The only study in Europe that compared traditional vocational rehabilitation with Individual Placement and Support (IPS) in people with psychotic and bipolar disorders clearly showed that IPS is more effective. Based on these data, this paper will review the current situation of vocational rehabilitation in Europe and analyse whether these or other research do influence the daily practice in vocational rehabilitation. Moreover, it will summarise potential for further development of Supported Employment in people with severe mental illness.

Delirium is a frequent condition and affects 20-60% of the elderly during hospital stay. It is associated with a worse functional outcome, increased length of hospital stay and mortality. Risk factors have been identified like age, dementia, sensory inhibition, infections, dehydration and polymedication. Prevention programs with multi-faceted interventions are in development.

In the German speaking area at least two models deserve further interest because they got a high rate of acceptance in the staffs and were meanwhile implemented into routine care of the respective hospitals. Both models will be presented. One focuses on the continuous individual care through the perioperative process, the other consists of an algorithm with standard assessments of risk-patients by the nurses to identify a beginning delirium just at onset for early interventions.

Alzheimer" disease (AD) is a major public health problem, and it is at the origin of a significant burden: 15% of direct costs in dementia are attributed to pharmacological treatment. Persons with dementia often have comorbidities and receive multiple medications. Both factors increase the risk of drug-drug interactions (DDIs) which can result in adverse drug reactions (ADRs). In a study, a total of 1058 spontaneous reports were identified that involved cholinesterase inhibitors (ChEIs) in the French Pharmacovigilance Database; 35.5% contained at least one DDI; 118 of them (31.4%) were the cause of ADRs. Pharmacodynamic interactions play a far greater role than pharmacokinetic interactions in the significance of DDIs. Some known interactions with ChEIs are:

1. 1. atropinic drugs aggravate cognitive disorders;

2. 2. combinations of ChEIs and antipsychotics are associated with an increased risk of extrapyramidal adverse effects;

3. 3. combining ChEIs with drugs that reduce the heart rate, depress cardiac conduction, or induce torsades de pointes increases the risk of arrhythmias and cardiac conduction disorders.

Elderly patients suffering from mental diseases are frequently comedicated with different psychopharmacological agents including antidepressants, antipsychotics, anxiolytics, hypnotics, cognitive enhancers and anticonvulsants used as mood stabilizers. In addition, somatic drugs are co-prescribed for the treatment of other concomitant diseases. This situation increases the risk for pharmacokinetic interactions with pharmacodynamic consequences. This population is particularly sensitive to adverse effects due to an impaired homeostatic reserve. Moreover, drug absorption, distribution, metabolism and elimination (ADME) may be altered in the elderly. However, studies in very old patients (> 80y) are often lacking. Therefore, treatment needs to be carefully and individually tailored. Therapeutic drug monitoring may be a useful tool to optimise treatment, as some “classical” indications apply for this population: Lack of compliance, adverse effects despite the use of generally recommended doses, suspected drug interactions, combination treatment with a drug known for its interaction potential, patients with pharmacokinetically relevant comorbidities (hepatic or renal insufficiency, cardiovascular disease). The increasing knowledge on the role of cytochrome P-450 isozymes in the metabolism of drugs and their interaction potential has fortunately led to a situation, which allows, to some extent, predicting risks for adverse effects after introducing a polymedication.

There are limited number of studies about dissociative disorders and substance abuse/dependence. Ross et al (1992) found that 39.0% of 100 chemically dependent patients had a dissociative disorder. Dunn et al (1995) found that this rate was 15.0% for 100 patients with substance use disorder at the end of their inpatient treatment. In the third study, 215 consecutive inpatients were recruited. The prevalence of the DSM-IV dissociative disorders was 17.2%. 67.6% of these patients’ dissociative experiences had started 3.6 (SD=2.9, range: 1.0-11.0) years before onset of the substance use in average. Patients with dissociative disorder were younger and average duration of their remission periods was shorter. Dissociative patients tended to use more than one substance whereas drugs were used more frequently than alcohol in this group. The frequency of borderline personality disorder, somatization disorder, history of suicide attempt, and childhood abuse and neglect in this qroup was more than that in the non-dissociative group. Suicide attempt, female gender, and childhood emotional abuse were significant predictors of a dissociative disorder diagnosis. Significantly more patients with dissociative disorder stopped their treatment prematurely. These findings suggest that dissociative disorder comorbidity is not a phenomenon limited to a cross-sectional observation and to a crisis period, but it is involved in all phases of substance dependency and it may have tremendous impact on the course and treatment outcome of the process.

In the city of Rotterdam prostitution used to take place not only in sexclubs but also in and around a designated prostitution street-zone in the harbor area outside the city center. The group of sexworkers at this street-zone consisted primarily of severely addicted women. For a long period of time the harm reduction approach had been the major intervention for this socially marginalized group of women. From January 2003 to December 2004 184 of them could be interviewed and diagnosed according to DSM IV. Nearly all of them were addicted to heroin and cocaine and most of them also were dependent on alcohol and benzodiazepines. Psychiatric comorbidity was almost 100 %. Co-morbid conditions existed of cluster B and C personality disorders, psychotic disorders (26 %), affective disorders (31 %), acute PTSD (9 %) and adult-ADHD (8%). In 2006 the government had closed the prostitution street-zone and many of the women could be placed in therapeutic and protected homes. Now, 2 years later, we reinvestigate these women with respect to their actual social situation, their quality of life, psychiatric comorbidity and persisting (acute and chronic) PTSD. During the interviews we use the WHO Quality of life questionnaire and the KIP (clinical interview for PTSD). It is an ongoing study and the (preliminary) results will be presented during the symposium.

The author will review the published data on complex posttraumatic stress disorder (Complex PTSD) in patients with substance abuse. Especially after interpersonal traumatization in childhood PTSD symptoms may be complicated by personality changes suchs as disturbed affect regulation, memory, self-image and relational problems. This syndrome has been labelled "PTSD with associated features" in DSM-IV-TR and is known by clinicians as "complex PTSD" or "Disorders of Extreme Stress NOS". The recognition of the range of interrelated problems associated with a history of early severe interpersonal trauma is an important development with much relevance for the field of substance abuse. Despite the evidence that a majority of women who are seeking treatment for addictions have been exposed to early and multiple traumatic experiences, standard treatment programs do not typically assess or target these associated impairments, which greatly complicates the prognosis. In practice, integrating interventions that specifically target the associated features are often recommended for these patients. Suggestions will be given for furture research.

Diagnostic criteria for bipolar disorder in DSM IV require the occurrence of a manic or hypomanic episode. The scant appropriateness of these criteria compared with Kraepelin"s concept of manic depressive insanity has been repeatedly reported and the concept of bipolar spectrum has been proposed for more than 30 years. The negative consequences of pure adherence to operational diagnostic criteria on clinical needs are presented in terms of community epidemiology results and in terms of clinical evidences and the inadequate treatment of depressive and anxiety episodes and the risk of manic switch with antidepressant drugs are discussed.

The epidemiological survey conducted in Sesto Fiorentino showed that depressive episodes in patients with subthreshold mania or hypomania were different from the clinical presentation of pure unipolar depressives episodes confirming not only the numeric impact but also qualitative differences between these groups of patients.

Our clinical study where predictors of mania have been prospectively evaluated in a trans nosographic sample of outpatients demonstrated that aspects related to bipolarity predicted manic shift regardless of the diagnosis. DSM IV criteria seem not to be able to detect and describe a group of patients relevant both on epidemiological and on clinical level. These findings underline the need of a careful examination of patients treatment and validate the rule of further research in definition of mood disorders boundaries for prevention strategies.

Depression is associated with a formidable disease burden and has substantial economic ramifications. Its burden can only be partially alleviated through treatment. To make a more substantial impact on population health, we need primary prevention to reduce the number of new cases, and we need to do a better job about preventing relapses and recurrences. In this symposium we will present the latest evidence that prevention is a viable option: it is effective and cost-effective when offered as CBT-based self-help (bibliotherapy), and as preventive cognitive therapy for relapses and recurrences. The last couple of years witnessed a new approach to improving population health when some of these preventive interventions became available as internet-based interventions. These on-line interventions can be well structured and conducted either as pure self-help or with support by a therapist. We assume that on-line interventions are acceptable, because people can access these interventions in the privacy of their homes, at times they find convenient, and at a pace that suits them best. We also expect that these interventions can be cost-effective, especially when offered as self-help. Finally, we expect that on-line interventions have great potential to reach many people. It is therefore interesting to outline some of these new strategies and present evidence of their (cost) effectiveness.

Within the last decade, success criteria of antipsychotic treatment became more ambitious. The most important change is the long overdue consideration of the patient"s perspective. Among other scales, a self-report instrument has been constructed to evaluate “subjective well-being under neuroleptics” (SWN). Studies indicate:

1. a. schizophrenic patients, if no longer acutely psychotic or suffering from severe cognitive deficits, are able to reliably assess their SWN,

2. b. high SWN is correlated with high compliance,

3. c. atypical antipsychotics increase SWN,

4. d. individual improvements of SWN and of PANSS are not strongly related (r=-.30 - -.40), and e) dopamine D2 receptor blockade is highly correlated to reduced SWN (r = .66 - .76).

Several open trials reveal the relevance of early improvement of subjective well-being: In a 12-week trial with 727 patients, 95% of those with early subjective response (within 4 weeks) showed later subjective and/or psychopathological improvement, but only 9% without early subjective response showed later improvement. In another 3-year trial of 2690 patients, again psychopathological response as well as symptomatic and functional remission were mostly related to early (within first 3 months) subjective improvement. Finally, in a first-episode study of 110 patients with a follow-up of 5 years, within the first 6 weeks of antipsychotic treatment only improvement of SWN was related to enduring symptomatic remission (p=.004) while early reduction of PANSS did not predict long-term course. These data indicate the usefulness of self-rating in schizophrenia, insufficient subjective improvement needs to be identified early.

While in the past most attention was paid to psychopathology, these days outcome-parameters such as cognitive and occupational performance, emotional stability, quality of life and the psychosocial functioning have been recognized as an important determinant of treatment success. Instead of only reducing the symptoms a therapy with antipsychotics must attain higher goals such as remission and recovery nowadays. The Psychosocial Performance Scale (PSP) offers a validated, reliable and operational tool to assess the psychosocial functioning of patients during the course of treatment as well as in the acute state. Mini-ICF-P might be a similar instrument for measuring psychosocial functioning. In the future, medication and non-medication treatment strategies will also be judged by the ability to improve the psychosocial functioning of patients with schizophrenia, as measured by PSP and Mini-ICF-P.

Recovery and normalized psychosocial functioning are the main targets for the treatment of schizophrenia. However antipsychotics have limited benefit for improving cognitive functions and negative symptoms that predict the patient's ability to work and function independently. Meta-analytic and latest large scale studies such as CATIE and EUFEST have found that Clozapine seemed to be superior compared to other antipsychotics regarding efficacy and Olanzapine was associated with significantly longer time to discontinuation although both were significantly associated with metabolic syndrome. Nevertheless mortality rate is about two times greater than general population in schizophrenia patients, mainly due to metabolic side effects which affect patient's satisfaction and let nonadherence to treatment. One of the important results driven from the CATIE trial has shown that the majority of the patients in each antipsychotic treatment group had discontinued their first treatment due to either inefficacy over schizophrenia symptoms or intolerable side effects. Since clinical effectiveness for antipsychotics is strongly related to adherence, long acting antipsychotics may play an important role in long term treatment. As well as adherence to treatment, patient related variables such as differences in pharmacogenetic and psychosocial factors may also affect outcome and recovery in schizophrenia. Also it is essential to identify outcome measures. Remission of schizophrenia symptoms does not always mean to be recovered from the illness. Outcome measures should include cognitive functions, quality of life and psychosocial functioning. Pharmacotherapy alone is not enough to achieve recovery, therefore psychosocial interventions should be established and integrated with antipsychotics.