In elderly patients who suffer from depressive symptoms and cognitive impairment the clinical decision between the diagnoses of depression and dementia may be difficult. In addition, patients with dementia and depressed patients frequently show a disturbance of sleep. Sleep EEG registration in depression revealed a characteristic sleep EEG profile concerning distinct alterations of sleep architecture and REM-sleep (reduction of SWS, increase and advance of REM-sleep). In dementia polysomnographic assessment has been done less intensively, mainly in patients with dementia of Alzheimer type (DAT). The most significant polysomnographic finding in DAT is a reduction of REM-sleep, which may reflect impaired cholinergic neurotransmission. Therefore, predominantly REM-sleep variables clearly differ between depressed patients and patients with DAT.

In this presentation polysomnographic data and data of cognitive performance in dementia and depression will be reviewed. In addition, own long term studies in patients with different types of dementia and in depressed patients will be presented. The polysomnographic findings of these studies will be discussed with respect to differential diagnosis, prediction of treatment response and the long term course of both diseases. In addition, the results will be related to the current knowledge of the neurochemical and neuroendocrine regulation of sleep.

Mental health care has traditionally been provided within the framework of a verticle mental health services system. Additionally, mental health care is often provided through a variety of agencies or organizations that have a number of different mandates, responsibilties, authorities and accountabilities. These are not well linked with or to each other.

Furthermore, mental health services for children and youth are often not well integrated into adult mental health services. This profusion of confusion regarding mental health care for young people can be much better defined and operationally developed if a model of care based on population mental health care needs and provider mental health care competencies can be applied. This presentation will present the conceptual framework for such a model that allows for mental health care to be intergrated into all levels of health and other systems that provide interventions for young people suffering from a variety of mental health problems.

The physical well-being of people with schizophrenia is remarkably neglected. Physical illnesses in these people are underdiagnosed and undertreated. A recent study in Australia showed that, although people with schizophrenia suffer more frequently from cardiovascular problems than the general population, they receive catheter much more rarely. People with schizophrenia have been also reported to be less likely than the general population to receive HbA1c and cholesterol monitoring, to receive a retinal examination for diabetes screening, and to be treated for osteoporosis. They have been also found to be more likely to be treated for physical illnesses only when the latter become life threatening. Among the factors contributing to this underdiagnosis and undertreatment of physical illnesses in people with schizophrenia are a low motivation of patients and their relatives to access medical services, the isolation of psychiatric services from other medical facilities, and a tendency of psychiatrists to overlook physical health problems in their patients. However, the most important factor is likely to be the stigma surrounding schizophrenia. The neglect of physical health in people with schizophrenia should be regarded as an expression of discrimination and disregard for their dignity and their rights as human beings and citizens. Due to the lack of prevention and intervention strategies, people with schizophrenia and their families bear the costs of the mental disorder and those of the concomitant physical illnesses, which can exacerbate psychopathological manifestations and impair the subjects’ ability to adhere to treatment. Access to physical health care of the same quality as that available to the rest of the population should be considered a basic right of people with schizophrenia and a crucial dimension on which their quality of life has to be evaluated.

Many patients with schizophrenia experience persistent symptoms or side effects on their current antipsychotic regimen. Such patients, particularly those treated with conventional antipsychotic agents may benefit from switching to atypical agents, which offer broader efficacy and improved tolerability compared with earlier counterparts. In addition, patients already receiving treatment with an atypical agent may benefit from switching to an alternative atypical, given that there is great variation in (1) individuals’ response to different atypical antipsychotics, and (2) the side-effect profile of the atypicals. With switching from one antipsychotic to another becoming increasingly common, there is an urgent need to define optimal switching strategies. The main goal when switching antipsychotics is to improve or (in stable patients) maintain the symptomatic and functional level, while improving (or not worsening) tolerability. It is important to identify patients who would be likely to benefit from switching and to discuss with them and their carers the advantages and potential problems of the switching process. To date, four strategies have been effective in controlled studies of switching to atypical antipsychotics: therapeutic dose initiation of the new antipsychotic and abrupt discontinuation of the first (‘abrupt switch’); gradual dose escalation of the new antipsychotic and abrupt discontinuation of the first (‘ascending switch’); therapeutic dose initiation of the new antipsychotic and gradual discontinuation of the first (‘descending switch’), and; gradual dose escalation of the new antipsychotic and gradual discontinuation of the first (‘cross-titration’). An individualized approach is key to the success of switching, as are patient co-operation and carer support.

Combination therapy is well established in bipolar disorder; however, the evidence for this approach in schizophrenia is less robust. Despite the absence of clear guidance, antipsychotic combinations are commonly used in real-life practice, with estimates suggesting that 20–60% of patients receive multiple antipsychotics concurrently. Such polypharmacy may be clinically useful, combining diverse pharmacological actions. However, a clear pharmacological rationale for specific antipsychotic combinations has not yet been elucidated. In this presentation, we consider the varying pharmacological profiles of agents currently used for schizophrenia and explore how best this pharmacology may be exploited to maximize the newer atypicals in clinical practice. For decades schizophrenia has been treated with some success using typical antipsychotics, which are antagonists at dopamine D2 receptors. Atypical antipsychotics were then developed, having D2 antagonism with additional affinity for other receptors, such as serotonin 5-HT2A and 5-HT1A receptors. Most recently, partial D2 agonists have been developed with efficacy to treat schizophrenia and bipolar disorder. These agents have lower intrinsic activity than full agonists, so can act either as functional agonists or antagonists. Additionally, actions to increase noradrenergic function in the prefrontal cortex may be implicated in the efficacy of some antipsychotics. Given the rich pharmacology of antipsychotics, can the combined use of agents with synergistic mechanisms of action provide a true clinical advance in schizophrenia treatment? Polypharmacy is a complex challenge that requires further study in well-designed, randomized, controlled studies. We will review the pharmacological rational for antipsychotic combination therapy and recent clinical evidence for their benefits.

Although the induction of sleep was originally considered to be a desirable therapeutic endpoint for the rapid control of agitation, it is increasingly recognised that sedation is not a prerequisite for acute symptom control. Moreover, excessive sedation or ‘over-sedation’ can interfere with the physician's ability to evaluate the patient and establish an effective therapeutic alliance with them, thus potentially influencing future compliance and treatment outcomes. Over-sedation is also strongly disliked by patients. Thus, achieving control of agitation via rapid calming rather than sedation is becoming an important therapeutic goal. Sedative agents, such as lorazepam, have traditionally been used for the management of acute agitation. However, problems with over-sedation have led to the increased use of intramuscular (IM) antipsychotics – which are easy to administer and provide rapid symptom relief of acute agitation – as a first-line approach in the acute setting. The recent availability of atypical antipsychotics as IM formulations represents a significant step towards meeting the goal of efficacy without over-sedation. Aripiprazole, olanzapine and ziprasidone have demonstrated efficacy in the management of acutely agitated patients with schizophrenia. Indeed, IM aripiprazole has been shown to be equally effective as IM haloperidol with a lower risk of extrapyramidal symptoms. Importantly, calming of acutely agitated patients without excessive sedation is emerging as a significant clinical advantage of IM atypicals over older treatments such as typical antipsychotics or benzodiazepines. Thus, physicians should consider the specific, sedation-independent calming effects of atypicals.

The investigation of the comparative efficacy of the combination of pharmacotherapy and psychotherapy versus either modality alone has to consider several methodological issues. Neglect of these methodological aspects can lead to severe pitfalls. Also, the interpretation of the results of such studies should be performed very carefully, considering several aspects. Among others, the following questions have to be addressed:

• – Was the study performed in a more psychopharmacology-oriented or more psychotherapeutically-oriented institution?

• – Were the patients acutely or chronically ill?

• – Were the patients already refractory to pharmacotherapy or psychotherapy prior to inclusion in the study?

• – Was the pharmacotherapy performed according to the state of the art?

• – Was the psychotherapy performed according to the state of the art?

• – Was the pharmacotherapy administered under double-blind conditions, using a placebo control or another kind of control?

• – Was the psychotherapy administered in the context of a pseudo placebo control group?

• – Was the sample size adequate for a confirmative trial?

Generally it has to be taken into consideration that it is much more difficult to prove efficacy of a combination therapy versus an active mono-therapy then to prove efficacy of a mono-therapy or combination therapy versus placebo. Overall, there seems to be evidence for superior efficacy of the combination of antidepressants with cognitive behaviour therapy, especially in certain subgroups of patients.

There is now a large body of controlled trial research into the efficacy of psychological treatments in unipolar affective disorder, indicating their place in acute treatment and in prevention of relapse and recurrence. In bipolar disorder the evidence is still less strong, but studies are rapidly accumulating. Psychological treatments have been almost always combined with medication. The psychological approaches have included psychoeducation, cognitive therapy (CBT), interpersonal and social rhythm therapy (IPSRT), family therapy. Some approaches have used mixtures of elements, particularly psychoeducation with family or cognitive therapy. Benefits found have included symptom improvement, improvement in social function, relapse prevention and improved adherence to drug regimes. However findings have not been entirely consistent, so that definitive recommendations are still premature. Effects may be weaker than in unipolar disorder. In contrast to unipolar disorder, where the strongest body of empirical evidence favours cognitive therapy for symptom remission and relapse prevention, in bipolar disorder psychoeducationally-based approaches may emerge to be of greater benefit.

How do social networks add value for the work of leaders? What are key network mechanisms? How can you improve the strategic impact of your social capital? This session introduces the idea of ‘social capital’, along with social network concepts, tools, and strategies. The evidence comes from recent findings about how collaboration in basic research in biotechnology occurs, how firms explore innovative technologies, and on how individuals create professional advantage. The themes focus on how social networks change the terms of value creation, create de facto systems of opportunity and advantage, and extend basic leadership in contested, ambiguous professional settings. The session is interactive, rather than one-way lecture.

Read aheads for the session

• – Hargadon, A. 2006. ‘Brokers of innovation.’ Focus, vol. VIII, no. 1.

• – Uzzi, B and S Dunlap. 2005. ‘How to build your network.’ HBR, December.

• – Reprint # R0512B

• – Weick, K. 1996. ‘Prepare your organization to fight fires’ HBR, May-June.

Half of the world's population are children or adolescents. Nearly 5% of them suffer from mental disorders and another five percent have conduct disorders.

Even in highly developed industrialized countries mental disorders in this age are often not recognized nor taken seriously. The situation is made worse by the lack of awareness of the magnitude and severity of the problems caused by mental disorders of children and adolescents by political and health decision-makers, by health professionals and by the general public; and by the fact that health professionals and others involved in child care and development have often only rudimentary knowledge about appropriate methods of prevention and treatment of mental and neurological disorders in childhood and adolescence.

It is for this reason that the World Psychiatric Association (WPA) carried out in collaboration with the World Health Organization (WHO) and the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP) this unprecedented program.

This program aims at; increasing the awareness of health decision-makers,health professionals and the general public about the magnitude and severity of problems related to mental disorders in childhood and adolescence and about possibilities for their resolution; at promoting the application of measures of primary prevention of mental disorders in childhood and adolescence and of interventions that will contribute to the healthy mental development of children and adolescents; and support to the development of services for children and adolescents with mental disorders and to facilitate the use of effective methods of treatment.

In Sweden, CAP (Child and Adolescent Psychiatry) has a history of more than 100 years. The discipline developed out of paediatrics, education, child social welfare and psychiatry in that time order. In similarity to the situation in Switzerland, “school -psychiatry” was established as a branch of CAP with the aim to understand the link between cognition, behaviour and health and to promote health for children with slow learning capacity and mental retardation who in those days were children at a high risk for juvenile delinquency. The first CAP units opened at the end of World War I in the Stockholm Public School system and at the Paediatric Clinic of Norrtull's Children's Hospital, one of the two Paediatric University Clinics at the Karolinska Instituted in Stockholm. From 1920-1970, school psychiatry was an important part of child and adolescent work in Sweden. It was based on a true cooperation between CAP and Education using the principles from “heilpädagogie” i.e. “curative education”: as follows:

To support pupils’ creativity, language and speech competence and their social competence

To accept each pupil's individual maturity/developmental level and behavior by introducing “School-maturity tests” before school-start.

To introduce different school curricula for children with average intelligence, school-immaturity, slow learning capacity (IQ 70-90), mental retardation etc.

To introduce special training for teachers in order to have teachers that knew how children with “problems” should be taught.

To use screening and monitoring of skills i.e. screening of intellectual skill, language, reading, spelling, math's, maturity, behavior, health at preschool start,

Suicide among young people age 15 – 24 constitutes a considerable burden on the global level. Data from 90 out of the 130 WHO members states show that suicide was the fourth leading cause among young males and the third for young females. Suicide rate is higher in young males (world average 10.5 per 100 000) than in young females (world average 4.1 per 100 000). A rising trend of suicide in young males is observed in many countries and particularly marked on other continents than Europe.

Since suicide risk is high among psychiatrically ill young people. Therefore, an adequate treatment of psychiatric disorders and improved detection of psychiatric illnesses in the general population is important. Preventive measures in the health care services after a suicide attempt and an early recognition of children and young people at risk in schools by screening, gate keepers training and other awareness programs are essential strategies.

The results of those studies as well as the worldwide initiative launched by the WHO in SUPRE for the prevention of suicide, will be presented.

Previous studies have shown that most patients in forensic services are men with schizophrenic disorders who have a long history of treatment in general psychiatry, during which time they were committing crimes and engaging in aggressive behaviour. The present study was designed to examine violent behaviour among severely mentally ill (SMI) patients in general psychiatry and the treatments that they received. A representative sample of 220 inpatients with SMI in an urban area in the UK was examined. The prevalence of at least one conviction for a violent crime (46.7% of the men,16.5% of the women) was higher among the patients than among an age and gender matched cohort of the UK population. The elevations in risk for violent offending by patients with SMI compared to the general population were similar to those observed previously in other countries. In the six months prior to interview, 49.2% of the men and 38.8% of the women engaged in physical aggression towards others, and one-in-five engaged in serious violence. Two years later, 79% of the patients were re-assessed. All patients had been receiving antipsychotic medications and meeting with their care co-ordinators (nurses, social workers), on average, once a week, but only 6 patients received treatments relating to substance misuse and 2 patients participated in an anger management programme. More than 80% of the patients experienced at least two negative outcomes defined as high symptom levels, aggressive behaviour, substance misuse, and physical victimisation. General psychiatric services did not address patients’ problems with violence.

The prejudice of the outstanding dangerousness of individuals with severe mental illness is one of the major reasons for the special position of psychiatry among the several medical disciplines. The mental health reforms initiated during the second half of the 20th century had the principal aim to move the locus of treatment and care from the big mental hospitals into the community and to strengthen the patients’ civil rights - so reducing stigmatization and ‘normalizing’ the aforementioned special position of psychiatry. Despite all doubtless improvements for the majority of mental patients every European country is reporting on rapidly growing admission rates of mentally ill offenders to forensic hospitals. A possible association with the introduction of mental health reforms is under continuous discussion.

It will be shown that not single details of the reforms but, rather, the changed attitude towards a subgroup of severely mentally ill subjects being at higher risk of violence could be the crucial issue. These patients hamper the desired ‘normalization’ of the position of psychiatry, and, in fact, modern community care hardly offers sufficient treatment options for them.

The basis for this development may lie in the societal changes of the last decades. Today, we do dispose of the ‘technical’ (financial, pharmacological) preconditions for the treatment of severely mentally ill patients. However, the emotional preconditions of society and its representatives seem to be only insufficiently developed. Therefore, forensic hospitals are in danger to take over the role of the old psychiatric asylums.