The last decade has seen a remarkable resurgence of interest in psychedelic drugs such as psilocybin (from magic mushrooms) LSD and DMT (dimethyl tryptamine – the active ingredient of ayahuasca). This has been driven by the discovery that these psychedelics all act agonists of 5-HT2A receptors. Human imaging studies have revealed this action leads to profound alterations in brain measures of activity particularly in terms of increased entropy of EEG MEG and fMRI signals and reduced within-network, but increased between-network, connectivity. In addition they all can increase synaptic growth and brain plasticity. These findings not only explain the subjective nature of the psychedelic experience but also have implications for the treatment of internalising disorders such as depression addiction anorexia and OCD that are characterised by increased within network connectivity especially of the default mode network. Subsequent trials, particularly of psilocybin, in these disorders has revealed significant clinical benefits from even just a single administration. A number of companies have now been set up to extend these discoveries with regulatory-level trials that could result in market authorisations within a few years. My talk will explore these brain mechanisms and clinical data and discuss the potential place of psychedelic medicine in the future of psychiatry.

Culture is not simply the aggregate of individual traits but a more or less coherent system of shared meanings, institutions and practices (i.e. beliefs, attitudes and values). It is a repository of meaningful symbols that structure experience both implicitly and through explicit models. Culture shapes how and what psychiatric symptoms are expressed, influences the meanings that are given to symptoms and impacts the interaction between the patient and the health care system. Explanatory models are the ways in which individuals in different cultures see the core reasons of their suffering. The DSM-5 cultural formulation interview is developed to be used as clinical instrument and valuable tool. It is evident that phenomena such as the increasing migratory flows and the globalisation of prevailing social criteria referred to the economy, trade, religion and the perception and the attribution of the causes of disease have determined a shift in the world cultural balance that have direct repercussions on World Mental Health. More specifically, it needs to be seen how the transcultural differences in the personality configurations and psychological operations can be correlated with the cross-cultural differences in psychopathology to arrive at an understanding of these. Furthermore, understanding the central role of culture of mental health and illness must, therefore, be central to any vision of the future of psychiatry. In this presentation transcultural aspects of mental health care in psychiatry will be highlighted and discussed.

Early Intervention Programmes in Psychosis Mental illness is associated with high burden of disease and it has severe individual and societal consequences. In first episode psychosis, specialised Early Intervention Services with team-based intensive case management and family involvement are superior to standard treatment in reducing psychotic and negative symptoms and comorbid substance abuse and improving social functioning and user satisfaction. The results of the OPUS-trials will be presented together with meta-analyses based on similar trials. The sustainability of positive effects will be highlighted with results from three different trials. Results of long-term follow-up studies indicate that the prognosis of first episode psychosis is very diverse with the extremes represented by one group being well functioning and able to quit medication without relapse; and another group having a long-term chronic course of illness with a need for support to maintain daily activities. The latter is, in spite of many efforts, still poorly served. A substantial proportion of patients with psychosis have treatment resistant auditory hallucinations. The UK-based AVATAR-trial was the first to demonstrate effect of simulation training on devaluating voices. The Danish CHALLENGE-trial aim to replicate the findings from the AVATAR trial in a virtual reality setting.

Schizophrenia is synonymous in the public’s mind with madness. To see someone experiencing a florid psychosis, who has lost the ability to distinguish between the real and the imagined, is to know that you are in the presence of insanity. Schizophrenia has existed for centuries. It’s one of the leading causes of disability in the world, with a lifetime prevalence of about 1 percent of the population. That’s 3.3 million people in the US and 78 million worldwide. Schizophrenia afflicts rich and poor, genders, all races and ethnic groups. Schizophrenia has been subject to many misconceptions, from spiritual affliction to social deviance, psychodynamic conflicts to romanticized notions of iconoclastic creativity. Perhaps, the most significant myth about the disease is that there are no effective treatments or cure. But the reality couldn’t be more different: today’s treatments are effective and often lifesaving. Beginning in the mid-twentieth century, scientific progress has enhanced our understanding of schizophrenia as a brain disorder that disrupts thought, perception, and emotion. Findings of abnormalities in brain structure, biochemical analytes and genetic mutations have revealed its causal mechanisms and have guided the search for effective pharmacologic and psychosocial treatments. This presentation traces the evolution of our social and scientific understanding of Schizophrenia. It will elucidate how science and medicine dispelled the superstition and myth surrounding this ancient malady of the mind and forged a path toward its understanding as a brain disorders and offers affected people, not just humane treatment, but the promise of its ultimate prevention.

More than 800 randomised controlled trials have examined the effects of psychotherapies for depression and compared psychotherapies with control conditions, with each other, with pharmacotherapy and with combined treatments. These trials have also examined the effects of therapies in specific target groups, such as women with perinatal depression, children and adolescents, older adults, people with general medical disorders and many others. Furthermore, the effects have not just been examined on depressive symptoms, but also on other outcomes, such as quality of life, functional limitations and social support. In this presentation I will present the results of a large meta-analytic project in which new trials are continuously added. I will show that the most important therapies are effective, that most therapies have comparable effects, that these effects remain significant up to one year follow up and that the therapies are effective in most specific groups. But meta-analyses should also be considered with caution, because they overestimate the effects of therapies. The effects of therapies are comparable to those of pharmacotherapy, but at the longer term psychotherapies are more effective. Combined therapy is more effective than either one alone, at the short and longer term.

Since ancient times, the close connection between disturbed sleep and mental disorders has been well known. And yet, it was not until the middle of the 20th century that these connections could be studied in detail, after the EEG and REM sleep were discovered. Especially the study of the sleep EEG of depressed patients has brought to light alterations of SWS and REM sleep that could be of considerable clinical value, but at least in part still await broad confirmation. In the treatment of disturbed sleep in psychiatric patients, cognitive behavioral therapy in particular has become increasingly established in recent years, whereas only limited innovations have been recorded with regard to pharmacological treatment. Only in recent years it has become clear that psychiatric disorders are often accompanied by clinically relevant somatic disorders of sleep, such as obstructive sleep apnea syndrome, and that such comorbidities urgently require attention and treatment. It is becoming increasingly clear that detailed knowledge of sleep disorders is essential for the effective treatment of mental disorders. Moreover, it is likely that the scientific study of sleep in mentally ill people still has untapped potential in terms of understanding the pathophysiology.

Within psychiatry, there is a need for more personalized and person-centered care. Whereas the focus has largely been on the search for biomarkers to advance the field, I will focus on the use of digital technology to further personalized care in psychiatry. I will discuss how using a structured diary applet could help in developing a much more fine-grained understanding of how psychopathology emerges in the realm of ordinary life, often in interaction with contextual factors. This digital mobile health tool makes patients active partners in the clinical process as they will have to actively collect their own data. This will not only increase empowerment and self-management, it also will allow to provide more detailed evaluations of both medical and psychological interventions, it will point towards individualized treatment goals as well as provide a tool for shared decision making. In addition, I will discuss the possibility of digital mobile health tools for blended care, where standard clinical therapeutic interventions are extended outside the therapy room into the daily life of people. I will give some examples of such Ecological Momentary Interventions, where digital tools are used to offer psychological intervention in daily life, with a specific focus on young people.

Schizophrenia remains a challenging illness to treat despite considerable progress. The heterogeneity of symptoms and variability in course, outcome, and treatment response lead to considerable uncertainties in treatment guidelines. One of the most challenging issues is how to determine the need for and duration of the maintenance treatment that is intended to reduce the risk of exacerbation, relapse, and hospitalization. It is clear that in large populations, antipsychotic medication is very effective in reducing those risks, however, there is likely a subpopulation of patients with diminished risk for such outcomes even when medication is discontinued. Although attempts have been made to utilize “intermittent” or “targeted” treatment, those randomized controlled trials that have been conducted show a statistically significant advantage for continuous treatment. At the same time, many patients continue to receive higher than necessary doses of antipsychotic medication and practice needs to be reevaluated in terms of dosage requirements. The challenge remains that there are no good biomarkers or predictors of who is at risk and, therefore, dosage reduction is only titrated against exacerbation or relapse. We need to proactively reconsider who requires maintenance treatment by establishing predictive biomarkers (clinical or biological) that can help us to have a more personalized approach.

While current psychiatric treatments, especially pharmacological ones, are mainly based on initially serendipous findings, recent developments in many research areas promise unprecendented advances in translation to clinical application. The advent of large scale multiomics with single cell resolution, patient-derived induced pluripotent stem cells that can be differentiated to brain cells and even form cerebral organoids as well as the possilibility to generate humanized animal models using CRISPR-technologies have been exciting developments on the molecular and cellular side. These advances are paralleled by new technologies to increase resolution in brain imaging and electrophysiological measures as well as brain stimulation techniques. In addition, we have now access to multilevel data from very large cohorts, increasingly with longitudinal measures and using data collection with digital devices and wearables. Artificial intelligence methods open new possibilities to analyze these large scale, multilevel datasets in unbiased ways. This side of the debate will highlight the translational potential of these advances in research possiblities, giving examples from the areas of novel pharmacological treatments and personalized medicine among others. Furthermore, it will highlight how a better understanding of risk factors, genetic, social and environmental, can lead to improvements in prevention programs.

Even if most people use cannabis without many negative consequences, some experience cannabis related harms. At higher levels of intake, one of these harms could be psychotic symptoms and even cannabis-induced psychosis. During the last years, we have seen increased treatment seeking for cannabis use disorders in Europe. Parallel with this increase we have seen an increase in the incidence of cannabis induced psychosis in all Scandinavian countries and an increased population attributable fraction for cannabis on the prevalence of schizophrenia has been demonstrated. All this may reflect increased use of cannabis, but more likely increased content of D9-tetrahydrocannabinol (THC) is most cannabis products. Many have also pointed to the fact that we have seen an increase in the incidence of schizophrenia in the same period, maybe attributable to cannabis use. If we also take into consideration that up to one third of those with cannabis-induced psychosis over time receive a diagnosis of schizophrenia, we may see at least two implications. Firstly, these findings strengthens the evidence for a causative relationship between cannabis use and schizophrenia, a causative relationship that man have suggested for several years, but that has had some opponents. Secondly, it points to cannabis-induced psychosis should be considered to be a part of the ICD-10 F2-chapter rather than the F1-chapter. This may be true also for the other substance-induced psychosis (F1x.5). An additional argument for this is that for no other psychotic diagnosis, a precipitation factor is mentioned in the diagnosis.

Regular cannabis use is associated with several adverse health outcomes including psychosis and cannabis use disorders. In the last decade, prevalence of last-month cannabis use increased by 27% and rate of treatment demand rose from 27 to 35.1 per 100000 inhabitants in Europe. Cannabis legal status is changing worldwide, and recently two European countries (Malta and Luxembourg) legalized its production, sales and use. Even United Nations withdrew cannabis from Schedule IV of the Single Convention on Narcotic Drugs (retained in Schedule I). This new scenario aligns cannabis more closely with alcohol, prescribed drugs or tobacco than illegal drugs. Implementing prevention and harm reduction strategies will be even more relevant in the nearly future. Based on the history with alcohol or tobacco, frequency of use alone misestimates the risks due to limited capture of variations of quantity per day of use on regular users. Standardisation of cannabis use has been proposed in the literature as an instrument to assessing the level of risk. In the Lisbon Addictions Conference (2019) a group of 32 professionals from 13 countries and 10 disciplines participated in a back-casting foresight exercise aiming to addresses challenges of implementation of SJU. They proposed three key steps in the implementation of SJU: 1) constitution of task-force for an evidence-based approach to SJU; 2) expanding the available data on cannabis-related risks; 3) examining the relationship between ‘risky use’ and SJU.

Psychiatry is facing major challenges during times of a pandemic as illustrated by the current COVID-19 pandemic. The challenges involve its actual and perceived role within the medical system, in particular how psychiatric hospitals can maintain their core mission of attending to the mentally ill while at the same time providing relief to general medicine. Since psychiatric disorders are the top leading causes of global burden of disease, we need to strengthen mental health care in the wake of the massive onslaught of the pandemic. While nobody can deny the need to act decisively and swiftly and ramp up intensive care readiness, we believe that the immediate availability of psychiatric care is just as important. In order to provide the best possible treatment conditions for people suffering from mental illness but as well for those suffering from the immediate pandemic’s consequences such as isolation, reduced social interaction etc. instant and comprehensive provision is inevitable.

Resilience, mental health, and well-being are currently being discussed in general and for healthcare workers. Employees in the mental health workforce are subject to a variety of stresses. There have been long-standing stresses due to structural and discipline-specific conditions. In addition, there are special challenges due to the pandemic.

The systemic perspective of the biopsychosocial model of human development focuses on biochemical, muscular-neuronal, emotional, cognitive, and environmental risk and protective factors. These systemic events are embedded in different environmental systems that represent micro- to macrosystemic conditions. All these factors need to be reflected, evaluated, and positively developed in a profession- and workplace-specific manner. In this sense, “career resilience” can be promoted individually, at team level and organizationally. Corresponding evidence-based programs for prevention and intervention are presented. In the discussion, it becomes clear that expectations of societal requirements can also be derived under the concern of prevention and promotion. It is necessary to complement self-care with the “caring team community” to promote the development of a comprehensive “caring society”. Thus, we contribute to an overarching conception in terms of transdisciplinary consilience of resilience and wellbeing in mental health workforce.

Over the past decades, researchers and psychiatrists in the field of psychosis have moved from a conception of a chronic presentation to a more dynamic paradigm. Accordingly, schizophrenia is now conceptualized as a progressive illness that typically emerges during late adolescence and follows different stages: early vulnerability, ultra-high risk state, first episode of psychosis, and chronic disease. Only one-quarter of the ultra-high risk patients will convert to a full-blown psychotic episode within 3 years while the others, called non-converters, will remain at-risk, develop other psychiatric disorders, or fully recover. The reasons for this differential outcome are not yet understood but this concept opens the way to scientific research to determine the protective factors involved in resilience for non-converters. Based on the Gene X Environment interaction model, schizophrenia results from genetic vulnerability and environmental aggressions which can have an impact on the epigenome and gene expression. Recent studies have shown that genetic variants play a role in the resilience of psychosis. Polygenic risk scores, computed as the addition of genetic polymorphisms, can modulate the effects of genetic at-risk deletions (i.e. del22q11) that predispose to psychosis and may also influence the cognitive symptoms of ultra-high risk patients. Resilience, defined as the ability to withstand adversity, is not only related to external skills or psychotherapeutic care but could also be explained by internal molecular factors. Identifying the genetic factors of resilience might help to stratify the risk and to develop precision medicine in psychiatry.

The arrival of Covid-19 had huge impact on all aspects of life and psychiatry was no exception. Significant changes to mental health services were introduced to reduce the risk of infection among the inpatient population, patients in the community and in outpatients consultations. Use of virtual consultations in the community and stringent infection control in inpatient setting are examples of many. Those changes were associated with significant differences in patients’ presentation and access to services. Multiple studies reported increased proportion of psychotic patients being admitted to inpatient care. However, there were no reports on increased suicide contrary to the expectation. This is despite increased reports of mental distress, depression, and anxiety in the wider population. These reports are consistent with our knowledge of mental health problems reported in times of wars and disasters. Hence, some of the learning from experience proved relevant when facing this pandemic. Unfortunately, Covid-19 continues to represent a challenge and relaxing of the restrictions introduced were short-lived with every variant reported. In addition, some of the changes adopted by mental health services proved to be innovative and more efficient way of delivering care in psychiatry. Therefore, the early indications suggest that some of those changes would become the new normal.

Pandemic-related extraordinary work burden on all healthcare professionals had a greater toll on younger colleagues, especially residents in diverse medical fields. Although psychiatry residents’ degree of engagement in COVID-19 related services depends on the state’s and institution’s management of the crisis, it has often led to a significant interruption in the schedule of the training requirements. This interruption also was a consequence of the change in provision of the psychiatric services during the pandemic, such as a decrease in the size of the inpatient clinics, lower number o patients in the outpatient services, fewer ECT. These changes made it more difficult to fulfill the training requirement, which was adopted in some countries. Even when the tasks related to the training were accomplished the quality was difficult to determine. Furthermore, most of the educational activities were switched to online format due to pandemic-related precautions, a change that persists in some activities. Psychiatry education and training, not only postgraduate but also during medical school, requires observation and direct engagement. The switch from face-to-face to online in psychiatry training, including supervision, and service provision constituted a major challenge in psychiatry education. This required further adaptations by the teaching staff as well as the trainees, in their methods of teaching, learning, and interaction. The assessments of competencies presented another challenge for the psychiatry training. Despite all, the introduction of online education provided increased diversity in resources and in some situations increased access. Some challenges required modifications, whereas some beneficial changes are there to maintain.

In addition to the global negative impact on mental health of general population, as well as psychiatric patients, Covid-19 pandemic affected significantly research. Initially, lockdowns and restrictions of human contacts temporarily disrupted clinical research activities, but the unprecedented health crisis also provided unique opportunity to study epidemiology of mental disorders, direct and indirect effects of the pandemic on psychiatric disorders, underlying pathophysiological mechanisms, or long-term neuropsychiatric consequences. Research has refocused now on better understanding of the causes, presentations, outcome trajectories, and therapy of mental illnesses. New research topics are followed by the surge in publications covering Covid-19 and mental health and/or psychiatric disorders and treatments. The impact of the pandemic on research and publications is also evidenced by the results of a survey among psychiatric researchers.

France has been severely impacted by the pandemic. The first wave imposed a major lockdown, never seen before. The second and third wave lockdown responses were somewhat less dramatic. People were allowed to travel to work. Nursery and elementary schools were left open while high schools had part-time attendance. Spring 2021, still presented with a terrible death toll of 300/day, for a 67million population country. For many months the spotlights were focused on the high levels of mortality and morbidity of the elderly. This somehow obliterated the younger generation’s mental health issues. It now appears that children and adolescents have had to pay a steep price to Covid 19. In France, during the first lockdown, child and adolescent morbidity and mortality due to abuse heightened considerably compared to 2019 during the same period. And during the second and mostly the third lockdown, pediatric emergency wards have been underwater with youth mental health issues ranging form suicidal ideation to acute dissociation. Different hypotheses have emerged on how the pandemic has so dramatically impacted the mental health of children and adolescents, specifically the most vulnerable ones. The consequences this might have for child development and mental health during the years to come will be debated.

Background Transcranial direct current stimulation (tDCS) has shown promise as a treatment for obsessive compulsive disorder (OCD) in a small number of trials. We performed a feasibility study to inform the development of a definitive trial, focussing on acceptability, safety, feasibility of recruitment, adherence and tolerability of tDCS and the size of any treatment-effect. Methods FEATSOCS was a randomised, double-blind, sham-controlled, cross-over multicentre study. Twenty adults with OCD received three courses of tDCS targeting the two most favourable stimulation targets; supplementary motor area (SMA), orbitofrontal cortex (OFC) and sham-stimulation, randomly allocated and delivered in counterbalanced order. Each course comprised four 20 minute-stimulations, over two consecutive days, separated by a four weeks washout period. Clinical outcomes were assessed by ‘blinded’ raters before, during and four weeks after stimulation. Results: tDCS was acceptable, well tolerated and safe; adherence was good, with few dropouts, there were no serious adverse events, and adverse effects were mostly mild. Recruitment to target was feasible. Yale-Brown Obsessive-Compulsive Scale scores numerically improved from baseline to 24 hours after final stimulation (primary outcome) across all interventional groups. The greatest effect was seen in the OFC arm. Additional significant within-group improvements in secondary outcomes occurred in the OFC, and to a lesser extent in the sham arms, but not with SMA. Discussion tDCS appears a promising potential treatment for OCD. The OFC represents the optimal target. A full-scale trial to determine optimal stimulation protocols (current, frequency, duration), longer-term effectiveness and feasibility of home delivery is indicated.