Improving real-life functioning is the main goal of the most advanced integrated treatment programs in people with schizophrenia. The Italian Network for Research on Psychoses used network analysis in a four-year follow-up study to test whether the pattern of relationships among illness-related variables, personal resources and context-related factors differed between patients who were classified as recovered at follow-up versus those who did not recover. In a large sample (N=618) of clinically-stable, community-dwelling subjects with schizophrenia, the study demonstrated a considerable stability of the network structure. Functional capacity and everyday life skills had a high betweenness and closeness in the network at both baseline and follow-up, while psychopathological variables remained more peripheral. The network structure and connectivity of non-recovered patients were similar to those observed in the whole sample, but very different from those in recovered subjects, in which we found few connections only. These data strongly suggest that tightly coupled symptoms/dysfunctions tend to maintain each other’s activation, contributing to poor outcome in subjects with schizophrenia. The data suggest that early and integrated treatment plans, targeting variables with high centrality, might prevent the emergence of self-reinforcing networks of symptoms and dysfunctions in people with schizophrenia.

Although antipsychotics were discovered over fifty years ago, it took another decade until dopamine antagonism was demonstrated as central to their clinical effectiveness. Since accumulated evidence implicates the dopamine system in the pathophysiology of schizophrenia, all licensed first-line treatments operate primarily via antagonism of the dopamine D2 receptor. However, dopamine D2 receptor blockade does not effectively treat negative, cognitive and affective symptoms and, in a significant proportion of patients, it does not improve positive symptoms either. Therefore, additional neurochemical targets were considered. The “revised dopamine hypothesis” proposes that positive symptoms emerge due to hyperactive dopamine transmission in mesolimbic areas, while hypoactive dopamine transmission via the mesocortical pathway in the prefrontal cortex is linked to negative, cognitive, and partly affective symptoms. In this context, the role of D3 receptors were recognised. However, there is also evidence for the involvement of other neurotransmitter systems, suggesting that dopamine signalling relies on a suite of receptors that are thought to either facilitate or inhibit neurotransmitter activity through several interconnected neural circuits. Furthermore, there seem to be clusters of symptoms that cross the boundaries of disorders. Symptoms having similar pathophysiology at neurotransmitter level can be treated with the same drug or class of drugs. Thus, one particular drug might be effective in more than one indication. This lecture aims to illustrate the process of a new drug development by explaining how the underlying pathophysiology on receptor level impacts clinical studies and vice versa.

Traditionally, psychopathology has been classified based on the publications of authoritative bodies, such as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (APA’s DSM). Recently, researchers have expressed an interest in basing classification more on data, as opposed to authority. This movement led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) consortium. Working from data, the HiTOP approach emphasizes dimensions of human individual differences that are arranged hierarchically, as opposed to categories that are arranged based on traditional DSM chapter rubrics. In this talk, I will describe the origins and status of the HiTOP approach, as well as current and future HiTOP directions and priorities.

Background Urban birth, urban living, and ethnic minority status are established risk factors for schizophrenia, but the mechanisms are unclear. Previous evidence suggests a causal role of social exposures and adverse experiences, but experimental evidence is scarce. Methods We combine multimodal neuroimaging with ecological momentary assessment, geolocation and geospatial analysis in an epidemiological longitudinal sample in Germany. Results We find that established risk factors converge on the perigenual cingulate-amygdala-ventral striatal pathway as shown by structural and functional imaging, supporting a role for the ventral-striatal system in psychosis risk. Using a combination of PET and fMRI data in migrants, we suggest a mechanistic link to psychosis by increased dopamine release and synthesis in striatum secondary to prefrontal dysregulation. Importantly, the regulatory system identified overlaps with that implicated in racial stereotyping and prejudice. Moreover, an experiment measuring information flow during an exchange between migrants and non-migrants indicates that during a trust interaction, cultural distance governs the exchange. Conclusions This work shows a convergent risk circuit related to minority position and migration that could guide primary prevention of schizophrenia through reduction of manifestation risk by contextual intervention.

Aging persons can become involved in the criminal justice system, more commonly as victims but also as offenders. They are a growing group of interest in forensic psychiatry, due to the ageing of the population. Moreover, they are overrepresented in long-stay facilities. Forensic psychiatrists may be asked to evaluate elderly individuals whose behaviour has become problematic to their families, caregivers, or third parties. We will focus here on problematic behaviors in eldery people, particularly disinhibition, agitation and aggression, and criminal behaviour and the incarcerated eldery. Forensic psychiatric assessment with new-onset criminal behaviour require special inquiries regarding criminal responsibility or competency to stand trial. Little research is available regarding criminal behaviour in eldery persons in correctional settings. In this paper a forensic-psychiatric expert report will illustrate these topics.

Old age population is growing steadily during last decades (WHO 2017). Old population suffer from more morbidity including mental disorders (De Lorito,2018). This fact also applies for prison population (Yortons 2006) and in the lasts years has been an increasing interest for this topicThe aging of the world population is reflected in the penitentiary setting, with a progressive increase of elderly inmates. These prisoners present complex clinical processes with multiple comorbidities, requiring a specialized approach. In the 2020, the old age population in prison (considered over 60 years old) is around 5% in Catalonia (377 inmates,), same proportion (5%) in Spain.If we consider the cut-off point 50 y.o. (as other research) the proportion is 12% Our aims are to describe sociodemographical and clinical characteristics of old age inmates (over 50 y. o.) who required to be admitted to psychiatric unit in Catalan prisons between 2016 and 2020. The asample of this study will be around 150 inmates admitted in our unit. Elderly inmates present a high prevalence of substance abuse (especially alcohol), affective symptoms (depression) and cognitive deterioration. Likewise, is observed a significant presence of personality disorders, anxiety, post-traumatic disorders, psychotic disorders, and physical comorbidities. Prisoners over 50 have a different profile from the rest of the prison population. They suffer more physical and mental illnesses, so they require specific health and social approach. It would be advisable to adapt clinical care by optimizing resources, developing prison psychogeriatrics and establishing specific evaluation and treatment method

Homicide and suicide are complex phenomena raising questions and interest which go far beyond the medical and psychiatric field, as they represent a challenge for an understanding which is, first of all, human. In older adults, homicide and suicide may present together in the homicide-suicide phenomenon. The most common motive underlying this behavior in intimate partner relationships is the so-called “mercy killing”, where the perpetrator kills the partner to eventually allow relief from declining health conditions, and then commits suicide. Actually, older adults account for a disproportionately high number of suicide deaths and approximately 55% of late-life suicides are associated with physical illness, notwithstanding psychiatric comorbidity. Physical illness is more likely to eventually lead to suicidal behaviour when it represents a threaten for the individual’s independence, autonomy, self-esteem and dignity, and when it impacts on quality of and pleasure with life, sense of meaning, usefulness and purpose in life. As the current historical period is one marked by opportunities which have allowed a rapid increase of life expectancy and longevity, it clearly emerges the need to balance benefits and harms of curative and palliative therapies, especially for painful, terminal illnesses. The expression of suicidal thoughts in older adults, as well as behaviours suggesting “silent” or indirect suicidal attitudes, should be carefully investigated and clinicians should try to decode the possible communicative role of suicidal behaviour while avoiding premature conclusions about the “rationality” of patients’ decision to die.

Human beings need social group identities. These may be based on age, sex, gender and gender identity, ethnicity, religious beliefs, language, nationality and etc. In fact, in-group identities, collaborations and reference systems have positive effects on health / mental health. But, the problematic issue is the process of Othering and Dehumanization of the group designated to be the Other. Othering, rising from imagined or the expectation of generalized differences and used to distinguish groups of people as separate from the norm reinforces and maintains discrimination. Social power relations determine the stratification of ‘them’ and ‘us’. Whether a group is to be designated as the Other and labelled with prejudice will depend on the zeitgeist of the current dominant social power. Dehumanization created many tragedies via genocide, slavery, racism, sexism, and other intolerant forms of violence. Theories, generally termed as scientific racism of late 19th. & early 20th. centuries, times of colonialism, assumed that some races are inferior to others, and that differential treatment of races is consequently justified. Such approaches led to movements of unification / purification practices which cannot be legitimate and caused vast individual and institutional racial discrimination, human rights violations and violence. As a social determinant of health, racial discrimination and ethnocentrism, a powerful force that weakens human relations, continue to afflict the health and mental health conditions of people. Albeit racial discrimination, peoples of the world also have a history of effective praxis of inclusive ways of solving conflicts of interests between in-groups and out-groups.

Mental health care remains a pillar of suicide prevention also in late, but the range of interventions should include attention to the many socio-environmental conditions that are relevant to this stage of life. Community programs that promote a sense of worthiness and belonging should be strongly encouraged in order to preserve personal identity and social integration. Loneliness has to be counteracted in its many facets and with vigour, given its multiple negative impacts. The fight against stigma and ageistic views - still deeply rooted even among health workers – should be carried out with determination. Active promotion of a culture of resilience and adaptation to different phases of life and the changes imposed by them should constitute the founding bases of all efforts aimed at promoting a successful aging process. Combating discrimination against older people, as well as promoting basic social determinants of health, would help prevent suicide. However, these issues are still very underrepresented in the global agenda of health care. While having an effective impact on the numerous forms of discrimination would require legal interventions by governments, fighting stigma would primarily involve education aimed at changing beliefs and attitudes. Promotion of human rights, with particular regard to protection against abandonment, abuse and violence - particularly deleterious aspects in old age – appears as essential for personal empowerment of older individuals. Once become more powerful, older people may become more capable of defending their interests in terms of quality of life and protection against risk factors for suicide.

Older persons represent a large, and the fastest growing, segment of the global population. Women form the majority of older persons with global demographic data consistently showing that women tend to live longer than men, especially at advanced ages. Older women also make substantial contributions to our societies and economies, including as informal caregivers, volunteers and community leaders. Ageing, however, is not gender-neutral and inequality and discrimination experienced by women during their lifespan is often exacerbated in older age. For example, older women are at a higher risk of living in poverty and of facing barriers in accessing basic rights such as health, adequate housing, and protection from violence, abuse and neglect. Yet, the specific challenges created by the intersection between age and gender often remain invisible and understudied. This also applies to people living in Europe. And elderly women with mental disorders face a triple stigma: suffering from mental disorders, being a woman, being old. The presentation emphasises the UN-decade of healthy ageing with fight against ageism, and a paper of the WHO and IPA on the topic of this presentation.

The number of persons with 60 years and more worldwide is estimated to triple by 2050. With the raising burden of the mental health conditions that accompany population ageing, mental health care for older adults has to be under pined by a dignity and human rights based approach. The extraordinary number of human rights violations of the older population during the COVID-19 pandemic has come to the forefront, as consequence of this population vulnerability, the lack of political will to give prior attention to this group needs and the disseminated ageistic attitudes. Discrimination based on age can lead to catastrophic social consequences such as elder abuse, neglect and all forms of violences. Their access to services become reduced, including health, social and justice services. These negative attitutdes, more than only morally unacceptable, are source of unnecessary suffering and increase morbidity and mortality rate. Intersecting across psychiatric diagnoses and interventions are the principles of dignity, autonomy, respect and equality which are all at the base of the call for an United Nations Convention of Rights of the Older People. Keeping all thes points in mind, the World Pschiatric Association Section of Old Age Psychiatry and the International Psychogeriatric Association are working together to promote the Human Rights of Older Adults. The presentation of a webinar, the publication of joint position statements, the organization of symposia in several international congress and the publication of a recent special issue of the America Jornal of Geriatric Psychiatry (October 2021 - https://www.ajgponline.org/issue/S1064-7481(21)X0010-3) are some examples of this common effort.

Despite the multiplication of the therapeutic strategies for psychiatric disorders during the last decades, the incidence of suicide has not decreased substantially. Specifically, the most commonly used strategy, which is the use of antidepressant treatments, is clearly nonsufficient to attain the goal of a substantial reduction of suicides. Then, we will discuss the hypothesis that people who are more sensitive to experiences of social disconnection may activate a pathophysiological process which lead to a greater risk of suicide, and by such its study may offer new avenues for assessing the suicide risk as well as in providing new therapeutic targets. It is well demonstrated that both the objective condition of being alone and loneliness are strongly associated with suicide. From a series of cognitive imaging studies, it appears that suicidal patients are more sensitive to social exclusion, relying on a neural network implicated in the pain matrix, and individuals experiencing more psychological pain in daily life would be less prone to activate orbitofrontal cortex in social contexts which would facilitate disadvantageous decision-making, leading to choose options (i.e. suicidal act) with short-term reward (i.e. relief from pain) in spite of the risks (i.e. death). As psychological pain predicts suicidal behaviour, suggesting the need in assessing it in clinical practice, in using alleviating drugs i.e. opiates or ketamine, and in implementing evidence-based psychosocial strategies, based on caring contacts and social prescription. In conclusion, there are many innovations available to help tackle social vulnerability, which should be a priority in suicide prevention.

We’ll present the Catalan experience of follow up by phone contats of suicide attempters, and the results up to 10 years. We develop a Suicide Prevention Program that started with the EAAD project in 2008 in a 0,5 M people catchment area, later generalized to 7,5 M people through the Catalonia Suicide Risk Code (SRC-Cat). The SRC-cat is a real-time registry of suicide attempts (65% women) that allows immediate attention and telephone follow-up and ensures continuity of care for 12 months. To evaluate the effectiveness of our telephone management plan, we conducted two types of analysis; a) 12-month short-term analysis: non-randomised controlled analysis of suicide reattempts comparing two cities (2007-2008); b) 8-year long-term analysis with the evolution of suicide rates (men and women) between our area, and two other cities (territorial differences and over time from 2010 to 2017). Results: a) the SRC-Cat in our catchment area reduced significantly the proportion of people who re-attempt suicide by 57% over 12 months (from 14% to 6 %); b) we found lower standardized suicide death rate among women in our catchment area (both territorially and over time). Conclusions: a) Short-term telephone management (12-month), ensuring chain of care after hospital discharge, reduces more than 50% the proportion of patients who re-attempt; b) Long-term telephone management (8-year) of suicide attempt survivors over 12 months, significantly reduces suicide deaths in women only (64% of patients in telephone follow-up are women).