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.

Malta is a small country in the middle of the Mediterranean. It is a member of the European Union and has a population of around 400,000. The culture is European, and around 99% of the population is Roman Catholic. There are no studies on the prevalence of schizophrenia in the Maltese population, but it is most likely that it is about 1%. During the last few years, thousands of illegal immigrants from Africa have been arriving in Malta especially during summer. It seems that the prevalence of schizophrenia in this subgroup is more than that in the local population. Studies are needed to study this phenomenon further to see if this is the case, but they are definitely being a big burden on the local psychiatric services. The National Health Service in Malta provides all treatment for schizophrenia free of charge. The pharmacological management of schizophrenia is similar to that of other European countries. Oral atypical antipsychotics are available within the National Health Services, but depot preparations are not yet available. For admissions there is a main Psychiatric Hospital, Mount Carmel Hospital, and two units in two General Hospitals. Community services are in the process of being developed. An NGO association, the Richmond Foundation also provides community and rehabilitation services. The Maltese family is still a relatively strong unit, with a lot of support in times of help being provided by the extended family. Thus in most psychosocial interventions, the family plays a central role.

Along the coast of the Adriatic, several small projects have developed to improve treatment of patients with Schizophrenia. All these projects have benefited from links with the Department of Psychiatry in Cambridge.

In Ljubljana, The Ljubljana Prodrome Project has developed a system of early intervention and treatment which has a strong research arm. It has contributed knowledge about how psychosis develops, and shown that treatment in the prodromal phase of illness gives patients significant advantages.

The Assertive Outreach Team in Ljubljana Psychiatric Hospital has reduced readmissions for the chronic patients it deals with. Case Management in the Community has also been established at Vrapce Hospital Zagreb, where there has also been established a ward for first episodes of Psychosis. Non Governmental Organisations have been working with patients and their families in Central Croatia, using group interventions for carers.

In Sarajevo, one doctor is working with identifying psychosis early.

All of these projects are successful and amount to a major contribution in improving treatment for schizophrenia for patients in these countries.

Staff from Croatia and Slovenia have visited the UK to learn Early Detection and Intervention techniques and case management.

Further development nationally of these techniques for delivery of Mental Health Care in the Community is now awaited.

In Italy 30 years ago a very radical psychiatric reform has been carried out. All psychiatric hospitals have been closed by law. This reform received very strong political support but was not scientific or evidence based. After 30 years it is necessary to evaluate the Italian reform scientifically.

Basaglia's law was oriented, first to create a net of community care, and then to close Psychiatric Hospitals. The challenge was to improve the quality of life of patients that had spent their life in an Asylum. The patients admitted to psychiatric hospitals, normally had a diagnosis of Chronic Psychosis, Chronic bipolar disorder, mental retardation, but not other more prevalent psychiatric, sometimes more prevalent, diseases. The hypothesis was that psychiatric illness would improve further if the medical interventions were less specialised, thus the psychiatric intervention have to be very generic and supportive, specialization or pharmacologic treatment was perceived as bad practice. Many psychiatric illnesses did not receive specific treatment (panic attacks, personality disorders e.g)

After 30 years this model shows some evidence of efficacy. We must consider weather we can really can apply this model in community treatment or whether we need a scientific based reform in which we can apply algorithms of treatment, early detection of disease and integrated and specialist treatment for severe psychopathology. Data from national health service will be presented and also some specific proposals in a European perspective.

The professional identity of psychiatrists is recently generating controversies and uncertainty, which are reflected in psychiatric education and training throughout Europe.

In Europe, the organization of psychiatric education and training mostly depends on the range of mental health services available at individual sites. It has been recently proposed residents to rotate compulsory in different settings, such as hospital wards, outpatient clinics and community services, in order to learn how to provide different interventions for the different mental disorders. Moreover, while young psychiatrists are skilled in several pharmacological and psychosocial interventions to be provided in the community, they seem to be less experienced in providing these interventions within an hospital framework. The need for “balancing” community- and hospital-based mental health care needs to be specifically addressed during psychiatric training.

The shortage of funds for research projects is one of the major challenges for young researchers. In most European countries, it is becoming more and more difficult to have access to independent funds. National and international networks, as well as exchange programmes involving residents and young researchers, should be promoted.

Finally, it has been documented that residents in psychiatry are at a high-risk of “professional isolation”, which may contribute to the development of burn-out symptoms, particularly frequent among young colleagues.

Difficulties faced by young psychiatrists in the above-mentioned domains of psychiatry are illustrated and possible solutions discussed on the basis of recent results from European research networks involving young psychiatrists.

Psychiatric training is designed to educate psychiatrists to the highest standards of competence in prevention, diagnosis, treatment and rehabilitation of persons with mental disorders. At the same time, it may be an extremely stressful period characterized by intensive work demands, lack of job autonomy, poor salary, high degree of work-home interference and severe dilemmas regarding one's clinical skills. Trainees may be at increased risk of burnout syndrome and associated mental and physical health problems. Burnout syndrome is defined as a psychopathological reaction to prolonged occupational stress. Most recently, a unique international study - "The International Psychiatry Trainee Burnout Syndrome Study: Europe BOSS 2008” - was introduced across Europe in order to evaluate the prevalence and degree of burnout syndrome among psychiatry trainees. The aim is to use the study findings to improve the professional status and the working environment of young psychiatrists. The study itself is run through the national trainee associations in collaboration with the European Federation of Psychiatric Trainees. At this point, fifteen countries are engaged - Austria, Czech Republic, Croatia, Denmark, France, Germany, Greece, Hungary, Italy, Netherlands, Romania, Russia, Slovenia, Turkey and UK. The sample comprises all trainees in the country. They are asked to complete the questionnaire, translated into their native language, by entering data directly into anonymised online database. The study has already started in France and Croatia, and next two countries are Hungary and Romania. Results from the study, as well as detailed study design and methodology will be presented and discussed.

Beyond the awareness that psychiatry and contemporary medicine have undergone a dramatic change in recent years, walking the first steps as recently-qualified consultants in psychiatry is a major challenge. As a consequence of changes in society, technological progress and restricted funding availability, modern psychiatrists have to face problems that are new, and difficult to be faced, but also representing an opportunity to grow and contribute massively to medicine.

This is particularly true in two specific fields, cross-cultural psychiatry and consultation-liaison psychiatry. The former is defined as psychiatry of disorders influenced by the cultural background; the latter is defined as the care of psychiatric disturbances in the medically ill. Though generic, these definitions highlight what is challenging in these branches of psychiatry: the disposition towards an inter-disciplinary approach to human illnesses. Both deepen their roots in the bio-psycho-social paradigm of George Engel and were in fact frequently mentioned in Engel's writings as the future of psychiatry. Training and clinical experience in cross-cultural and consultation-liaison psychiatry are to be major components of the curriculum of psychiatric trainees.

Therefore, the role of psychiatrists and psychiatrists-to-be in the contemporary scientific community and society must be a strong one: on the side of scientific knowledge, by marking the complex, systemic nature of physiopathology and therapy; on the side of epistemology, by marking the paradoxes of bio-medicine; on the side of organization of health care, by promoting the need for a person-oriented approach to illness; and finally on the side of culture, society and ethics.

Good Medical Practice and Good Psychiatric Practice are key documents in the UK, indicating characteristics of a good doctor and a good psychiatrist respectively. Individual aspects of what constitutes a professional can be seen in relationship with other disciplines, team members and stakeholders. A key task of any organisation that purports to speak for the profession is to identify what these qualities are, how they are to be inculcated and developed. The Royal College of Psychiatrists, therefore, is in a unique position to do this and take it forward without guilt and shame. Leadership, teams, education, appraisals, careers and research are themes which have to be looked at. For any leadership to be successful it must have vision, strategic thinking, motivation and trust, all of which are being challenged at present. The profession of psychiatry must move from nostalgic professionalism to ‘new’ professionalism. of We as psychiatrists must ascertain our civic and fiduciary responsibilities by identifying and agreeing standards of quality of care, altruism and values of the profession identified by us and worked at with other stakeholders. The primacy of patient welfare and advocacy for our patients is critical. For our medical-moral interdependence we must be honest with ourselves as to what our strengths and weaknesses are, but also with society to declare what we can deliver in reality and what our aspirations are. Courses in ethics, humanities and human values (medical history, social sciences, literature and films) can sensitize the clinician by raising awareness and developing critical reflection.

One of the concrete projects resolved at the 2nd EPA European Platform of Psychiatrists meeting in Nice 2008 concerns the development and implementation of evidence-based treatment recommendations in psychiatry with an European dimension named "Recommended Guidance". The major objective is to improve quality of mental health care in Europe by providing evidence-based information and advice regarding core clinical questions and to identify and minimize health care gaps. As following steps it was targeted to establish a steering committee, to obtain clinical core priorities by contacting national psychiatric societies, to provide examples of good practice based on existing information, and to develop (first) "recommended guidance" for selected topics as pilot work. To promote this process, information regarding existing guidelines in psychiatry, methodological aspects of their development and evaluation as well as implementation strategies will be provided.

Europe can hardly be considered as homogeneous. There are gross historical, climatological, cultural, developmental, religious, political and economic differences that render generalizations inappropriate and European “globalization” a mission impossible (and, by and large, undesirable).

Psychiatry is no exception to the above and in the historical evolution of our discipline, psychiatric practice has varied. Because this evolution has followed a different course and has occurred at a different pace in the various parts of Europe, the present situation reflects all these developmental stages, thus rendering homogeneity questionable.

In spite of these differences, however, there is a degree of consensus regarding the basic requirements for the practice of our discipline and the desired competencies of its practitioners. The development of a common language through the modern classification systems, the organizations of specialist psychiatrists (e.g. the UEMS) the WPA and the European Psychiatric Associations have played a useful role in the harmonization of psychiatric practices and are expected to play a more useful role in the future.

In conclusion, what is required (and what can be realistically achieved) is consensus on some basic clinical, research, administrative and teaching requirements, in association with agreement on the basic ethical principles of our profession and, basically, the beneficence and non maleficence principles. European Psychiatry Guidance should involve these basic requirements that can be achieved by all European countries.

Nowadays different professions are involved in mental heath care in Europe, e.g. general practitioners, psychiatrists, psychologists, psychotherapists, social-workers, case-managers, prevention specialists, health ministry bureaucrats etc. As mental health represents a weak concept with vague and ambiguous definitions and delimitations it remains quite unclear who should be responsible for mental health today and in the future. In the last decades psychiatrists gained high expertise in treating mental disorders (e.g. psychopharmacological, psychotherapeutic and social measures) but lost terrain in mental health matters because of a lack of interest in such questions leading to the hardly acceptable contemporary situation that professionals without any psychopathological knowledge and without clinical experiences in mental illnesses as well as in the various transitional states between mental health and disordered health have taken the leading positions in the field of mental health care. Of course, the main tasks of psychiatry are to diagnose and to treat mental disorders, but as the prognosis of mental disorders and the treatment efficacy highly depend on the time of recognizing the disorder (the earlier the recognition of a mental disorders and the earlier the start of therapy the better the treatment out-come and prognosis) early recognition of mental disorders and prevention measures (esp. secondary and tertiary prevention) have to become core fields of psychiatry. Therefore psychiatry cannot any longer restrict itself to the treatment of severe mental disorders but has to take again a crucial role in future mental health care system in cooperation with other mental health stake-holders. This implies that future training programs for psychiatrists have to take into account such considerations and have to include beside usual fields of interests (e.g. psychopathology, neurosciences, psychopharmacology, psychotherapy, medical humanities, etc.) also topics like early recognition, transitional states and prevention of mental disorders as regular parts.

This project is a documantary about a schyzophrenia patient whose name is Sewusen. Sewusen has got popularity in Tunceli around East region of Turkey. After his death in 1994, the people in Tunceli have established his sculpture at the center of the city. Most of the schyzophrenia patients live around the people at Tunceli and the people behaves well towards them. The difference of Sewusen is that, he has lived about 40 years at the street and he had no relationship between money and goods. When he gets hungry, he eats in any restaurant and nobody demands any money from him. The people look to the situation as normal. With the effect of the religious aspect of the community, they see Sewusen as Holy but not mad.

In that project, I made a documentary which defines in general the point of view about mental disorders of the community of Tunceli but at custom it gives information about Sewusen.

As a result, this project is about cultural psychiatry and it is made against Stigma. It takes 30 minutes to present and it is English subtitled.

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis function is associated with suicidal behaviour and age-associated alterations in HPA axis functioning may render elderly individuals more susceptible to HPA dysregulation related to mood disorders. Research on the role HPA axis function in suicidal behaviour in elderly mood disorder patients is sparse.The study sample consisted of 99 depressed elderly inpatients 65 years of age or older admitted to the department of Psychiatry at the Karolinska University Hospital between 1980 and 2000. 24 % of patients had attempted suicide just before admission. The hypothesis was that elderly mood disorder inpatients who fail to suppress cortisol in the dexamethasone suppression test (DST) are at higher risk of suicide.

During a mean follow-up time of 17 years (range 6-25.5 years), six suicides were identified from the death certificates. The DST non-suppression distinguished between suicides and survivors in elderly depressed inpatients and the suicide attempt at the index episode was a strong predictor for suicide. Additionally, the DST non-suppression showed higher specificity and predictive value in the suicide attempter group. Due to age associated alterations in HPA axis functioning, the optimal cut-off for DST non-suppression in suicide prediction may be higher in elderly mood disorder inpatients.

Gerald Klerman, Myrna Weissman and colleagues (Basic Books, New York, 1984) created IPT as a psychotherapeutical agent, analogous to a psychopharmacological one, antidepressants. With psychodynamic roots, IPT shows cognitive behavioral aspects: therapeutic stance, problem-solving attitude and the encouraging role of the therapist; he/she does not give homework to the patient. IPT overlaps with family therapy, but is mainly individual, although other formats (couple, groups) exist. As an eclectic formalization of procedures often used by psychiatrists, IPT is a semistructured way to guide the patient over a few months. It is user-friendly, confortable and well-accepted. IPT shows a solid ground based more on empiric knowledge and less on belief systems. So, school faithes should not obstacle IPT to improve with research and even be a model for it in the field. Psychotherapeutic training should include at least the psychodynamic, the cognitiv-behavioral and the interpersonal approach.

I translated the original manual's Part II included in “Psicoterapia Interpersonal” (Elsevier, Barcelona, 1998), the only Spanish IPT textbook in use. In the Comprehensive Guide to IPT (Weissman, Markowitz & Klerman, 2000) I am quoted as its introducer in Spain. Members of the Sociedad Española de Terapia Interpersonal -psychiatrists and psychologists, mainly- have given presentations and imparted courses in Spain and abroad (Portugal, Latin America). Since my seminal 1995 paper “Qué es y donde está la psicoterapia interpersonal” (Revista de Psiquiatría, 6:141-159), a number of Spanish papers have been produced. Spanish research programmes on IPT are still lacking, although promising initiatives have been published in local journals.