The proposed course targets a major international public health issue: the cause of death of about 100, 000 children and adolescents world-wide each year, suicide. It is the second leading cause of death in that age group in many European countries. There are over three million suicide attempts made by adolescents annually. Although genetic and family risk factors are highly associated with both suicide and with suicide attempts, the specific genetic alleles that transmit this vulnerability between generations have yet to be identified.

Some risk factors for teen suicide attempts and completion have been identified and will be discussed, including an Axis I psychiatric disorder (e.g. mood disorder), family discord, aggressive-impulsive traits and physical and sexual abuse. One key factor consistently associated with suicide and suicidal behavior and will get a special attention in the course is a family history of suicidal behavior. This is as strong a risk factor as major depression, and stronger than environmental factors such as abuse. Suicidal behavior runs in families, independently of axis I or II diagnosis. Gene-environment interaction models in children and families will be presented and discussed. We will propose a stress-diathesis model of suicidal behavior and a practical tool for risk assessment for the clinician.

Sexual behavior is determined by a compelx interplay of pschosocial and biological factors. Evaluation of sexual disorders inlcudes an evaluation of psychosocial factors such as cultural influences, life history, individual psychodynamics, couple interaction patterns, life stage as well as biological factors such as current medications, medical illness, psychiatric illness and endocrinological status. Sexual fucntioning usually declines in woman during the menopausal transition and this decline is related to decling estradiol levels. In spite of this, the major factor predicting postmenaopausal sexual function is premenopausal sexual function and relationship with the sexual partner. THere has been minimal study of psychologicalfactors influencing male sexual desire. Intervention requies an integrated approach with equal consideration to numerous possible etiological factors.

Impaired arousal has been defined, in physiological terms, as lack of/or impaired erection in males, and lack of/or impaired lubrication/swelling in females. However, these criteria lack any correlation with the subjective experience of arousal

Treatment of sexual arousal disorders has been the most successful area of treatment of sexual dysfunctions. Nevertheless, the initial enthusiasm about the efficacy of phosphodiesterase-5 inhibitors in male erectile disorder has been tempered by studies demonstrating that pharmacological agents alone do not address all the complexities of the causative factors or treatment-subsequent psychological issues. It is also obvious that the effectiveness of pharmacological treatments is lower than their efficacy, especially in long term treatment. The results of treatment trials of female arousal disorder with pharmacological agents (oral or topical) suggest that no agent alone has been really consistently efficacious in this indication.

The interplay of physiological and psychological factors in the etiology of female and male sexual arousal disorder and the results of treatment trials underscore the need for an integrated approach to the treatment of this disorder.

Several trials suggest that the combination of pharmacological and psychological treatments may be the most suitable approach. For instance, one study demonstrated higher rates of success of the combination of sildenafil and cognitive-behavior sex therapy over sildenafil alone in male erectile disorder.

This presentation discusses the advantages of integration of pharmacological, psychological and other treatment modalities in the management of impaired sexual arousal and proposes a stepwise integrated approach to this disorder in both males and females.

For about a century male ejaculatory disorders were considered to be caused mainly by psychological disturbances. However, since the 1990s, daily SSRI treatment has become very popular to delay ejaculation in men with lifelong PE. In addition, research has shown that it is likely that the persistent occurring very short ejaculation times of less than 1 minute in lifelong PE are related to neurobiological dysfunction in the central nervous system. On the other hand, epidemiological studies have shown that “complaints” of PE may not only occur in men with very short intravaginal ejaculation latency times (IELTs) but also in men with normal and even long ejaculation latency durations of, for example, 20 minutes. As their complaints are probably highly psychologically determined, treatment by counseling, psychotherapy of other non-medical interventions have been suggested. Integration of drug treatment, psycho-education, counseling and psychotherapy increases the chances for better coping mechanism in men affected by ejaculatory and orgasm problems. For female orgasmic disorders, particularly anorgasmia, medication is not yet available. Primary female anorgasmia is difficult to treat as multiple factors are involved in its pathophysiology. Neurobiological and pharmacological research is needed to develop drug treatment for those women who would like to alter this state. But with or without drug treatment, counseling may be of great value and contribute to better coping styles.

The selective breeding of Wistar rats for high (HAB) versus low (LAB) anxiety-related behaviour resulted in two rat strains which have been validated as a suitable animal model for studying neurochemical and genetic mechanisms underlying anxiety- and depression-related disorders. The robust differences in the anxiety phenotype are accompanied by alterations in neuroendocrine and neuronal stress-responsiveness to various stimuli, and in relevant brain neurotransmitter systems including arginine vasopressin (AVP), CRF and serotonin, and by impaired hippocampal neurogenesis. Manipulation of the endogenous vasopressin or oxytocin systems reveals their significant involvement as neuromodulators of anxiety behaviour in HAB rats.

HAB and LAB rats also provide an excellent model for studying interactions between early environmental factors (i.e. early life stress: prenatal stress, maternal separation) and the genetic predisposition for either high or low stress susceptibility. Thus, differential, partly opposite effects of prenatal or postnatal stress on adult emotionality, stress coping, neuropeptide expression patterns within the hypothalamus or hippocampal cell survival have been found in adult HAB and LAB rats.

Finally, selection for low trait anxiety in LAB rats goes along with the development of high intermale aggression during the resident-intruder test, and with a generally high neuroendocrine and neuronal response to social stimuli. Therefore, LAB males may develop as a promising animal model for studying neurobiological mechanisms of pathological aggression and its link to the genetically determined level of anxiety.

Affective disorders are widely distributed disorders with severe social and economic effects. Strong evidence underlines that effective treatment helps to restore function and quality of life. Unfortunately, patients with major affective disorders respond variably and, at times, unpredictably to different treatments, which underline the need of alternative approaches. Due to the action of most modern antidepressant drugs, serotonergic mechanisms have traditionally been suggested to play major roles in the pathophysiology. However, recent clinical evidence strongly suggests involvement of neurodegenerative pathology in the disease. Since there is accumulating evidence that the novel neurotransmitter NO acts as a neuromodulator, and participate in several sub-cellular processes, such as cellular memory and neuronal toxicity, nitrergic pathways may have an important role in hippocampal degenerative pathology and cognitive deficits seen in patients with affective disorders.

A few clinical and several pre-clinical studies, strongly suggests involvement of the nitric oxide (NO) signalling pathway in these disorders (Harvey 1996). Several of the conventional neurotransmitters, including serotonin, glutamate and GABA, are intimately regulated by NO (Wegener et al. 2000). Interestingly, distinct classes of antidepressants (Imipramine, Tianeptine, Citalopram and Paroxetine) have been found to modulate the NO level in the living rat hippocampus in clinically relevant doses (Wegener et al. 2003). Moreover, our recent work, using selective inhibitors of phosphodiesterase 5, indicate that the whole NO signalling pathway may play a major role in the behavioural and neurochemical effects observed.

The NO system is therefore a potential target for antidepressant and anxiolytic drug action in acute therapy as well as in prophylaxis.

The development of a therapeutic alliance with the patient is a challenge for emergency psychiatry. The therapeutic alliance could reduce the number of non-voluntary admissions and of compulsory administration of medication. Moreover, a better dialogue with the patients could increase the patients’ compliance with ambulatory care, and could prevent inutile hospitalizations. To evaluate the level of satisfaction with the emergency psychiatric treatment we created and validated a 10-item questionnaire. The questionnaire focuses on the “human quality” and the empathy of the psychiatrist, but also on his professional skills, the delay in the waiting room before medical evaluation, the level of satisfaction concerning the proposed care and a comparison between psychiatrists, nurses and the security staff. The same questionnaire is proposed to the patients and to the psychiatrists. The validation is still running and focuses on around 5000 patients admitted in emergency during one year (June 2007-June 2008). Preliminary results are discussed, taking into account diagnosis and differences between patients and psychiatrists about their therapeutic alliance.

Acute psychiatric care has historically had limited involvement from psychological practitioners and there is limited published assessment of the efficacy of psychological treatments in this context. Recently a number of authors have argued strongly that Cognitive Behaviour Therapy (CBT) should be more available to psychiatric inpatients. Hoewever, the evidence for the efficacy of psychological therapies in this setting is estremely limited. Furthermore the acute environment provides a number of challenges in gathering evidence for psychological approaches. In particular, the complexity of this setting often does not lend it self to single model approaches and many psychological interventions may be preparatory. It may often be difficult to define good outcomes and psychological interventions frequently occur in conjunction with other treatments.

Several attempts to measure outcomes and studies based on user experiences are reviewed. It is argured that these actually provide very little in the way of evidence for psychological therapies. Particular attention is paid to difficulties in translating existing research into an acute psychiatric setting and measuring outcomes. A number of suggestions are made for developing research in this area including consideration of a range of outcome indicies and the ways in which psychological ideas may be employed in care planning.

The interest of educational programs concerning crisis intervention in the managament violent behaviour remains a challenge for emergencies departments. A preliminary study done in Geneva (Caihol et al., 2007) showed a significant reduction in violent behavior during 5 months in emergency psychiatry, after the introduction of a specific educational program. The aim of this study was to evaluate the impact of a specific staff educational crisis intervention on managing violent behaviour after the end of the 5 month planned study. Thus, two year after the initial study, we re-evaluated the impact of the educational program by another project focusing on the management of agitation in emergency. We included all patients admitted in emergency during a same 5-month period (N= around 2000 patients), in order to determine if the promising initial published data could be extended on long term? The percentage of patients with violent behaviour will be compared with the data of the previous study, before and after educational programs. The results will be correlated with different factors which could influence the data: sociodemographic factors, diagnosis, staff characteristics.

Cailhol L, Allen M, Moncany AH, Cicotti A, Virgillito S, Barbe RP, Lazignac C, Damsa C. Violent behavior of patients admitted in emergency following drug suicidal attempt: a specific staff educational crisis intervention. Gen Hosp Psychiatry 2007;29: 42-44.

Deficiencies in the delivery of community mental health services in developed countries have been adduced as the reason for the large number of mentally ill in prisons. The large number of mentally ill persons found in prisons in many countries that have different mental health systems, however, could be an indication that system delivery may not be the only reason for this phenomenon. It may be that the “balloon theory” whereby it has been sustained that as mental hospitals beds decrease, prison beds increase and vice-versa will have to be reconsidered. In this presentation, data indicating the flow of mental patients into prisons in several countries will be reviewed. This type of data, however, tends to be statistical aggregates that will need to be contrasted with theoretical considerations and case reviews of mentally ill inmates in order to demonstrate that a relationship between mental illness and crime does exist at different levels of interaction. Such a relationship may be a more fundamental reason for mentally ill persons ending up in prisons than systemic service delivery concerns.

Quality of care in emergency psychiatry is correlated with rapid diagnose, application of validated clinical guidelines for emergencies and focus on therapeutic alliance. We propose a specific diagnosis and intervention program for the management of patients with suicidal thoughts and behaviour. The specificity of this program involves the evaluation of the level of suicidal risk, the lethality of the suicidal thoughts and the timeframe planned before the occurrence of the suicidal behavioural. Risk level depends on age, gender, substance use, etc. Evaluation of these items and intervention programs concerning these issues will be discussed in a real life emergency department environment.

In a period of growing interest in expert's guidelines on the management of psychiatric emergencies, there are few empirically validated data in the emergency settings. Based on this observation, we developed an International Research Network in Emergency Psychiatry, by connecting several European Centers (Switzerland, France, Belgium, Romania) and United States. The aims of our collaboration are to evaluate and ameliorate the quality of care, to develop European clinical guidelines, to provide a structured educational program for trainees and students and to conduct international studies focused on Emergency Psychiatry. Clinical research and the use of some standardized tools appear to be successful in improving the quality of care as an ‘effective medication’ administered to the emergency staff [Damsa et al., 2006]. Moreover, introducing new psychotherapeutic models in emergency psychiatry, could avoid unnecessary hospitalizations, by increasing the compliance of the patients to ambulatory follow-up care, and might have a positive economic impact on the health systems. In conclusion, we hope to develop new links with other emergency psychiatric teams, through the Emergency Psychiatry Section from the AEP.

Damsa C, Ikelheimer D, Adam E, Maris S, Andreoli A, Lazignac C, Allen MH. Heisenberg in the ER: observation appears to reduce involuntary intramuscular injections in a psychiatric emergency service. Gen Hosp Psychiatry. 2006; 28: 431-433.

The challenges of providing mental health care to a culturally diverse patient population include having sufficient knowledge about cross-cultural issues in generally and especially knowledge about cultural background of the specified ethnic groups. Asylum seekers are certainly individuals with specific needs that are combination of potential traumatic experiences, current political situation in home country and asylum policy in third country where they seek the asylum. Language barriers, a mistrust of authority, and fears about confidentiality are well documented obstacles to the effective care of asylum seekers. Therefore, the language abilities and cross-cultural background of the therapist are not negligible. Current assessment and/treatment of asylum seekers in Denmark raises several controversial but important ethical dilemmas:

Sufficiency and satisfaction by the assessment and/or treatment provided via interpreters seen by the patient and the therapist

The impact of psychiatric statement on the process of asylum determination (used and/or abused by authorities and asylum seekers)

This paper describes clinical cases related to mentioned issues and give potential useful hints for future development within assessment and/or treatment of asylum seekers.

A growing body of research links the experience of racism to a variety of health and mental problems, with stress as the most direct link. The understanding of racism has become more complex in recent years, wherein investigators have shifted the focus away from overt forms of racism such as that associated with white supremacy to unintentional or "aversive" racism. Racism in mental health care is an ethical issue for psychiatrists and psychologists because it represents a very damaging force that is associated with mental health problems, and as such requires effective response. Racism and race related issues may enter the consulting room indirectly through the experiences of patients in the outside world, or, indeed, directly through the clinician's implicit and unintentional behavior. Both cases clinicians demand the awareness and responsiveness necessary to ensure that patients are not harmed. Conventional therapeutic approaches situate the locus of change in the individual yet racism is not a psychological problem as such. Recent work on racial microaggressions indicates that mental health professionals are prone to low level acts of racism that are of relevance only to the racially different patient; the clinician is unaware of such an act and as such not inclined to take corrective action. The Racial Identity Interaction model will be presented as a basis from which to understand the ethical impact of racism in the clinical context.

Suicide has a profound effect on the family, friends, and associates of the victim that transcends the immediate loss. Health professionals as well family members are usually unaware of immediate suicide risk and often present disbelief. The event is totally unexpected. This is a key issue in suicide prevention as underestimation of suicide risk and

As those close to the victim suffer through bereavement, a variety of reactions and coping mechanisms are engaged as each individual sorts through individual reactions to the difficult loss. Literature suggest that health professional in general and mental health professionals in particular are often unprepared and uneasy when it comes to deal with suicide risk. Communication of suicide intent has been reported as a common feature among suicide victims, yet some patients barely let other people know their intention to commit suicide or clinicians are not trained to notice warning signs. So it is of paramount important to integrate such communications with tactics to better identify suicidal patients. Managment of these patients is therefore a great issue and a difficult task which can be accomplish with the help of GPs, family members, psychiatrists and community members. Substance abuse disorder comorbid with other psychiatric disorders impairs positve outcome and dramatically increase suicide risk. Combined treatment is not always provided for such patients and proper management of suicidality is generally reduced. This symposium addresses some of the key issues in suicide prevention related to the role of health professionals in the assessment of suicide risk.

From psychological autopsy studies emerged that suicide victims do communicate their intent to end their life; nevertheless health professionals are often stricken by surprise when a suicide occurs. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Two third of the suicide victims communicated their suicidal intent over a period of weeks prior to their death, usually several different persons, 40% communicated their suicidal intent in very clear and specific terms. About 90% of suicide victims had received some kind of health care attention in the year prior to death, but this care was not provided by a mental health professional. Half of the persons dying by suicide had never been in contact with a mental health professional in their lifetime, not even once.

There are various elements that impair recognition of suicide risk by treatment professional and that are associated with stigmatization such as: Lack of knowledge and skills in relation to treatment of self-destructiveness; Professional's loss or absence of concern; Acceptance of patient's suicide as a solution to problems; Wishes that patient would commit suicide as a solution to his or problems; Degree of familiarity with patients; Unfounded optimism in relation to treatment; Fear of patient; Defects or problems associated with treatment system. This presentation explores possible educational interventions for health professional in general and mental health professionals in particular. Reactions after patient's suicide are also discussed.

Suicide attempt and particularly committed suicide are relatively rare events in the community, but they are quite common among psychiatric (mostly depressive and schizophrenic) patients who contact different levels of healthcare some weeks or months before the suicide. The most common current psychiatric illness among consecutive suicide victims is major depressive episode (56-87%), which, in the majority of cases, is unrecognized or untreated. The current prevalence of patients with major depressive episode in the primary care practice is around 8-12%, and earlier studies, performed 15-20 years ago, found that less than 20% of them were recognized by their GPs, and the rate of adequate antidepressant pharmacotherapy was under 10%. More recent papers reported much higher rates (62-85%) of recognition and treatment of depression in primary care indicating that the situation shows improving tendency. Since succesfull acute and long-term pharmacotherapy of depression significantly reduces the risk of both attempted and committed suicides, and 34-66% of suicide victims (two-thirds of them should have current depression) contact their GPs 4 weeks before their death, GPs play a priority role in suicide prevention. Although prior suicide attempt (particularly in the presence of major depression or schizophrenia) is the best single predictor of future suicidal behaviour, two-thirds of suicide victims die by their first attempt. Therefore the prediction of the first suicidal act is particularly important for the prevention. Followed the pioneering Swedish Gotland Study, several large-scale community studies demonstrated that education of the GPs on the diagnosis and treatment of depression.