Current service configuration of distinct Child and Adolescent Mental Health (CAMHS) and Adult Mental Health Services (AMHS) is considered the weakest link where the care pathway should be most robust. Transition-related discontinuity of care is a major health, socioeconomic and societal challenge for the EU.

The overall objective of the MILESTONE project is to improve transition from CAMHS to AMHS in diverse healthcare settings in Europe.

To improve the understanding of current transition-related service characteristics, and processes, outcomes and experiences of transition from CAMHS to AMHS using a bespoke suite of measures; to explore the ethical challenges of providing appropriate care to young people as they move to adulthood; to test a model of managed transition in a cluster randomized controlled trial (cRCT) for improving health, social outcomes and transition to adult roles; and to develop training modules for clinicians and policy guidelines.

Data will be collected via systematic literature reviews; bespoke surveys to CAMHS professionals, experts and other stakeholders; focus groups with service providers and users and members of youth and mental health advocacy groups; and a longitudinal cohort study with a nested cRCT in eight EU countries (Belgium, Croatia, France, Germany, Ireland, Italy, Netherlands, UK) involving over 1000 CAMHS service users, their parents/carers, and clinicians, with assessments at baseline, 9, 18 and 27 months.

First results are expected in 2016 with further major findings following in 2019.

The MILESTONE project will provide unprecedented information on the nature and magnitude of problems at the CAMHS-AMHS interface, and potential solutions to overcome these.

The authors have not supplied their declaration of competing interest.

Alcohol dependence has long been related to impaired processing and handling of negative emotions. This is the first study to compare emotion regulation (ER) at a behavioral and neural level in alcohol dependent patients (ADPs) and healthy controls (HCs). It also examines the effects of high-frequency repetitive transcranial magnetic stimulation (rTMS) on ER abilities and related craving levels in ADPs.

Thirty-six ADPs and 32 HCs matched on age, sex, and education, were included in a within-subject fixed-order study with one functional magnetic resonance imaging (fMRI) session and one rTMS plus fMRI session, with high-frequency (10 Hz) rTMS over the right dorsolateral prefrontal cortex (dlPFC). An fMRI emotion regulation task (ERT) was administered during both sessions and craving was measured before and after each ERT.

ADPs were impaired in the regulation of negative emotion and showed a higher activation of ER related brain areas compared to HCs. Furthermore, active rTMS improved ER abilities in both ADPs and HCs, but was accompanied by a decrease in anterior cingulate and left dlPFC activity only in ADPs. In addition, the ERT-induced increase in craving levels in ADPs was trend-significantly reduced by active rTMS, with a large effect size.

ADPs are impaired in the regulation of negative emotion and show enhanced neural activity in the ER brain circuit. High-frequency rTMS improves ER in ADPs and HCs and normalizes neural activity and tends to reduce craving in ADPs. Future studies are needed to test the long-term effects of (multiple session) rTMS on ER, craving, and drinking.

The authors have not supplied their declaration of competing interest.

Preclinical and clinical data suggest modulating effects of the appetite regulating peptide ghrelin on food intake. Recent data suggest that in food intake the “endostatic” energy-homeostatic systems of the lateral hypothalamus (LH) and the motivational, mesolimbic reward system operate in dynamic interplay with each other. Ghrelin receptors have been detected in the ventral tegmentum of the midbrain (VTA), where they modulate the activity of dopaminergic neurons projecting to the NAc. Assuming that Ghrelin modulate mesolimbic reactivity, the question remains: is this only the case in response to food cues? Or is this the case in response to reward-associated cues in general (including those related to nicotine and alcohol)?

Study 1: a consecutive sample of 61 alcohol-dependent male inpatients was included. Blood was drawn at onset of withdrawal 12-24 hours after admission, and following 14 days of controlled abstinence in order to assess plasma concentrations of both active and total ghrelin. In parallel, we assessed alcohol craving applying the Obsessive Compulsive Drinking Scale (OCDS) as well as symptoms of depression (Beck Depression Inventory [BDI]) and anxiety (State Trait Anxiety Inventory [STAI]). The severity of alcohol dependence was assessed with the Alcohol Dependence Scale (ADS). Study 2: 54 non-treatment seeking smokers and 30 healthy controls with normal eating behavior, as measured by the Three Factor Eating Questionnaire (TFEQ) participated in this study. We measured plasma concentrations of both active and total ghrelin, using a blood sample taken two hours after a standardized meal during early nicotine abstinence in the smoking group. Additionally we quantified severity of addiction in the smoking group using the number of cigarettes smoked per day, cotinine plasma concentration and the Fagerström Test for Nicotine Dependence (FTND).

Study1: we found a significant positive correlation between the plasma concentration of active ghrelin and alcohol craving in both blood samples. Plasma concentrations of active ghrelin increased significantly during early abstinence. In a linear regression model, the plasma concentration of active ghrelin on day one, the scores of the ADS, and the BDI explained 36% of the variance in OCDS sum score (P < 0001). By day 14, these same factors accounted for 54% (P < 0.0001). We did not detect any association between the plasma concentration of total ghrelin and patients’ alcohol cravings. Study 2: plasma concentration of acetylated ghrelin but not total ghrelin was significantly higher in smokers than in non-smokers. Moreover, we found significant negative correlations between acetylated ghrelin and all measures of the severity of nicotine dependence.

In conclusion, both studies supports the general idea that ghrelin's central effects go beyond the endostatic regulation of energy homeostasis, also involving pathways underlying reward expectation and craving. Physiologic factors modulating the reactivity of mesolimbic pathways represent an important research topic for developing pharmacologic treatments for disorders characterized by altered reward-related behaviors, such as substance use disorders and behavioral addictions.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Heritable factors account for approximately 50–60% of the risk for alcohol dependence. However, which genes confer this risk remains to elucidate. Moreover, genetic association studies are hampered by non-replication. Several strategies can be applied to approach this issue. One option is the application of intermediate phenotypes. Neurobiological measures that are closely related to the addiction phenotype may be more directly related to genetic variation. Intermediate phenotypes related to dopamine function seem particularly suitable, given the strong dopamine hypothesis in addiction. Another strategy is to include environmental factors, such as childhood adverse experience, in genetic association studies. We tested the effect of COMT Val158Met and DRD2 Taq1A genotypes, as modulators of brain dopamine function in the context of self-reported environmental factors, like childhood adverse experience.

Alcohol-dependent patients (n = 110) and healthy controls (n = 99) were genotyped for the COMT Val158Met and DRD2 Taq1A genotypes. Childhood adversity was measured using self-report questionnaires. Dopamine sensitivity was assessed using an apomorphine challenge with cognitive performance and plasma growth hormone levels as main outcome measures.

COMT genotype modulated the effect of apomorphine on cognitive performance, but was not directly associated with alcohol dependence. Yet, the interaction between childhood adversity and COMT genotype did predict alcohol dependence. DRD2 genotype modulated the effect of apomorphine on plasma growth hormone levels and was also not directly associated with alcohol dependence. Yet, the interaction between parental rule setting and DRD2 genotype did predict alcohol use in a separate population-based sample of adolescents.

This study provides evidence for a role of COMT and DRD2 genotypes in alcohol dependence using both the GxE and intermediate phenotype approach. This confirms that both an intermediate phenotype approach and GxE interaction analyses can be useful tools in understanding mechanisms mediating addiction vulnerability. The clinical relevance of dopamine genes and intermediate phenotypes for staging and profiling of alcohol use disorders remains to be investigated.

The author has not supplied his declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Consultation-liaison psychiatry (CLP) deals with clinical, research and training activities at the interface between psychiatry and the rest of medicine. The main clinical competencies of CLP include medical-psychiatric comorbidity (co-existing psychiatric and non-psychiatric disorders affecting reciprocally); medically unexplained physical symptoms, “somatization” and functional disorders; and liaison activities, addressed to medical workers and teams.

To describe and discuss typical clinical scenarios that CL psychiatrists have to work in, and suggest effective, evidence-based solutions.

Long-standing everyday clinical experience of the authors combined to evidence derived from international literature consented to create a list of the most common and complex problems or difficulties typical of the CLP clinical context, and related possible solutions.

Most common/complex problems include the following: stigma and prejudice (of patients, relatives, colleagues, and own); excessive technicality of language; short/unpredictable duration of hospital stay of patients, and more in general pressure in clinical practice due to shortness of time and resources; tendency of colleagues from other disciplines to disregard setting features related to time and space (inadequate rooms, e.g. too busy or noisy); limited time for face-to-face discussion of cases or problems; conflicts with patients/relatives/colleagues, and fear of reciprocal manipulation.

Moving on the interface between psychiatry and the somatic disciplines, CL specialists need to develop special skills, not only those strictly technical, but also those “soft skills” including relational abilities and flexibility. Understanding the systemic aspects of referrals in the relationship between physician, staff and patients is usually essential in the process of consultation.

The authors have not supplied their declaration of competing interest.

The author has not supplied his declaration of competing interest.

Multimorbidity and polipharmacotherapy are crucial features influencing the psychiatrist's prescription in the consultation-liaison psychiatry (CLP) setting.

to provide an example of computer-assisted decision-making in psychotropic prescriptions and to provide hints for developing pharmacological treatment strategies in the CLP setting.

Case report. A clinical vignette is presented, followed by a review of available online computer-assisted prescription software.

A woman in her seventies was repeatedly referred for psychiatric consultation. Eleven different medications were administered daily, because of multimorbidity. A diagnosis of distymia was established, with comorbid mixed pain (partly fulfilling the criteria of somatic symptom disorder) and substance use disorder (opioids). After the first assessment, six follow-up visits were needed during hospitalization. Mirtazapine and benzodiazepines were introduced. Beside the pharmacological intervention, conflict mediation was performed in the relationship with the patient, her relatives, the ward personnel and the GP, to develop a long-term rehabilitation project. Pros and cons of online computer-assisted prescription software were discussed together with the ward personnel, as well.

Computer-assisted decision-making in psychotropic prescription is becoming more common and feasible. The use of available software may contribute to safety, effectiveness and cost-effectiveness of clinical decision-making. Risks are also possible: depending for example from regional differences in prescription indications, different guidelines, pharmacogenomics, frequency with which databases are updated, sponsorships, possible conflicts of interest, and real clinical significance of highlighted interactions – all issues the clinician willing to benefit from this modern tools should pay attention to.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

In most European countries postgraduate training for specialization in psychiatry and psychotherapy is acquired over the course of 4–6-year programs. In the European Union, qualification in one country is recognized within other countries of the Union.

To analyze the present situation of psychopharmacology-pharmacopsychiatry postgraduate teaching in Europe and to present the needs and preliminary instruments for improving the situation by harmonization of the programs.

Analysis of the data available from national psychiatric societies and from the literature; development of a consensus among experts in this field.

Despite efforts to standardize post-graduate training, the curricula in different European countries vary greatly. This variability limits comparability between countries and international exchange while carrying consequences in the breadth and quality of education that trainees receive. Literature and curricula mainly published in USA as well as a recently published curriculum and learning catalogue in Germany [1] offer useful tools for the development of a curriculum at a European level.

There is clearly a need for standardization of psychopharmacology-pharmacopsychiatry teaching at the European level. This can be achieved by the introduction of a curriculum and learning catalogue developed by European experts and based on tools already available.

The authors have not supplied their declaration of competing interest.

The author has not supplied his declaration of competing interest.

The author has not supplied his declaration of competing interest.

The author has not supplied his declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Recruitment of young doctors into psychiatry is declining in many countries, which might become a threat to the survival of the profession.

To identify potential reasons for this threat.

To look at psychiatry with concepts used by the sociology of professions.

Professions are characterized – and these concept will be used for analysis here – by (1) ownership of a specialized body of knowledge and skills, which defines the field of competence and the scope of potential clients, including the demarcation from other professions; (2) holding a high status in society; (3) being granted autonomy by society, e.g. in recruiting and excluding members; and (4) being obliged, in return for the above, to guarantee high quality standards in providing services and following ethical rules.

Six intertwined areas of concern are identified: three of them, the increasing criticism by users and carers, the intrusion of other professions, and psychiatry's negative image in society, can be traced back to problems with the other three concerning the “ownership of a specialized body of knowledge and skills”. With the preparation and advent of DSM-5, discussions about the lack of validity of psychiatric disease entities have gone viral in the time of the internet. The attempts to “carve nature at its joints” have failed, and this is more and more perceived from outside, threatening psychiatry's status in society and potentially turning away to be psychiatrists.

Looking at psychiatry as a profession may help to better understand its current situation.

The author has not supplied his declaration of competing interest.

The author has not supplied his declaration of competing interest.

The author has not supplied his declaration of competing interest.

The author has not supplied his declaration of competing interest.

The author has not supplied his declaration of competing interest.