In 2018, the Swiss Academy of Medical Sciences (SAMW) published a new guideline on physician-assisted dying (PAD). In line with the SAMW guideline published in 2004, the patients’ ability to judge, their self-determination, careful consideration and permanence of their wish to die as well as the lack of therapeutic options were set as necessary conditions. However, while the previous wording considered assisted suicide to be ethically justifiable if the patient’s condition is terminal, the new guideline requires that it is unbearable. This difference has been the subject of intense discussion in Swiss healthcare professionals and the population alike. This controversy is particularly important for those affected by mental illness who have a persistent desire to die. This is because mental disorders cannot usually be classified as terminal illnesses, but they can certainly lead to suffering that is perceived as unbearable. Furthermore, it is known that persons with mental illness are subject to stigmatization. It is therefore likely that there is a connection between the stigmatization of mentally ill people and the position on PAD for this group. This talk provides theoretical background on this discusion and proposes a study protocol to investigate the acceptance of PAD in relation to the type of illness as well as the factors of unbearable suffering and terminality. It will furthermore look into the criteria of the 2004 and 2018 guidelines and will explore if there is a connection between stigmatization and the assessment of whether a person should be granted access to assisted suicide.

Involuntary psychiatric hospitalization for suicide prevention and physician assistance in dying (PAD) for patients with severe and persistent mental illness (SPMI) combine to create a moral tension. Switzerland has the longest history of non-medicalized assistance in dying, considered as a civil right even beyond pathological situations. The debate in Switzerland centers on the notion of suffering in the context of PAD. In 2018, the Swiss Academy of Medical Sciences revised their end-of-life policy stipulating intolerable suffering due to severe illness or functional limitations and acknowledged as such by the physician as a core criterion for PAD. However, we argue that suffering is a necessary but insufficient condition for PAD, the other criteria being decision-making capacity (DMC) and refractoriness of the suffering. Moreover, we hold that suffering is a subjective experience that can only be quantified by the patient and cannot be compared between two persons in an objective way. According to this concept, however, some patients with SPMI, refractory suffering, and preserved DMC will meet the criteria for PAD. Therefore, we call for palliative care approaches in psychiatry which includes relief of suffering as much as possible, but also accepting PAD after a conscientious assessment of the criteria.

Childhood maltreatment (physical, sexual or emotional abuse, and physical or emotional neglect, by a parent, caregiver or other adult) is a major problem of global significance. Children who suffered maltreatment of any kind are known to experience a range of mental health problems, including depression, anxiety, psychosis, substance abuse, eating disorders, suicidal symptomatology and personality disorder. These problems often emerge in childhood and last through adulthood to old age. Furthermore, people with a history of childhood maltreatment show a worse-than-usual response to standard treatment approaches to improve their mental health. There is growing evidence that emotional abuse, one of the most prevalent forms of childhood maltreatment, may have the most wide-ranging impact of all maltreatment types on mental health outcomes as it appears to be a transdiagnostic risk factor for several psychiatric disorders, and found to me more strongly associated with development of affective disorders than physical abuse or neglect. There is a need to move beyond simple association studies and shift the research focus on sophisticated multimodal studies to fully understand the psychobiological mechanisms underlying affective morbidity, as well as the protective factors that might promote resilience, in the face of (specific forms of) childhood maltreatment.

Persistent negative symptoms are associated with worse outcome in both first-episode and chronic subjects with schizophrenia. The identification of these symptoms in recent-onset subjects is still controversial as retrospective data are often unavailable. The prospective assessment of persistence of negative symptoms might represent a valid alternative but the length of the persistence is still to be established. The present study investigated the prevalence of negative symptoms of moderate severity, unconfounded by depression and extrapyramidal symptoms at baseline in a large cohort of patients in the early stage of a schizophrenia-spectrum disorder, recruited to the OPTiMiSE trial. Persistent unconfounded negative symptoms were assessed at 4, 10 and 22 weeks of treatment. Symptomatic remission, attrition rate and psychosocial functioning was evaluated in subjects with short-term (4 weeks) persistent negative symptoms (PNS) and in those with negative symptoms that did not persist at follow-up and/or were confounded at baseline (N-PNS). Negative symptoms of moderate severity were observed in 59% of subjects at baseline and were associated to worse global functioning. PNS were observed in 7.9% of the cohort, unconfounded at both baseline and end of 4-week treatment. PNS subjects showed lower remission and higher attrition rates at the end of all treatment phases. Fifty-six percent of subjects completing phase 3 (clozapine treatment) had PNS, and 60% of them were non-remitters at the end of this phase. The presence of short-term PNS during the first phases of psychosis was associated with poor clinical outcome and resistance to antipsychotic treatment, including clozapine.

Negative symptoms are a core feature of schizophrenia spectrum disorders associated with poor outcomes such as low remission rates and impairments in daily functioning and quality of life in early psychosis. The assessment of negative symptoms in early psychotic disorders is predominantly conducted by use of first-generation scales such as the PANSS and the SANS, along with the SIPS and CAARMS for the psychosis clinical high-risk (CHR) state. Following the progressed conceptualization of negative symptoms, it has, however, been recognized that these scales suffer important methodological limitations. This warrants a use of second-generation scales such as the Brief Negative Symptom Scale (BNSS) and the Clinical Assessment Interview for Negative Symptoms (CAINS) in early intervention settings in order to achieve a more accurate assessment of the negative symptom complex. Advancing the assessment of negative symptoms in early psychosis may also guide more targeted intervention approaches aimed at improving functional outcome. Albeit recognizing that negative symptoms constitute an important barrier to a good functional outcome in psychotic disorders, few studies have directly aimed at alleviating negative symptoms in early psychosis. Meta-analytical evidence does, however, exist on the efficacy of the combined treatment modalities incorporated in Early Intervention Services (e.g. intensive and assertive case management, family involvement etc.) in reducing negative symptoms in first-episode psychosis. Evidence on the effect of interventions for improving negative symptoms in the CHR state is lacking. Developing targeted, and possibly more individualized negative symptoms treatment approaches, constitute an essential future research area.

Certain percentage of the first-episode schizophrenia patients presents with negative symptoms, which persists over the year and influence treatment outcomes (Galderisi et al. 2013). Treatment of negative symptoms has been a significant continuous clinical challenge. Majority of recently published guidelines recommend antipsychotic monotherapy as the standard of care, recommending antipsychotic combination therapy only after a failed trial with clozapine (George A. Keepers et al. 2020; Faden et al. 2020). However, real-life forces clinicians to look for possible combinations of medications early on, especially to tackle negative symptoms. The systematic review of global prescribing practices covering four decades found the pooled median rate of antipsychotic combination therapy approximately 20% (Gallego et al. 2012). One of the largest retrospective studies every conducted (n = 62,250) assessed rehospitalisation rates and the long-term use of antipsychotic polypharmacy in schizophrenia. Antipsychotic combination treatment was associated with an approximate 10% lower relative risk of psychiatric rehospitalisation compared with antipsychotic monotherapy (Tiihonen et al. 2019). Real-world effectiveness study of antipsychotic monotherapy vs. polypharmacy in schizophrenia from Eastern Europe is also supporting this approach (Katona, Czobor, and Bitter 2014). At the same time antipsychotic combination therapy can increase the total antipsychotic dose burden, frequency of adverse effects, potential drug-drug interactions and incur additional costs. In our recent naturalistic study in schizophrenia outpatients (n=120) with insufficient effectiveness of previous antipsychotics therapy on negative symptoms, we were able successfully switch therapy form several different antipsychotic combinations to monotherapy and gain clinical benefits (Rancans et al, 2020).

The future of psychiatry as a discipline (and as the main source of knowledge in the construction and functioning o mental health services) can best be grasped on the basis of an examination of the development of psychiatry over the past century in the light of current options for its functioning. Such an examination demonstrates that psychiatrists will have to expand their field of work to include the management of comorbidity of mental and physical disorders and public health approaches to the primary prevention of mental and other brain disorders. Their engagement in research will have to become restricted to psychopathology and participation in the formulation of hypotheses which will be tested in laboratory and field work;; and their involvement in teaching about mental health and illness will have to undergo a fundamental change in terms of content, methods and evaluation of effects of education which they will organize. The presentation will focus on the future tasks of psychiatrists in these areas

For a Mid-career Professor in Germany, there are defined clinical and teaching responsibilities. One can focus either on one’s research or on clinical work and teaching. When tasks are becoming more demanding or significant overarching decisions need to be taken, there is always a chairperson to be asked or to help delegate tasks. As chairperson, one is mostly independent from other persons except for the dean of the medical faculty. One is however, at least in Germany, the chairpersons fully responsible for keeping up teaching, patient care, research as well as running the department. The Chairperson is measured by the achievements of these four tasks. It need special attention to keep up a balanced time schedule to cover clinical care, research, teaching and departmental management. A good chairs means working together with your staff on long-term goals, developing the department fruitfully and trying to fulfil these goals.

In the last years several social, economic and scientific changes have occurred, which have had a significant impact on psychiatric clinical practice, research and training. Some traditional syndromes seem to be disappeared, while new forms of mental health problems are coming to psychiatric consultation. The psychosocial distress caused by the current ongoing crisis due to the COVID-19 or the maladaptive use of the new technologies among the younger generation, are some good examples of psychosocial factors causing new mental health disturbances. Psychiatrists and mental health professionals are not yet well-equipped for managing these, which represent major unmet needs in modern clinical practice. Furthermore, in this evolving social context, the societal role of psychiatrists is completely changed, moving from being “alienist” working in asylums to “mental health care providers” working in the communities. The role of psychiatrists is to improve global mental health and to promote well-being in the general population according to a life-span perspective. Nowadays, early career psychiatrists report several unmet needs that we are not able to manage. In this symposium, I will describe my personal experience of moving from my role of mentee to mentor.

People with psychosis are commonly socially isolated, both due to their condition, and the stigma towards them. Remote volunteering over smart-phone can be a way to overcome social isolation and physical distance, promoting social inclusion. This talk will present the qualitative findings from a feasibility study – the Phone Pal – which connected in the United Kingdom patients with psychosis with community volunteers, to communicate with each other for up to 12 weeks via smart-phone (through texts, WhatsApp messages, e-mails, audio or video calls). Participants described at the end of the study their experiences of communicating with their match over the smart-phone in terms of frequency, duration and timing of communication, their communication method, content and style, and the changes of communication over time. Several participants reported a positive impact of being connected with someone, meeting a new person, feeling supported and feeling better, and a few described challenges, such as disappointment, guilt and burden. These interview findings show that some matches were able to develop a positive and friendly relationship, and were willing to continue to be in contact with each other beyond the study duration. It is hoped that this talk will generate a lively discussion, gathering further understanding about the potential benefits and challenges of remote volunteering over smart-phone for patients and volunteers, and its potential usefulness in the current pandemic times.

Psychiatry has long been battling with a recruitment crisis in the UK which is also reflected across much of Europe. Covid-19 has brought about widespread changes to our ways of working, as well as driving technological developments, which provides potential opportunities for the profession to draw people into the speciality. Covid-19 has brought interest in digital psychiatry from the peripheries to the mainstream. Mental health professionals are currently using sophisticated technologies such as Virtual Reality, Artificial Intelligence and Natural Language Processing in the diagnosis and treatment of mental health disorders. Highlighting the ways in which our profession is at the cutting edge of innovation to junior doctors offers a fruitful avenue to improve recruitment into the speciality. Many outpatient clinics have made the move to online service delivery during the pandemic to varying degrees. For many clinicians this has allowed more flexible and efficient ways of working. Psychiatry is better placed than most other medical disciplines to retain online patient contact in future clinical practice, post pandemic and may provide an attractive proposition for future psychiatrists. This talk will review some of the ways in which developments in digital psychiatry have been used to help generate interest for recruitment into the discipline as well as evaluating the benefits and challenges of the shift to telepsychiatry during Covid-19 and will offer some suggestions what the profession can learn from this to help future recruitment.