving a sentence in the long term. We also try to compare these groups with people suffering from a mental illness and no serving sentences. Economic differences between the groups will be also analysed.

There is robust empirical evidence for the efficacy of offense-oriented treatment programs. These programs help reducing the rate of recidivism. In the case of sex-offender treatment, a lower rate of recidivism results in lower rate of victims. For the victims, experiencing sexual assaults is a relevant risk factor for the development of a series of mental health disorders. It is thus not surprising that sex-offenses lead to substantial financial costs and preventing sexual re-offending help reducing treatment costs.

In Switzerland, a longitudinal study, that started in 2000, allowed to compare the outcome of more than 300 treated violent and sex-offenderswith a control group of untreated offenders. Though the risk for re-offending was estimated to be higher in the treatment group, the rate of recidivism was considerably lower. Using this difference of re-offending among the groups, it could be demonstrated that the treatment program was cost-efficient since the costs of the treatment programs were substantially lower than the expected treatment costs for the victims.

The Dutch criminal justice system (CJS) and the mental health system (MHS) have been standing alongside of each other for many years because in the Dutch criminal law legal provisions for psychiatric care are arranged in the MHS. Nowadays the prison services are aware of the possibilities of forensic treatment to prevent recidivism. As the mental health services could not fulfil their role as a psychiatric institution for all the mentally disordered offenders, more emphasis has been laid by the criminal justice system on the diversion of these offenders over differentiated units within the CJS itself. New developments are the purchasing by the CJS of forensic psychiatric care in the MHS, but paid by the system itself and under its own safety conditions.

Suicidal behaviour in children and adolescents is a matter of great concern and suicide-related behaviour during psychopharmacological treatment has been analyzed during the last years. Medication-related suicidality is defined as any suicide-related symptoms reported during the period of treatment. Suicide-related symptoms have several components that need to be considered to study suicide risk and its relationship with medication. The components have been classified and named in different ways, but the main are: Suicide ideation (thoughts about death, wish to be death), Suicide plans (to think about methods of carrying out a self-injurious behaviour that can result in death), Suicide communication or threats (to transmit or comment thoughts or intention of suicide, either explicit or implicit), Suicide behaviours of self-harm or suicide attempts (self-inflicted, dangerous behaviour with intention to die with nonfatal outcome). Self-injurious behaviour without suicidal ideation is not included in the concept of suicide-related symptoms by many authors, but it is also necessary to register it in order to have a complete picture and also because the intentionality behind these behaviours is not always clear. All of these concepts can be of different level considering real intention to die, determination of plans and severity of self inflicted injuries. Other important aspects to assess suicide risk are the moderating and mediating variables. The evaluation of suicide-related symptoms and association to medications has to be carried out with a validated instrument that assess all these components and their relation to different drug side-effects, prior treatment starts and subsequently during control visits.

Time conceptualization is tricky and influential concepts of time and timing seem to help in a competent discussion of this topic. The distinction between time and temporality is key to the debate of time disturbances in psychiatric disorders. This presentation will discuss these concepts and clarify what authors as Kant, Fink, Schelling, Husserl, Heidegger, Fuchs and others have offered. In this process we’ll differentiate possible changes in personal and interpersonal time and notions of synchronization.

Although unaccounted in DSM-IV and ICD-10 time experience and temporality are clearly altered during depressive and manic episodes. There seems to be a dialectical relation of mood to these experiences. Moreover, patients’ descriptions of lived time are enlightening of seminal accounts of these disorders and seem pervasive to other experiences in these patients. This presentation will further illustrate the phenomenology of time in depression and mania. It will propose to acknowledge time as a feeling, sharing phenomenological features with this type of experiences. We hope additionally to present through it relevant epistemology of fundamental experiences in depression (e.g. experience of inhibition, loss of vital contact with the world).

The recognition and treatment of the simultaneous presence of mental and physical disorders has become a central challenge for health care systems worldwide. The co-morbidity of mental and physical disorders is frequent and its consequences for the persons who have both types of disorders are numerous - ranging from a worsening of the prognosis of both disorders (and a more severe impairment and consequent disability) to the exposure to risks of inappropriate or insufficient treatment. The management of problems related to the co-morbidity of mental and physical disorders meets problems resulting from the traditional separation of psychiatry from general medicine and from the attitudes of psychiatrists and other medical specialists who have been trained in a manner reflecting similar attitudes of their teachers. It also meets problems due to insufficient knowledge about the pathogenesis of co-morbidity and the impact that co-morbidity may have on the reaction to treatment of either or both disorders that are present.

The presentation will refer to epidemiological findings concerning co-morbidity of mental and physical disorders and enumerate problems that arise in care as well as possible solutions to them.

The prognosis of diabetes is highly dependent from diabetes self care. Mental disorders are a major barrier for effective self care in diabetes. Thus mental disorders in diabetes contribute to a poor long term prognosis of the disease. Depression is the most common mental disorder in diabetes. Approximately 30–40% of diabetic patients reported elevated depressive symptoms in self-report measures and 10–15% of diabetic patients suffer from a depressive disorder, according to clinical criteria. The impact of depression in diabetic patients is well understood, compared to other mental disorders. Therefore the presentation will focus the impact, diagnosis and management of depression in diabetes.

Depressed diabetic patients have a poorer glycaemic control, a higher risk of multimorbidity and mortality, increased functional impairment, and poorer adherence to diet and other diabetes self-management behaviours. In addition, co-existing depression has a negative impact on the quality of life of patients with diabetes and is associated with a significant increase in total expenditures on health care. The negative effect of depression in diabetes is not only established for more severe clinical cases of depression but can also be demonstrated in patients with mild depressive symptoms or sub-clinical depression. The detrimental consequences of depression in patients with diabetes are not inevitable, because effective treatments for depression are available. They include specific forms of diabetes education for mild depression, counseling, cognitive behaviour therapy or antidepressive medication for clinical depression. The presentation gives an overview about evidence based treatments of depression in diabetes. A prerequisite for effective treatment of depression is the detection of depressed diabetic patients. Experts estimate that currently only 25% of depressed diabetic patients are identified in clinical practice. Thus, timely identification of depressed diabetic patients is suggested by several guidelines for diabetes treatment. Screening methods for depression in clinical practice are briefly reviewed.

In the final part of the presentation the results of a step care approach for management of depression in routine care is demonstrated. This step care approach has proven efficacy with regard to the reduction of depressive symptoms.

Additionally, cost-effectiveness of a step care approach for management of depression in clinical care settings could be demonstrated.

The relationship between mental disorders and cancer is complex. This lecture has three aims:

1. 1. It will show epidemiological data on the prevalence and incidence of different types of cancer in people with mental illness;

2. 2. It will highlight clinical aspects in people with cancer; and

3. 3. It will discuss methodological issues when researching the relationship between mental disorders and cancer.

Metabolic syndrome, diabetes and other cardiovascular risk factors are highly prevalent in people with schizophrenia. Patients are at risk for premature mortality and overall have limited access to physical health care.

In part these cardio-metabolic risk factors are attributable to unhealthy lifestyle, including poor diet, high rates of smoking and sedentary behaviour. But over recent years it has become apparent that antipsychotic agents can have a negative impact on some of the modifiable risk factors.

The psychiatrist needs to be aware of the potential metabolic side effects of antipsychotic medication and to include them in the risk/benefit assessment when choosing a specific antipsychotic. He should also be responsible for the implementation of the necessary screening assessments and referral for treatment of any physical illness.

Multidisciplinary assessment of psychiatric and medical conditions is needed. The somatic treatments offered to people with severe and enduring mental illness should be at par with general health care in the non-psychiatrically ill population.

The recently published joint recommendations of EPA, EASD and ESC on diabetes and cardiovascular risk in patients with severe mental disorders should be implemented in all mental health services.

It has been estimated that 30 to 45% of adequately treated major depressive disorder (MDD) episodes in a psychiatric setting fail to achieve an adequate response. The Group for the Study of Resistant Depression (GSRD), a collaborative project between 8 centers in Europe in Belgium, France, Greece, Italy, Israel, and Austria developed a staging model that distinguishes between’non-responders’ (patients who fail to respond to one form of treatment, administered for 6–8 weeks), a condition which is now termed “insufficient response” by the European Medicines Agency (EMA),’treatment resistant depression’ (TRD, patients that fail to respond to two or more adequate antidepressant trials of different classes of antidepressants), and’chronic resistant depression’ (CRD, patients being treated with several antidepressants for more than 12 months). The aim of the European multicenter project performed by the GSRD, was to study methodological issues, operational criteria, genetic variables, clinical characteristics and treatment factors associated with treatment response in the largest sample published to date focusing on patients with major depressive disorder. The aim was to study methodological issues, operational criteria, genetic variables and clinical characteristics associated with TRD. The findings of the GSRD provide a set of 11 clinical variables associated with treatment response, among them comorbid anxiety disorders as well as melancholic features. The GSRD performed the until now largest candidate gene studies to investigate associations with treatment response phenotypes. It emerged that metabolism status as studied by cytochrome P450 genes (CYP1A2, CYP2C9, CYP2C19 and CYP2D6) may not be helpful to predict the rate of response and remission to antidepressants. Due to the existence of genetic vulnerability to suicidality and reported associations of COMT with suicidal behaviour, we further elucidated the impact of COMT on suicidal behaviour in a sample of TRD patients. Significant single marker and haplotypic association (rs2075507, rs737865 and rs6269) with suicide risk was found in MDD patients not responding to antidepressant treatment, but not in responders. Although there is a plethora of hints in textbooks that switching the mechanism of action should be obtained when a patient does not respond to one medication, the results of the GSRD challenge this notion by describing that staying on the same antidepressant mechanism of action for a longer time is more beneficial than switching. Taken together the results of the GSRD European multicenter project contributes to clinical and genetic characterization of the subphenotype of TRD, and, since this is an ongoing project, will provide further insights to this clinical relevant issue in the near future.

Treatment resistant depression (TRD) is relatively common condition and represents significant public health problem. Applying usual definitions of response it affects 20–30% of depressive patients and this proportion rises up to 60% if remission is used as a criterion [1]. One of ways to improve the therapeutic outcome in depression is to identify patients who are more likely to benefit from treatment, i.e. to predict the treatment response [3]. There are many reports suggesting either biological or psychological predictors of response, but many of them are good only to inspire future studies. The requirements for “clinical” predictors are in fact more stringent. Positive and negative predictive values, cost and availability of used predictive tests as well as easy measure qualify factors associated with treatment outcome as useful clinical predictors. There are many methodological issues that must be taken into account in looking for predictors, such as an outcome definition, time frame, definition of patients' population (subtype of depression), medication adherence, sample size, adequacy of treatment etc. Several key predictors of treatment outcome have been identified and replicated in previous studies, including depression severity, subtype of depression, early improvement of depressive symptoms, baseline cholesterol plasma level, psychomotor slowing, theta cordance and other QEEG predictors, anterior cingulate metabolism, 5-HTT polymorphism etc.[2]. Herewith we briefly review recent studies on treatment prediction in patients with resistant depression and contribute to this topic with our own results (cordance, early improvement of depressive symptoms, etc.).Despite of intensive research in this field there is a lack of studies that would prospectively validate the predictive ability of identified predictors. Another goal of future research would be to integrate current concepts of prediction (neurophysiological, clinical, genetic, neuroimaging findings) in order to improve its validity for clinical outcome.

Although epidemiological data provides evidence that there is an interaction between genetics (nature) and the social and physical environments (nurture) in human development; the main open question remains the mechanism. The pattern of distribution of methyl groups in DNA is different from cell-type to cell type and is conferring cell specific identity on DNA during cellular differentiation and organogenesis. This is an innate and highly programmed process. However, recent data suggests that DNA methylation is not only involved in cellular differentiation but that it is also involved in modulation of genome function in response to signals from the physical, biological and social environments. We propose that modulation of DNA methylation in response to environmental cues early in life serves as a mechanism of life-long genome “adaptation” that molecularly embeds the early experiences of a child (“nurture”) in the genome (“nature”). Data that supports this hypothesis from rodent, non human primates, humans and population studies will be discussed.

Family, twin and epidemiological studies all indicate the importance of both genetic as well as environmental risk factor for mood and anxiety disorders, especially unipolar depression and posttraumatic stress disorder (PTSD). In this talk, I will try to illustrate examples of the interplay between genes and stressful early environment for these disorders. I will highlight the identification of potential molecular mechanisms, including allele-specific epigenetics, of such interactions for the glucocorticoid-receptor co-chaperone gene FKBP5 as an example. Finally, I will present data on the potential usefulness of genome-wide expression quantitative trait data and genome-wide DNA methylation data to identify novel targets for gene x environment interaction in stress and trauma-related psychiatric disorders.

Little is known about the molecular mechanisms governing developmentally regulated changes in gene expression and neuronal function during the maturation of human prefrontal cortex (PFC), including alterations in neuropsychiatric disease. Here, we separate neuronal and non-neuronal chromatin from postmortem PFC across the lifespan and map the genome-wide distribution of histone H3-trimethyl-lysine 4 (H3K4me3), an epigenetic mark associated with transcriptional regulation.

The impact of specific nutrients in the physiopathological pathways leading to depression [1] combined with the fact that diet is modifiable has emphasized the importance of research on the possible role of dietary factors into depression and depressive symptoms. Although a potential beneficial effect of some nutrients on a depression process may exist, focusing on individual nutrients or food may provide an incomplete picture of the relationship between diet and depressive symptomatology at least because the effect of single nutrient may be too small to be detected but also because meals consist of complex combinations of nutrients which interact with each other. The development of nutritional epidemiology methods[2] to assess overall diet were recently applied to depression. Our team previously showed an association between overall diet measured by dietary patterns and subsequent depressive symptoms [3] independently of other health behaviours. Since then, several other studies comfort this finding in adolescents [4, 5] and in adults [6–10]. The aim of this lecture is to present this literature and to discuss the impact of these studies in light of the potential causal inference of diet on depressive symptoms.